A MANUAL OF DISEASES 
OF THE 
NOSE, THROAT, AND 
EAR 
r - 
BY '•>- 
E. B. GLEASON, M.D., LL.D. 
Professor of Otology in the Medico-Chirurgical College; Aurist to the Medico- 
Chirurgical Hospital; Surgeon-in-Charge of the Nose, Throat, and 
Ear Department of the Northern Dispensary; Formerly one 
of the Laryngologists to the Philadelphia Hospital 
Illust rat ed 
THIRD ENTON* JMOEWG^Y, REVJSED 
PHILADELPHIA AND LONDON 
W. B. SAUNDERS COMPANY 
19 14 Copyright, 1907, by W. B. Saunders Company. Reprinted November, 1907, 
and July, 1908. Revised, entirely reset, printed, and recopyrighted 
August, 1910. Reprinted July, 1912. Revised, entirely 
reset, printed, and recopyrighted October, 1914 
Copyright, 1914, By W. B. SAUNDERS COMPANY 
PRINTED IN AMERICA 
PRESS OF 
W. B. SAUNDERS COMPANY 
PHILADELPHIA TO 
JHon. Menrp f. Walton, 
President of the Medico-Chirurgical College and Hospital, 
Philadelphia 
A LEARNED, GENIAL GENTLEMAN 
AND 
A GOOD FRIEND 
IN AFFECTIONATE APPRECIATION OF HIS MANY ACTS 
OF KINDNESS AND WORDS OF WISE COUNSEL 
THIS LITTLE BOOK IS INSCRIBED 
BY 
THE AUTHOR PREFACE TO THE THIRD EDITION 
The second edition has been carefully revised and all that 
seemed obsolete, or likely to become so, eliminated to make 
room for the numerous additions necessary to bring the book 
up to date without increasing its size. A book on one of the 
specialties in medicine designed for the use of students and 
general practitioners cannot be too concise, provided that the 
subject is efficiently covered and descriptions lose nothing in 
clearness by brevity. As in the previous editions of this little 
book, an effort has been made to eliminate all surplus words. 
More space has been given to diagnosis and treatment than 
to rare and difficult operations that the beginner should not 
do. However these operations are described with sufficient 
minuteness for the student to practice them upon the cadaver. 
This method of study cannot be too highly indorsed because 
it produces a practical knowledge of the anatomy and topog- 
raphy of the respiratory tract and ear and skill in the handling 
of instruments that cannot otherwise be readily obtained. It 
is true that the trend of opinion has lately been toward con- 
servative intranasal operations on the accessory sinuses rather 
than radical external operations, for example, like that of 
Killian, but such operations while rarely required upon the 
living are excellent practice for students upon the cadaver. 
The same is true of operations upon the internal ear. 
Considerable attention has been given to directions for the 
preparation and preservation of anatomical specimens and sec- 
tions through the nose and ear. The preparation of such speci- 
mens helps to fix the anatomy and relationship of the parts 
in the mind of the beginner, and hence specimens prepared by 
the student himself are more valuable for future reference 
and study than similar preparations purchased in the shops. 
In the commoner operations like tonsillectomy and sub- 
mucous resection of the nasal septum, when the methods of 
11 12 
PREFACE TO THE THIRD EDITION 
operating are almost as numerous as the operators, a technique 
is given which, in the experience of the author, is simplest, 
quickest, easiest, most free from unnecessary traumatism and 
risk, and yields the largest proportion of good results. The 
author has never had a death from tonsillectomy nor a case 
of severe sepsis; yet he feels that other methods of operating 
may be equally as good as that described. However, the 
beginner should acquire as soon as possible the technique best 
suited to him for the commoner operations and not abandon 
it without good reason; because operators who have no estab- 
lished techniqne but are constantly shifting from one method to 
another, usually have the largest number of fatalities and 
unsatisfactory results. 
The chapter on tonsils and adenoids although entirely 
rewritten for the second edition has again been carefully 
revised. Comparatively much space has been given to the 
consideration of diseases of the nasal accessory sinuses. While 
radical operations designed to obliterate these cavities have 
been advocated when indicated, the fact is clearly stated that 
the majority of acute inflammations recover as the result of 
comparatively simple treatment, and that in the chronic 
suppurations no operation should be done that will leave the 
patients in a worse condition than before. 
The chapter on diseases of the internal ear has been rewritten 
and considerable new material added to bring this part of 
the book completely up to date. The same is true of the 
intracranial complications of aural suppuration. 
The formulae at the end of the book have been carefully 
revised and only those retained which have not been super- 
seded by better remedies. The various methods of employing 
cocain, adrenalin, etc., have received careful attention and 
considerable new material added to this section of the book. 
E, B. Gleason. 
2033 Chestnut Street, 
Philadelphia, Pa., 
October, 1914. PREFACE 
This manual was written to supply students and general 
practitioners with the essential facts of Rhinology, Laryn- 
gology, and Otology in as concise a form as possible. 
The more important facts of the anatomy, physiology, 
and pathology of the upper respiratory tract and ear 
have received careful consideration, so that the volume 
might prove sufficiently complete for study or reference 
by undergraduates during their college years and for 
practitioners taking a post-graduate course in laryn- 
gology and otology. 
The details of inspection, examination, and diagnosis of 
the nose, throat, and ear conditions and the use of the 
commoner instruments of diagnosis and for the making 
of applications have received very careful and compara- 
tively lengthy detailed description. The same may be 
said of minor operations. Methods of treatment have 
been simplified as much as possible, so that in most in- 
stances only those methods, drugs, and operations have 
been advised which, by the actual experience of the 
author, have proved essential to the accomplishment of 
the desired result. At the end of the book is a collec- 
tion of Formulas designed to represent more than a mere 
catalogue of prescriptions. Hence a detailed description 
of the better methods of use of each of the more im- 
portant drugs has been interpolated, which it is hoped 
the reader will find useful and suggestive. 
13 14 
PREFACE 
The history of the gradual development of some of 
the more important instruments, methods of treatment, 
and, more especially, operations has been considered 
of sufficient practical importance to be briefly outlined. 
In some instances the prognosis in cases not operated 
on has been accentuated by quotations from the writ- 
ings of standard authors of the period before such 
operations were practised. 
The book contains 262 engravings, a considerable 
proportion being original or drawn from dissections 
made by the author. The value of carefully made 
sections through the upper respiratory tract and ear 
for purposes of study and reference is stated and a 
method of preparing and preserving such specimens 
described. 
E. B. GLEASON. CONTENTS 
PAGE 
The Laryngoscope 17 
The Art of Laryngoscopy 21 
Laryngeal Image 26 
Rhinoscopy 3° 
Otoscopy 36 
Accessory Instruments 40 
Sterilization of Instruments 50 
Examination of Patients 53 
The Nose 56 
Anatomy of the Nose 56 
Physiology and Pathology of Mucous Membranes .... 62 
Inflammation of Mucous Membranes 65 
Diseases of the Nose 66 
Diseases of the Nasal Septum 125 
Diseases of the Accessory Sinuses 150 
The Pharynx 193 
Anatomy of the Pharynx 193 
Diseases of the Nasopharynx or Postnasal Space 199 
Diseases of the Oropharynx 206 
Neuroses of the Pharynx 243 
Diseases of the Uvula 246 
The Larynx 250 
Anatomy of the Larynx 250 
Diseases of the Larynx 260 
15 16 
CONTENTS 
PAGE 
The Ear 3X4 
Anatomy of the Ear • 3X4 
The External Ear 3*4 
The Middle Ear 3^ 
The Internal Ear or Labyrinth 325 
Tests for Hearing 33° 
Pathologic Conditions of Nose and Pharynx Causing Disease 
of Ear 339 
Diseases of External Ear 35° 
Diseases of the External Auditory Canal 362 
Diseases of the Middle Ear 379 
The Membrana Tympani 379 
Diseases of the Tympanum 392 
Systemic Diseases Causing Otic Inflammation . . . .437 
Operations Upon the Middle Ear 442 
Intracranial Complications of Otic Disease . . • • 49° 
Diseases of the Perceptive Apparatus 515 
Formulas 533 
Index . . . . 567 DISEASES OF 
THE NOSE, THROAT, AND EAR 
THE LARYNGOSCOPE 
The laryngoscope is a combination of two mirrors arranged 
to enable the observer to see the interior of the larynx. The 
larger and concave mirror, called the reflector, is attached to 
the observer's head by a head-band, and the smaller and plane 
mirror, called the laryngeal mirror, is introduced into the back 
part of the mouth in such a manner as to be directly above the 
glottis; so that light reflected from the reflector upon the laryn- 
geal mirror illuminates the interior of the larynx, and enables 
the observer to see its image in the small mirror. 
In 1854 Signor Manuel Garcia, by means of a dentist's 
mirror and a hand-glass, studied the movements of his own 
vocal cords during phonation, and accurately described the 
registers of the voice in a paper read before the Royal Society 
of London in 1855, and hence the honor of inventing the 
laryngoscope is usually accorded to Garcia. 
The laryngeal mirror consists of an oval or round piece of 
silvered glass, mounted in a metal frame and attached to a 
wire stem at an angle of not less than 120 degrees. Such 
mirrors vary in size from | inch to i| inches in diameter, and 
are numbered 1, 2, 3, 4, 5 by instrument-makers. However, 
smaller mirrors, Nos. 00 and o, and larger mirrors, Nos. 6, 7, 
and 8, may be obtained, and are occasionally useful (Fig. 1). 
The reflector is a concave mirror 3I inches in diameter, of 
about 12-inch focus, and made of silvered glass, mounted in a 
17 18 
DISEASES OF THE NOSE, THROAT, AND EAR 
metal frame, so arranged that it is capable of attachment 
by a universal joint either to a head-band or the source of 
illumination. 
The instrument known as Fox's head-band (Fig. 
2) consists of steel or, preferably, brass strips 
hinged together so that they can be folded about 
the mirror to protect it and form a conveniently 
shaped package to be carried in a pocket. When 
in use the head-band assumes the position of a 
line passing over the head from the forehead to 
the occiput. It is held firmly in position by the 
hinged bands, which when unfolded act as a 
spring. It has the advantage that at once it 
adjusts itself to heads of varying shapes and sizes, 
and hence is convenient in class-demonstration to 
pass from student to student. However, a head- 
band of leather is decidedly the preferable instru- 
ment, because it is lighter. The leather should be 
black to prevent discoloration by sweat. The 
Fig. i.- 
Laryngeal 
mirror in 
u n i ver sal 
handle, j 
Fig. 2.-Reflector with Fox's head-band. 
joint by which the mirror is attached to the forehead is by 
no means a matter of indifference, a double ball-and-socket 
joint greatly facilitates.the adjustment of the reflected light, 
and renders it possible to bring the perforation in the center THE LARYNGOSCOPE 
19 
of the reflector closer to the eye, a decided advantage in ex- 
amining narrow cavities like the nasal passages or the auditory 
meatus. Some years ago the author had made for use in 
his class-room the head-band shown in Fig. 3. At that time 
his principal object was cheapness. The instrument, how- 
ever, proved so light, comfortable, and efficient that it has 
become his favorite head-band. 
Proper Method of Wearing the Reflector.-The reflector 
should be worn upon the forehead over the left eye, and the 
light should be reflected from it upon the face of the patient, 
so as to form a circle bounded above by the tip of the nose and 
below by the front of the chin. When worn over the left eye, 
Fig. 3.-Gleason's head-band. 
with the source of illumination to the left of the patient, it is 
possible to secure a better illumination of the nose and mouth 
with less frequent manipulation of the reflector. If, however, 
the source of illumination be at the patient's right, the reflector 
is more conveniently worn over the right eye. 
Sources of light used in otoscopy are natural and artificial. 
Daylight, preferably that reflected from a white cloud, arti- 
ficial light, furnished by a Welsbach mantle, Argand burner, 
oil lamp, or the electric light, are now generally used. What- 
ever the source of the illumination, the light is directed into 
the auditory canal, mouth, or nose by means of the reflector. 
The apparatus shown in Fig. 4 may be used either over an 20 
DISEASES OF THE NOSE, THROAT, AND EAR 
ordinary student's lamp, Argand burner, Welsbach light, or 
the electric light can be placed within the apparatus. The 
Welsbach light gives by far the most satisfactory illumina- 
tion, but because of the frequent moving of the bracket the 
mantle, which should be used without a glass chimney, has 
a much shorter life than if the light were stationary. How- 
ever, in spite of this disadvantage, the Welsbach light is prob- 
ably the best for office work and the Argand burner for the 
dispensary or elsewhere when the lamp is liable to rough 
handling. The electric light, after it has passed through the 
Fig. 4.-Adjustable gas bracket with light concentrator. 
lens and been reflected by the mirror, yields a bright image of 
the filament with deep intervening and surrounding shadows. 
The source of light should be at the patient's right somewhat 
behind him, and on a level with the top of his ear. As the 
heights of patients vary greatly when seated, it is well to have 
some means by which the position of the light can be quickly 
and conveniently changed. There are several forms of ad- 
justable gas brackets manufactured that answer fairly well. 
One that can readily be manipulated with the left hand while 
the operator remains seated will be found to be the most con- 
venient. That shown in Fig. 4 has large conic bearings which 
do not wear loose so rapidly and leak as some of the other 
patterns. THE LARYNGOSCOPE 
21 
THE ART OF LARYNGOSCOPY 
Laryngology is the seeing and describing what is present in 
the larynx. The word signifies a treatise on the larynx and its 
diseases. Laryngoscopy is simply the art of viewing the 
interior of the larynx. 
The optical law involved in laryngoscopy is that the angle of 
reflection is equal to the angle of incidence. This law is illus- 
trated by the fact that the laryngeal mirror must be placed 
Fig. 5.-Diagram illustrating the principle of the laryngoscope (Lennox Browne) 
in the patient's pharynx, above and behind the larynx, and at 
such an angle that light received on its surface is reflected 
downward into the larynx. The rays then forming the laryn- 
geal image will return along the same path, and be reflected 
at the same angle into the eye of the observer. From this 
it follows that the nearer the center of the head-mirror is 
placed to the eye of the observer, the better will the image of 
the larynx be seen (Fig. 5). 
We should bear in mind that the laryngeal image is a re- 
flected one, and that, therefore, it is reversed anteropos- 
teriorly, owing to the fact that the laryngeal mirror is above 
and behind the opening of the larynx (Fig. 6). 22 
DISEASES OE THE NOSE, THROAT, AND EAR 
The observer should sit opposite to the patient so that his 
eye is on a level with, and about a foot from, the mouth of the 
patient, whose head should be slightly raised and inclined 
backward. The knees of the observer should be either at the 
left or on either side of the patient's knees. For office use it 
is most convenient to have piano stools, or chairs, the seats of 
which can be raised or lowered, so that the difference in the 
heights of different patients can be com- 
pensated for, and the eye of the observer can 
be brought on a level with that of the patient. 
If a head-reflector be used it is advisable 
for the observer first to place his head in an 
easy position and then move the reflector 
until the disk of reflected light falls in the 
opened mouth of the patient with its center 
at the base of the uvula, thus illuminating 
all the surrounding parts. This method of 
procedure has the very practical advantage 
that if the observer has to turn his head to 
see to pick up an instrument or for any other 
purpose, bringing his head back into the 
former easy position at once reilluminates the patient's 
pharynx without readjusting the reflector. 
Introduction of Laryngeal Mirror.-The laryngeal mirror is 
first warmed by holding its reflecting surface over a flame for a 
short time to prevent moisture condensing upon it. The 
handle should be held between the thumb and forefinger of 
the right hand like a pen-holder, with the reflecting surface of 
the mirror downward. The forearm should be flexed upon the 
arm and the hand slightly backward upon the wrist and held 
a little below the mouth of the patient. By a forward motion 
of the hand and a slight raising of the arm and unbending of 
the elbow the mirror should be quickly carried into the mouth, 
following the curve of the hard palate until the back of the 
mirror touches and raises the uvula, pressing it upward and 
backward as far as possible. Meanwhile the left hand of 
Fig. 6.-Diagram 
of laryngeal mirror, 
illustrating the re- 
version of the re- 
flected image (Len- 
nox Browne). THE LARYNGOSCOPE 
23 
the observer has grasped the patient's protruding tongue, hold- 
ing it well forward by means of a towel or napkin to prevent 
slipping through the fingers. 
Controlling the Tongue.-The protruded tongue of the 
patient should be grasped between the outstretched thumb and 
index-finger of the left hand, protected by a napkin or towel to 
prevent slipping, in such a manner that the forefinger, being 
placed against the lower teeth, projects above their edge, and 
thus forms a roller upon which the tongue can move without 
its frenum coming in contact with the sharp edge of the lower 
incisors. The thumb being placed on the upper surface of the 
tongue and the middle finger above the chin of the patient, a 
slight rotatory motion of the observer's left hand will then not 
only control the motion of the tongue of the patient but also 
keep all involuntary movements of his head in check. When 
the operator has to use both hands in operating or making 
applications, the patient should be taught this maneuver and 
requested to hold his tongue forward himself. 
The mirror should not touch the tongue or palate; and, when 
in position, it should be held steadily and not allowed to 
tremble, or gagging and retching will result. Should the 
slightest sign of this occur, the mirror must be quickly with- 
drawn, and only reintroduced when the patient has had time 
to recover his breath and confidence; or the gagging will be 
repeated on an attempt to reintroduce the mirror, and the 
throat finally become so sensitive that a further examination 
will be impossible at that sitting. 
To bring the laryngeal image into view the handle of the 
mirror is brought to one side until it lays in the angle of the 
patient's mouth, and the hand holding it is steadied by one or 
two fingers resting on the cheek of the patient. This procedure 
brings the hand out of the line of vision. The mirror is next 
slowly but steadily turned until the image of the larynx 
appears upon its surface. The patient should now be requested 
to say "Ah" in order to raise the epiglottis (Fig. 7). 
Obstacles to laryngoscopy are: 1. Irritability of the pharynx, 24 
DISEASES OF THE NOSE, THROAT, AND EAR 
produced by trembling of the hand holding the mirror, causing 
gagging and retching. 2. Want of proper adjustment of the 
light, without which the larynx cannot be illuminated, even 
when the mirror is in the proper position. 3. Undue irrita- 
bility or peculiar formation of certain parts of the throat. 4. 
Raising of the back of the tongue upon the approach of the 
Fig. 7.-Method of making a laryngoscopic examination (Cohen) 
mirror, in spite of the traction made upon its tip. 5. Too 
large or pendent epiglottis. 
Gagging and retching can be prevented generally by 
avoiding to touch the tongue and palate while introducing the 
mirror, and by holding it steadily in its proper position when 
introduced. Irritability of the pharynx may be relieved THE LARYNGOSCOPE 
25 
by letting the patient swallow a glass of ice-water before in- 
troducing the mirror; or, if that should fail, the use of a spray 
of cocain solution from an atomizer will generally produce the 
desired effect. If the back part of the tongue rises so as to 
obstruct the view in spite of traction on its tip, it may be 
caused to lie flat in the mouth by steady pressure with a 
tongue-depressor (Fig. 8). When the epiglottis is so large or 
pendent as to obstruct the 
view, the glottis sometimes 
can be seen by causing the 
patient to laugh or sing in a 
high pitch. 
Autolaryngoscopy.-The ob- 
server who wishes to study his 
own larynx should seat himself 
with his back toward a window 
through which the direct light 
of the sun enters. In front of 
him should be a plane mirror, 
so placed as to reflect a ray of 
sunlight into his open mouth. 
All being in readiness, he seizes 
his tongue with a napkin held 
in his left hand, and pulls it 
forward. His right hand now 
carries a laryngeal mirror to 
the back of the mouth, its 
progress being watched in the 
mirror before him. When 
properly placed, the sunlight from the plane mirror is reflected 
by the laryngeal mirror into the larynx, and its image appears 
upon the laryngeal mirror and is reflected forward upon the 
plane mirror, where it may be studied by the observer. Arti- 
ficial light may also be used for autolaryngoscopy by having 
the source of illumination at one side of, on a level with, and 
slightly behind the observer's head; while a concave reflector is 
Fig. 8.-Bosworth's tongue-depres- 
sor. This is one of the most con- 
venient of numerous forms of tongue- 
depressors, some of which carry min- 
iature electric lights. 26 
DISEASES OE THE NOSE, THROAT, AND EAR 
placed at one side of the plane mirror to reflect the light upon 
the laryngeal mirror in the back part of the mouth. 
Infraglottic Laryngoscopy.-In some cases in which trache- 
otomy has been performed and the cannula is fenestrated, a 
small mirror may be so introduced into the cannula as to obtain 
a view of the under surface of the vocal cords, which are red 
instead of white. Unfortunately, the mirror must be so small 
that little else can usually be seen. 
LARYNGEAL IMAGE 
Normal Image.-At the upper part of the mirror (Figs. 
9-11) is seen the reddish-yellow arch of the epiglottis (l) with 
its cushion (c). In front of the epiglottis and extending 
downward across the mirror are seen two pairs of bands-'the 
Fig. 9.-The larynx in gentle breathing (Lennox Browne) 
Fig. io.-a, The larynx in tone-production; &, the larynx in deep breathing 
(Lennox Browne). 
outer red, and the inner of a pearly white. The former are 
tbe ventricular bands (p), while the latter are the vocal cords 
(v). In deep breathing a triangular opening is seen between 
the vocal cords, through which we can see into the inferior 
cavity of the larynx and view the anterior part of the cricoid 
cartilage as well as some of the tracheal rings below it (w, p). THE LARYNGOSCOPE 
27 
In some cases two dark circles can be seen in the depth of the 
trachea, indicating the openings of the bronchi (b). During 
tone-production the opening between the vocal cords is 
narrowed to a slit, and this space is called the rima glottidis or 
glottis (chink of the glottis). At the termination of the vocal 
cords are the arytenoid cartilages, with the interarytenoid 
space or commissure between them. From each side of this 
commissure, a fold, called the aryepiglottic fold, extends forward 
to join the arch of the epiglottis. Upon each of these folds are 
two nodules-the cartilages of Wrisberg (w) and those of 
Santorini (s). These latter surmount the arytenoid cartilages 
Fig. ir.-Modified Kahler tracheo-bronchoscope. The handle of the instrument 
can be rotated downward into a vertical position. 
Attaching the epiglottis to the tongue is seen in the mirror a 
light-colored band-'the glosso-epiglottic fold. On each side 
are two grooves, called the glosso-epiglottic fossae. The color 
of the mucous membrane, as seen in the laryngeal image, varies 
from the pearly whiteness of the vocal cords to the reddish 
yellow of the epiglottis and the pinkish red seen in other locali- 
ties. There is also considerable variations of color, within the 
limits of health, in different individuals, and even in the same 
individual under different conditions. As seen by artificial 
light it is always redder in color than by direct sunlight. 
Direct Laryngoscopy.-Kirstein long ago demonstrated 
that it was possible to get a direct view of the interior of the 
larynx by strong pressure on the base of the tongue, with a long 28 
DISEASES OF THE NOSE, THROAT, AND EAR 
curved tongue-depressor. His method never became popular. 
Killian modified the depressor into a tube with a beaked end 
designed to enter the vestibule of the larynx and lift the epi- 
glottis out of view. In this manner it is possible to see the 
interior of the larynx with the right hand free for the intra- 
laryngeal use of instruments. 
The laryngeal surface of the epiglottis, aryepiglottic folds 
and arytenoids are painted several times with 20 per cent, 
cocain to which an equal amount of 1-1000 adrenalin has been 
added. The patient is requested to cough and expectorate 
any excess of solution and if necessary the interior of the 
larynx is cocainized finally in the same manner. A Kahler 
bronchoscopic handle is fitted to a grooved spatula (Fig. 11) 
Fig. 12. - Killian's apparatus for suspension laryngoscopy. 
which under direct illumination is passed over the epiglottis 
which is pushed forcibly against the base of the tongue to 
bring the interior of the larynx into view. During this 
procedure, the patient is seated on a low stool with his head 
extended forward and upward; the operator standing in front. 
By this method it is possible to remove foreign bodies, tumors, 
etc., with straight instruments by direct vision. THE LARYNGOSCOPE 
29 
Direct laryngoscopy has been further improved by placing 
the patient on his back upon an operating table and support- 
ing his head by means of a Killian suspension laryngoscope 
which is clamped to the table (Fig. 12). Suspension laryn- 
goscopy has the advantage that the operator has both hands 
free for the manipula- 
tion of instruments 
and has a wide field of 
vision with the larynx 
at close range so that 
more extensive intra- 
laryngeal operations 
are possible than by 
the indirect method 
which, however, has 
the advantage that it 
is often possible to 
remove foreign bodies 
and small growths 
with less inconven- 
ience to the patient 
than the mere intro- 
duction of the instru- 
ments necessary for 
direct laryngoscopy. 
Direct tracheoscopy 
and bronchoscopy was 
first performed by 
Killian for removing 
foreign bodies. It is 
essentially the same as direct laryngoscopy except that the 
spatula is replaced by a tube, of a dimension corresponding 
to the patient's age. If done under local anesthesia, the 
trachea is cocainized as well as the larynx, after which the 
tube is passed between the cords into the trachea or bronchus. 
The mortality from the removal of foreign bodies in the lower 
Fig. 13.-Types of instruments for autoscopic 
operations. 30 
DISEASES OF THE NOSE, THROAT, AND EAR 
air passages has been reduced by this method to practically 
zero. The method is also of advantage for the diagnosis of 
obscure lesions of the lower respiratory tract. 
The advantages of direct laryngoscopy over the indirect 
are few. In cases where this epiglottis is low omega shaped, 
it is of decided advantage and also in cases where it is im- 
possible to obtain with a mirror a good view of a tumor at 
the anterior commissure. However, those who are skillful in 
the indirect method generally find the direct method much 
more distressing to the patient. 
RHINOSCOPY 
Rhinoscopy is the art of inspecting the nasal cavities, and 
may be divided into anterior and posterior rhinoscopy. 
Anterior rhinoscopy is the inspection of the anterior nares 
through the nostrils, and posterior rhinoscopy is the inspection 
of the vault of the pharynx and of the posterior nares from 
behind. 
The word nares should be applied solely to the anterior and 
posterior openings of the nasal cavities. The posterior open- 
ings are sometimes called the choanae. 
The postnasal space or nasopharynx is the cavity bounded 
in front by the posterior nares or choanae, above by the vault of 
the pharynx, behind by the pharyngeal wall, and below by the 
soft palate. 
Technic of Rhinoscopy.-The simplest method of inspection 
is to raise the tip of the nose with a finger, and draw the ala 
away from the septum by means of a bent probe. If now the 
patient's head is tilted somewhat backward, so that a strong 
light from a window or other source of illumination can enter 
the dilated nostril, the nasal cavity will be illuminated for a 
considerable distance, and the condition of its lining mucous 
membrane may be inspected. This was the method commonly 
employed previous to the invention of the forehead reflector. 
The opening of the nostril may, however, be effected more RHINOSCOPY 
31 
conveniently by means of a nasal speculum, of which there are 
a great variety. Of these one of the most popular is Killian's 
(Fig. 14). The instrument shown in Fig. 17, in most noses 
cannot be displaced by facial contortions of the patient. 
He has to use his hand in order to remove it from his nose. 
It is sometimes necessary, however, to snip away the vibrissae 
Fig. 14.-Killian's nasal speculum. 
Fig. 15.-O'Reilly's modification 
of the Killian speculum. 
before an operation in order to obtain a better view of the 
interior of the nose. This occupies but a moment and is a 
matter of little consequence. 
Two sizes of the instrument should be at hand, and the 
spring of the instrument should be adjusted by bending until it 
does not cause sufficient pressure to occasion the patient pain 
or annoyance. The instrument is introduced by directing its 
blades along the floor of the nose until they have nearly 
disappeared within the nasal chamber, when the instrument 
is turned upward until it grasps and separates the rim of the 
nostril as an eye speculum separates the eye lids. Allen's 32 
DISEASES OF THE NOSE, THROAT, AND EAR 
speculum Fig. 16, a later instrument acts on the same principal 
except that it widens the rim of the nostril vertically, instead 
of horizontally. 
When using a nasal speculum the instrument and patient's 
head should be moved in such a way that the different parts of 
Fig. 16.-Allen's nasal speculum. 
the interior of the nose are successively brought into view. 
Any secretions that obstruct the view should be removed by 
the atomizer or forceps, or wiped away with cotton wrapped on 
the end of an applicator; and any change in the bulk of the 
parts should be tested with the probe to determine its density. 
If an anterior hypertrophy obstructs the view of deeper 
Fig. 17.-Gleason's nasal speculum. 
structures, cocain solution should be applied to reduce its size 
and allow light to penetrate into the deeper parts of the interior 
of the nose. 
The first structure brought into view by anterior rhinoscopy 
is the vestibule, in which are a number of coarse hairs called 
vibrissae, while a fold of skin or mucous membrane lies between 
the vestibule and the inferior meatus. To the inner side is the 
septum and to the outer side the inferior turbinated bone, form- RHINOSCOPY 
33 
ing the roof of the inferior meatus. Above the inferior tur- 
binate is the middle meatus, roofed in above, except for the 
olfactory slit, by the middle turbinated body. Through the 
olfactory slit in some individuals a portion of the superior 
turbinate can be seen. 
Posterior rhinoscopy is, to all intents and purposes, the 
same process as laryngoscopy, except that a smaller mirror 
Lowerjaw. 
Fig. 18.-Course of light rays in posterior rhinoscopy. Sagittal section of head 
(Sahli). 
must generally be used, the reflecting face of which is turned 
upward instead of downward. The tongue, also, instead of 
being drawn forward with a napkin, is held down by a tongue- 
depressor. The relative position of patient and observer is 34 
DISEASES OF THE NOSE, THROAT, AND EAR 
the same as in laryngoscopy, except that the patient's head is 
not bent backward, but is either held perpendicularly or is 
inclined slightly forward. The rhinoscopic mirror, having 
been warmed, should be introduced into the pharyngeal cavity 
behind the velum palati, and so placed as to reflect the light 
upward and forward into the vault of the pharynx and into 
the posterior nares (Fig. 18). For this purpose mirror No. 
i, o, or oo is generally most useful, but a larger mirror can 
sometimes be used to advantage, and should always be em- 
ployed when the space between the palate and the pharynx 
is sufficient to permit it. Posterior rhinoscopy is much more 
difficult than laryngoscopy; but, except in the case of young 
children, patience and dexterity will almost always enable 
the observer to obtain a glimpse of the various parts of the 
posterior nares and vault of the pharynx without the use of 
accessory instruments. When disease of these structures 
exists, the examination is usually easy because of their inter- 
ference with the motion of the palate and the relatively 
wider space between the palate and posterior pharyngeal wall. 
Obstacles to Posterior Rhinoscopy.-In many cases the palate 
will rise forcibly as soon as the mirror has been introduced, 
thus completely shutting off the view of the parts above. 
This difficulty can often be overcome by requesting the patient 
to breathe through his nose, or emit a nasal sound like that of 
the French letter n, or say "One." Some operators ask their 
patients th snore or to "smell," that is, to draw the breath in- 
ward forcibly through the nose, as if endeavoring to perceive 
an odor. 
The observer should in all cases avoid touching the back of 
the tongue or pharyngeal wall, as otherwise gagging and retch- 
ing immediately occur, and further examination is rendered 
futile. 
Occasionally a palate retractor will be convenient. The 
wire hook of the instrument is passed behind the soft palate, 
and by pulling the stem gently outward the uvula and palate 
are pulled into the desired position and held forward by the RHINOSCOPY 
35 
pressure of wire loops, which are slid along the stem until they 
rest within the nose. 
Posterior Rhinoscopic Image.-Except in cases of cleft 
palate, it is impossible to obtain a complete posterior rhino- 
scopic image, such as is shown in Fig. 19, but by varying the 
position of the mirror the different parts may be brought into 
view and studied one after the other. Usually the first object 
seen is a triangular plate, with its apex downward-'the 
posterior margin of the nasal septum. Above it is a mass of 
glandular tissue-'the pharyngeal tonsil-while at each side 
Fig. 19.-Normal picture in posterior rhinoscopy. Diagrammatic, in that to 
obtain a complete picture, the position of mirror must be repeatedly changed: S.n, 
Septum; Ch., choana; P.m., soft palate; U., uvula; C.i., inferior turbinate body; 
C.m., middle turbinate body; C.S., superior turbinate body; occasionally visible. 
Beneath each turbinated is the corresponding fossa. O.R., roof of 'pharynx; T. 
opening of Eustachian tube; W., promontory of tube; R., Rosenmuller's, fossa 
(After Schnitzler.) 
lower down are the crater-like orifices of the Eustachian 
tube. In front of these, and projecting toward the septum, 
are the posterior aspects of the turbinated bones. The middle 
turbinated bone is usually first brought into view and rarely 
the dim outline of the superior turbinated bone may be dis- 
tinguished above and in front of it. Below the middle tur- 
binated bone the upper part of the inferior turbinated bone is 
readily perceived; but to see the lower part of this structure 
and the floor of the nose requires considerable practice in the 
use of the rhinoscopic mirror. A somewhat better view of 
Rosenmuller's fossae, the Eustachian tubes and the lateral and 36 
DISEASES OF THE NOSE, THROAT, AND EAR 
posterior walls of the nose can be obtained with the naso- 
pharyngoscope, Fig. 20, than with the mirror. In about 40 
per cent, of cases the ostea of the sphenoid sinuses are visible 
and frequently the ostea of ethmoid cells. 
Fig. 20.-Holmes nasopharyngoscope. 
OTOSCOPY 
Otoscopy is the art oE inspecting the visible parts of the ear. 
Ordinarily these parts are the auricle, the external auditory 
meatus, and the outer surface of the membrana tympani. 
Deeper portions of the ear are, however, visible when the 
overlying structures are destroyed by disease or are removed 
during an operation. Generally the dim outlines of the 
malleo-incudal joint can be seen through a normal or atro- 
phied drum-head, and occasionally the chorda tympani nerve 
and other structures. 
Otoscopic Reflector.-The reflector generally used to illu- 
minate the auditory canal and its fundus is the same as that 
employed in laryngoscopy and rhinoscopy (Fig. 2). 
The specula used in otoscopy are funnel-shaped instruments 
constructed of hard rubber or metal. Different forms are sold 
under the names of Wild's, Gruber's, Toynbee's, Boucheron's 
(Fig. • 21), Kramer's, and Politzer's specula. Gruber's specula 
are probably the best for ordinary purposes of otoscopy because 
a transverse section of their caliber at right angles to their 
long axes more nearly corresponds with a similar section of the 
external auditory meatus. However, Boucheron's specula 
(Fig. 21) are better adapted for use during an operation upon 
the middle ear, and with many otologists are favorite specula 
for purposes of inspection and treatment, because their wide OTOSCOPY 
37 
proximal rims afford greater space for the manipulation of 
instruments, and a firmer grasp to the thumb and fingers when 
the instrument is held within the auditory canal. Ear specula 
are usually sold in "nests" of three or four sizes fitting into a 
case. Those constructed of hard rubber are easily broken, 
and those manufactured of German silver and nickel plated 
are necessarily thicker than is desirable; 
a thin, solid silver speculum, aside from 
its expensiveness, being the preferable 
instrument. 
Relative Positions of Patient and Ob- 
server in Otoscopy.-The patient and 
observer may both stand in front of a 
window or the source of artificial light, 
or both may be seated upon chairs or 
piano stools so adjusted that the eye of 
the observer and the ear of the patient 
are in the same horizontal plane. The 
ear to be examined should be toward 
the observer, and the patient's face turned somewhat away 
from him, because the auditory canal generally extends in a 
direction inward, forward and somewhat downward. If the 
reflector is worn upon the forehead, the source of light should 
be above or to one side of the patient's head, and so placed 
as to throw the auricle into the shadow. 
To introduce the speculum the observer should first direct 
the light from the reflector upon the orifice of the meatus, and 
then straighten the auditory canal by gently drawing the 
auricle upward, backward, and slightly outward, at the same 
time endeavoring to see the drum-head without the use of a 
speculum. In many instances this can be accomplished satis- 
factorily, and the observer should not be in haste to introduce 
the speculum, as it may dislodge and push into the field of 
view a flake of wax or epithelium, which will greatly interfere 
with a distinct view of the membrana tympani. The auditory 
canal having been straightened in the manner described and the 
Fig. 21.-Bouciieron's 
specula. 38 
DISEASES OF THE NOSE, THROAT, AND EAR 
parts being fully illuminated, the speculum is held by its rim 
with the thumb and finger and gently introduced with a slight 
rotary motion into the auditory canal, so that its long axis 
exactly corresponds with that of the canal. The greatest 
care should be exercised in introducing the speculum not to 
use it as a lever in such a manner as to bring its sharp edge in 
contact with the wall of the canal and cause pain; obstruction 
to the progress of the speculum being overcome by moving 
Fig. 22.-Otoscopy with the reflector and ear speculum. The arrows represent 
course of light. 
the whole instrument in a direction opposite to that in which 
the obstruction is felt until the membrana is brought into 
view, when the speculum may, if necessary, be retained in 
position by grasping it and the auricle in the manner shown in 
Fig. 22. 
Obstacles to Otoscopy.-'The chief obstacle to the beginner 
is caused by so misdirecting the long axis of the ear speculum 
that it does not correspond with the long axis of the auditory 
canal, so that a portion of the auditory canal is brought into 
view or only a portion of the membrana is seen. Under such OTOSCOPY 
39 
circumstances the end of the speculum within the ear should 
be moved about until a satisfactory view of the drum-head has 
been obtained. Generally it will be found that the cause of 
failure has been that the axis of the speculum has been directed 
too far backward and upward. 
Another cause of difficulty is excessive sensibility of the 
auditory canal or swelling of its walls, the result of diffuse 
inflammation. Sometimes a satisfactory view of its deeper 
parts can be obtained under such circumstances by gentle and 
persistent effort, a small speculum being used to dilate the 
auditory canal. 
Siegle's pneumatic speculum (Fig. 23) is an air-tight 
chamber to which specula of various sizes can be attached by 
Fig. 23.-Siegle's pneumatic specula. 
means of a screw-joint. The side of the air-tight chamber 
carries a perforated knob, over which is slipped a rubber tube 
terminating in a rubber bulb. The proximal end of the 
instrument is glazed either with plane glass or with a convex 
lens set at an angle of 45 degrees with the long axis of the 
instrument. When the instrument is in position within the 
auditory canal, the surgeon is enabled to judge of the mobility 
of the whole or of a part of the menbrana tympani by observing 
its movements during condensation and rarefaction of the air 
in the auditory canal brought about by the action of the 
surgeon's hand upon the rubber bulb. Before using the 
instrument it is well to slip a short piece of wet rubber tubing 40 
DISEASES OF THE NOSE, THROAT, AND EAR 
over the end of the speculum to ensure its fitting into the 
auditory canal as nearly air tight as possible. When the 
Eustachian tube is impervious to air the pneumatic speculum 
furnishes the only means of determining the 
mobility of a part or the whole of the mem- 
brana tympani. 
Instead of using a rubber bulb to produce 
rarefaction and condensation of the air in the 
auditory canal, a piston-syringe may be em- 
ployed or the masseur of Delstanche. It should 
be borne in mind that it is entirely possible 
to rupture some membrana tympani by too 
vigorous use of aural massage. 
Machines whose motive power is compressed 
air, electricity, or a water motor are sometimes 
employed. They yield more rapid rarefaction 
and condensation of the air of the auditory 
canal than the hand bulb and occasionally may 
prove more useful. 
ACCESSORY INSTRUMENTS 
The laryngeal sound consists of a piece of 
silver wire, rounded at one end and inserted in 
a universal handle (Fig. i). It should be 
sufficiently long to reach the anterior angle of 
the glottis without bringing the fingers holding 
the handle into the patient's mouth, and thus 
obstructing the view, and sufficiently firm to 
resist a considerable amount of pressure without 
bending. 
The cotton applicator consists of a piece of aluminum or, 
better, copper or iron wire of about the same size and length as 
the laryngeal probe, with roughened ends; so that a piece of 
absorbent cotton can be tightly wrapped around one end with- 
out fear of its becoming loose. This tuft of absorbent cotton 
will carry enough solution for any application within the 
Fig. 24.-Allen's 
nasal applicator. OTOSCOPY 
41 
laryngeal or postnasal cavities. For applications to the nasal 
cavities smaller instruments are desirable, and Aden's applicator 
(Fig. 24) is better adapted for this purpose. Allen's probe 
(Fig. 25) consists of a conic piece of soft, malleable steel wire 
fitted into an aluminum handle. It is extremely light and 
delicate and may be used either for the nose or for the ear. 
When used as a probe, a few fibers of absorbent cotton are 
wrapped about its tip in order to cover its sharp extremity. 
Fig. 25.-Allen's probe. 
The tip of the instrument can be bent into the form of a hook 
to bring forward nasal polypi or ascertain their place of origin, 
the thickness of their pedicle, etc., or to probe the attic of the 
tympanum. The presence of exposed bone is readily detected 
by the spicules catching in the cotton fibers and imparting a 
characteristic resistance. It may be used also for the applica- 
tion of chromic acid and other caustics. 
The Atomizer.-In most forms of throat and nasal disease, 
sprays are extremely useful, not only to cleanse the parts and 
remove accumulated secretions, but also to spread medicated 
solutions over a large surface. For use in the laryngologist's 
office and as an atomizer to fit into the rhinologic instrument 
bag for use in treating patients at their homes, the atomizer 
(Fig. 26) is convenient, as it throws a fine spray either upward, 
downward, or straight forward. However, for the patient's 
use at home other types of atomizers are preferable and the 
physician should specify by prescription the atomizer that will 
yield the coarse or fine spray required for the judicious treat- 
ment of each case; also he should select for his patient an 
atomizer that is not readily broken and easily kept in order; 
or he will have the mortification of discovering that home 
treatment has been the merest pretence because of the in- 
efficiency of the atomizer. As a general rule, atomizers for 
patient's use should have a bottle made from thick, strong glass 42 
DISEASES OF THE NOSE, THROAT, AND EAR 
so shaped that it cannot readily be laid on its side. To prevent 
clogging of long fine tubes, the nozzle should be as short as 
possible, readily cleansed, and made of metal rather than 
brittle, hard rubber. The hand bulb should be large and made 
of good quality rubber. 
The air-current necessary to produce the spray from atomi- 
zers may be supplied either by a rubber hand bulb or an air- 
compressing apparatus. 
Fig. 26.-DeVilbiss atomizer. 
In spraying the nose, pharynx, or larynx with a hand 
atomizer, the bottle of the instrument should be grasped be- 
tween the thumb and first finger of the right hand with the 
rubber bulb in the hollow of the hand. The rubber bulb can 
then be pressed by the three remaining fingers with sufficient 
force and rapidity to give a continuous spray. This method of 
employing the atomizer leaves the left hand free to elevate 
the tip of the nose or manipulate a tongue-depressor. In 
spraying the nasal cavities the tip of the nose should be ele- 
vated with the finger and thumb of the left hand, and the end 
of the atomizer should rest against either the thumb or finger 
of the operator, and not the rim of the patient's nose. The OTOSCOPY 
43 
use of this method will prevent the necessity of sterilizing 
the end of the atomizer tubes each time they are used upon a 
patient. 
Because secretions tend to gravitate toward the floor of the 
nose, especial attention should be directed toward the inferior 
meatus in washing out the interior of the nose. The head of 
the patient is tipped slightly backward and the spray from the 
atomizer directed somewhat downward, that is, in a direction 
toward the lobe of the ear. Under such circumstances the 
nasal secretions that have accumulated on the floor of the nose 
are readily washed into the pharynx and are hawked down and 
expectorated. The stream of the atomizer can then be di- 
rected to any portion of the upper part of the nose which, on 
inspection, appears covered by secretions. 
Fig. 27.-Soft-rubber eye, ear, and ulcer syringe. 
However, masses of mucus are more readily removed from 
the pharynx by means of solid streams of fluid than by the 
coarsest spray from an atomizer. For this purpose a piston 
syringe holding about two ounces is generally employed. The 
patient opens his mouth and bends forward over a bowl. 
The conical nozzle of the syringe is introduced into one nostril 
and the fluid injected into the nasopharynx, around the sep- 
tum and out of the other nostril. 
For the patient's use at home a syringe, made of one piece 
of soft rubber (Fig. 27), answers a useful purpose for syringing 
the nose or ear. The nozzle of the syringe is made of soft 
rubber, and hence can be inserted in the auditory canal or 
nose with little danger or pain. 
When an atomizer or syringe is prescribed for a patient's use 44 
DISEASES OF THE NOSE, THROAT, AND EAR 
at home, the object that the surgeon wishes to accomplish 
should be carefully explained to the patient and he should be 
instructed in the use of the instrument and how to keep it 
in good order. If this is not done, the patient's use of the 
Fig. 28.-Syringes with interchangeable nozzles: a. Syringe of J-dram capac- 
ity for cleansing and applying solutions to the attic by means of Blake's cannulas 
(2, 3, and 4). Also for making applications to the Eustachian tube by means of 
nozzle 7 and an ordinary Eustachian catheter. When fitted with the bayonet tip 
6 and a hypodermic needle it may be used for the production of local anesthesia 
of the ear or tonsil by injections of solutions of cocain and adrenalin, b. Syringe, 
holding 21 drams, to be used with Blake's cannula for cleansing middle ear or with 
postnasal nozzle (1) for cleansing the posterior nares. It is convenient where the 
operator prefers a piston- to a bulb-syringe. C. Dentists' tooth syringe, capacity 
1 ounce. This is probably the best syringe for removing impacted cerumen and for 
coarse syringing of the auditory canal. When fitted with a moderately large long 
silver nozzle (4) any of the accessory cavities of the nose that can be probed can be 
washed out through their anatomic orifices. For this purpose the silver nozzle should 
be made of pure silver, so that it can be bent readily to the requisite curve, and the 
operator should be provided with four or five such nozzles about 5 inches long and of 
the diameter of Nos. 3, 5, 6, and 8 of the French catheter scale. Instead of these sil- 
ver nozzles a Eustachian catheter may be employed, or nozzle 5, fitting on to nozzle 
7, which screws on to the syringe when nozzle 8 is unscrewed. It is well for the opera- 
tor to be provided not only with several sizes of the straight cannula (4), but also 
with several sizes of Blake's cannulas (2 and 3), to be used with syringe b or c. 
atomizer, for example, at home will amount to practically 
nothing. If an atomizer and a detergent spray, such as 
Dobell's solution, is prescribed with the main object of cleans- 
ing the nose, the patient should throw his head back and point OTOSCOPY 
45 
the beak of the atomizer downward (not upward), so that the 
main force of the spray will be directed along the floor of the 
nose into the nasopharynx. It should be demonstrated to the 
patient so that he thoroughly understands that if while he is 
using the atomizer he breathes gently through his nose the 
spray will pass downward behind the relaxed palate into his 
mouth and can be expectorated. That, on the contrary, if 
he holds his breath, the fluid will be retained in the naso- 
pharynx upon the contracted palate and will run out of his 
nose as soon as his head is lowered, with the result that the 
nasopharynx is not as efficiently cleaned as would otherwise 
be the case. 
AIR INLET 
AIR OUTLET 
■WATER ' 
REGULATOR 
WATER 
INLET 
WATER 
OUTLET 
Fig. 29.-The Little Wonder pump. 
The interior of the nasal cavities can be cleansed as thoroughly 
by means of a hand atomizer as by an atomizer whose spray 
results from the use of the most expensive of air-compressing 
apparatus; but the latter are convenient, and where a large 
number of patients are to be treated save the surgeon's hand 
the fatigue that would result from long-continued use of the 
hand atomizer. 
There are a large variety of air compressors for sale in the 
instrument stores, and it is difficult to state which one is the 
most practical and useful. 
However, a satisfactory apparatus for furnishing compressed 
air is a water air-pump, such as is used by saloon-keepers for 46 
DISEASES OF THE NOSE, THROAT, AND EAR 
forcing beer and ale from the barrels in the cellar into the 
faucets in the bar-room. The water-pump is attached to a 
water-pipe in such a manner that water may run through it 
and flow into the waste-pipe or sewer. It is automatic and 
continues in operation until the air-pressure in the receiver 
equals that of the water in the supply pipe. Some pumps 
furnish an air-pressure double that of the water in the supply 
pipes, but are proportionately slow in their action. 
As an air receiver, when one of these pumps is used, an orna- 
mented copper cylinder may be placed in the surgeon's office; 
but nothing answers the purpose 
better than an ordinary galvan- 
ized wrought-iron cylinder or 
"boiler," such as is found in 
most American kitchens as a 
reservoir for hot water as a part 
of the so-called "circulating 
boiler" apparatus for supplying 
hot water for domestic purposes. 
The water air-pump may be 
attached to the water-pipes under- 
neath the sink in the physician's 
office, and the air receiver placed down cellar, or both 
pump and air receiver may be placed in the cellar should 
the plumbing permit of such an arrangement. Whatever 
the position of the air receiver, a pipe or tube should lead 
from it to a stop-cock upon the wall, immediately at the 
side of or beneath the adjustable gas bracket. Attached to 
the stop-cock there should be a rubber tube three or four feet 
in length, terminating in an automatic cut-off (Fig. 30). 
When compressed air is used for other purposes than supply- 
ing an air-current for atomizers, the pipe from the air re- 
ceiver should terminate in a bracket of stop-cocks from which 
rubber tubes lead to the nebulizer, the aural masseur, etc. 
The automatic cut-off is an instrument by which compressed 
air is conveniently supplied to an atomizer. The end of the 
Fig. 30.-Boekel's automatic cut-off. OTOSCOPY 
47 
instrument (a) is attached to the rubber tubing of the com- 
pressed-air apparatus, and the nozzle (b) of the instrument 
inserted into the hole in the nipple of the atomizer, from which 
the hand bulb previously has been removed, and by pressing 
down the lever (c) a current of compressed air is forced through 
the atomizer in the same manner as if a rubber hand bulb were 
used. The current of air ceases as soon as the lever is released. 
In using the automatic cut-off, the atomizer is held in the 
right hand and the lever of the automatic cut-off pressed down- 
ward by the thumb. 
Sinks.-A most convenient adjunct to a laryngologist's 
office is a sink. It should be supplied with hot and cold water. 
There have been a number of sinks manufactured for the use 
of physicians and hospitals. The best are constructed of 
white porcelain, and the flow from the spigot is controlled by 
foot levers. This arrangement prevents the necessity of 
turning off the water with the hands after they are washed. 
A swinging spittoon may be attached to the sink or wall in 
such a manner that it can be swung out of sight when not in 
use. A water spittoon such as is employed by dentists is not 
more convenient, but certainly looks better than even the most 
ornamental receptacle for expectorations, and although bulky 
adds somewhat to the appearance of care and neatness about 
the office. 
Pynchon's cabinet (Fig. 31), for instruments, linen, etc., is a 
convenient office accessory. It is provided with 18 drawers 
of different sizes (each partitioned to accommodate regular 
and special instruments) and compartments for clean and 
soiled linen. 
The nebulizer is useful because vapors will penetrate 
where fluids and the spray from an atomizer will not. These 
instruments, therefore, may be employed in the treatment of 
diseases of the middle ear and the accessory cavities of the nose 
and the smaller bronchial tubes. 
Nebulizers are manufactured in many styles, from the single 
nebulizer, for patients' use at home, to more elaborate instru- 48 
DISEASES OF THE NOSE, THROAT, AND EAR 
ments for office use, which consists of a number of nebulizers 
connected together in such a manner that one or more can be 
utilized at a time. 
Inhalers are employed for the inhalation of the vapors of a 
drug suspended in hot water. The simplest form of this in- 
strument is the bottle-inhaler. It consists of a wide-mouthed 
bottle, through the cork of which two glass tubes are thrust 
Fig. 31.-Pynchon's cabinet. 
One reaches nearly to the bottom of the bottle; the other passes 
simply through the cork, and is bent at the upper extremity. 
The bottle is filled one-third full of a solution, and the patient, 
by inhaling through the bent glass tube, causes air to bubble 
through the fluid and become impregnated with the volatile 
substances in the fluid before being drawn into the lungs. 
Compound tincture of benzoin (i teaspoonful to the inhaling 
bottle one-third full of hot water) is a domestic remedy 
of considerable reputation and some value in inflammation of 
the upper respiratory tract. OTOSCOPY 
49 
The Powder-blower.-Remedies are often applied to the 
interior of the nose and larynx in the form of an impalpable 
powder. For this purpose the instruments shown in Fig. 3 2 and 
33 will be found useful. The reservoir insufflators of David- 
son and similar instruments are very convenient and obviate 
the necessity of loading the powder-blower each time that it is 
used. However, they have the disadvantage of sometimes be- 
Fig. 32.-Davidson's reservoir powder-blower. The instrument is also made with 
a curved tip. 
coming temporarily clogged, and at the next attempt to use 
them discharge a much larger quantity of powder than is 
required. A very large amount of powder might be un- 
expectedly thrown into a patient's larynx from this instrument, 
causing momentarily great distress and severe laryngeal spasm, 
which, however, quickly subsides if the patient is given a glass 
of water to drink and told to hold his breath for a moment. 
Fig. 33.-Powder-blower. 
Such accidents can, however, be avoided by not using a reser- 
voir powder-blower for laryngeal work. 
The Hot-air Apparatus.-Hot air is occasionally beneficial 
in the treatment of diseases of the upper respiratory tract and 
middle ear. It allays the swelling and irritation and decreases 
blood-pressure. It is useful in acute inflammatory diseases of 
the accessory sinuses and middle ear, although the relief is often 50 
DISEASES OF THE NOSE, THROAT, AND EAR 
transient. An effective method of application of an apparatus 
used by dentists for drying tooth cavities or more elaborate 
apparatus, in which air is heated by an electric current, are 
occasionally useful, as they permit a continuous current of hot 
air tobe thrown on inflamed tissue in any portion of the mouth, 
nose, or auditory canal. Sometimes it affords at least tem- 
porary relief from the pain and tinnitus of acute middle-ear 
catarrh. 
STERILIZATION OF INSTRUMENTS 
All instruments used in operations upon the nose, throat, or 
ear should be carefully sterilized by boiling in a 5 per cent, 
bicarbonate of sodium solution. After an operation the instru- 
ments are placed in a tray and soaked for five minutes in cold 
water to dissolve the dried blood adhering to them. They are 
then scrubbed with hot water and soap. If they need polish- 
ing, sapolio or a fine sand-soap should be used. They are then 
boiled for five minutes in a 5 per cent, solution of sodium bi- 
carbonate and rapidly dried while still hot in order to prevent 
rusting. 
For the rapid drying of larger instruments, wiping with a 
sterile towel while the instruments are still hot answers every 
purpose. For smaller instruments and those with delicate 
joints-'Cannula, snares, etc.--it is better after boiling to wipe 
them with a towel and then immerse them in 95 per cent, al- 
cohol for a minute or two. They should then be carefully 
wiped with a towel, so that every particle of moisture is removed 
by the wiping and the evaporation of the alcohol. 
Instruments for examination and treatment, such as tongue- 
depressors, specula, probes, applicators, etc., used so fre- 
quently during the office hours or in dispensary work that, un- 
less the surgeon possesses a large stock of these articles that can 
be boiled at the beginning of the hour in sufficient numbers to 
furnish each patient a special instrument without exhausting 
the supply, are best sterilized by burning with wood alco- STERILIZATION OF INSTRUMENTS 
51 
hoi. This method has the advantage that it takes but a 
moment and can be done in the presence of the patient, who is 
thus assured beyond peradventure that only sterile instruments 
have been used in the diagnosis and treatment of his case. 
The operator should be provided with two white enameled 
steel trays. In the first of these should be placed instruments 
for the examination and treatment of a patient. Over the 
instruments should be distributed a teaspoonful or two of wood 
alcohol, which is then lighted with a match. The flame lasts 
Fig. 34.-Sterilizing instruments by flaming with alcohol. 
but for a moment, but the instruments are heated far above 
the temperature of boiling water and are, of course; rendered 
absolutely sterile. 
Small instruments treated in this manner cool almost as 
rapidly as they are heated. Larger instruments, like tongue- 
depressors, retain their heat for an inconvenient time, and it 
may be necessary to cool them by dipping them in water, 
spraying them with an atomizer containing an alkaline wash, 
or pouring a little grain alcohol over them. As the instru- 
ments are used they are placed in the second tray, and are 
sterilized in the same manner before being again employed. 
The disadvantages of the method are that it cannot be used 
for small aluminum instruments or those soldered with soft 
solder and that it soon tarnishes the instruments. 
Syringes, soft-rubber tubes, hard-rubber nozzles, and glass 
instruments are best sterilized by soaking them for five or ten 52 
DISEASES OF THE NOSE, THROAT, AND EAR 
minutes in a 5 per cent, aqueous solution of formalin (40- 
volume aqueous solution of formaldehyd gas). The barrel of 
the syringe should be filled with the solution and the entire 
syringe immersed. If the syringe is sterilized in this manner 
immediately before being required it should be carefully rinsed 
in sterile water before being used to prevent the irritating 
effects of formalin, for it should be borne in mind that even 
very dilute solutions of formaldehyd gas are very irritating 
to the mucous membranes of the nose, throat, or middle ear. 
Atomizers should be used in the manner previously described, 
so that the tips never come into actual contact with the patient 
on whom they are used. When made with interchangeable tips 
the extra tips may, of course, be kept in an antiseptic solution, 
that of formaldehyd being perhaps the most reliable. 
Although boiling in sodium bicarbonate solution and the 
other methods of disinfection described above are reliable, it is 
advisable for psychologic reasons at least to have a special set 
of instruments for syphilitics and another special set for those 
with tuberculosis. 
Preparation of Operator.-Before operating on the nose or 
throat the surgeon should prepare himself, as for any other op- 
eration, by scrubbing his hands and arms with green soap, 
rinsing in alcohol, and immersing his hands in bichlorid solu- 
tion, or prepare himself by any other method he has found 
satisfactory. 
Sterilization of Nose.-Unfortunately we do not possess a 
reliable antiseptic for sterilizing the nose or nasopharynx. 
Any solution of carbolic acid (probably the most sedative to 
mucous membranes of the common antiseptics) strong enough 
to kill bacteria would excite a local inflammation that would 
interfere greatly with the rapid healing of the operative wound. 
The same remark applies in still greater degree to other anti- 
septics. However, before an operation the mucous membrane 
should be freed, especially in atrophic cases, from adherent 
mucus by thorough syringing with an alkaline or normal salt 
solution. EXAMINATION OF PATIENTS 
53 
EXAMINATION OF PATIENTS 
First listen passively to the patient's story of his illness; 
asking judicious but not leading questions, so as to elicit the 
facts of the case, such as the influence of his employment upon 
his health, or any inherited tendency that he may have toward 
disease of the nose, throat, or ears, cause of the disease, the 
length of time that it has continued, and the symptoms other 
than disease of the nose, throat, or ears that may be present. 
In questioning the patient the physician should bear in mind 
the effects of "suggestions" upon patients of nervous tempera- 
ment as regards tinnitus. Many neurotics with disease of 
the middle ear will experience for the first time subjective 
noises in their ears upon being asked leading questions in 
regard to tinnitus, and afterward complain of the presence of 
this symptom, which previous to that time had not attracted 
their attention. 
Careful notes of the patient's history should be made in the 
case-book, and especial prominence be given to the symptoms 
of the disease from which he seeks relief. 
Examine the tongue, as to whether coated or clean, pale or 
flabby, or of a natural color and resistance; look for ulcerations 
or mucous patches upon the tongue or the inside of the mouth; 
and also notice the shape and condition of the teeth. Having 
depressed the tongue, observe the palate and uvula, the ante- 
rior pillars and tonsils, the posterior pillars and posterior 
pharyngeal wall. Notice any change from the natural color, 
shape, or mobility of the parts, the presence or absence of 
foreign bodies or hardened secretions. 
The nose should next be examined by anterior and posterior 
rhinoscopy and, finally, the laryngeal mirror should be intro- 
duced. In these examinations notice the condition of the parts 
in the following order, viz: (i) Color and condition of the 
mucous membrane; (2) size and shape of the part examined; 
(3) loss of substance by ulcers, etc.; (4) presence of foreign 
bodies, neoplasms, or accumulated secretions; (5) mobility of 54 
DISEASES OE THE NOSE; THROAT, AND EAR 
the parts and functional disturbances. During the examina- 
tion touch any suspicious swelling with the probe, so as to 
ascertain its mobility, and whether it is composed of bone, 
cartilage, or softer structures. Wipe away secretions and 
trace a flow of pus to its source in an ethmoid cell or one of the 
sinuses. As the examination progresses, the result should be 
jotted down in the case-book, and any deviation from the nor- 
mal in size or shape, or the presence of neoplasms or foreign 
bodies, sketched upon the margin of the page. 
In cases complaining of aural disease the hearing should next 
carefully be tested by the voice, the watch, and the tuning- 
fork. In making a record of the results of the tests for hearing 
it is convenient, to facilitate easy reference at a subsequent 
period, to devote one or more lines in the note-book to each 
ear, using abbreviations to economize space; for example, as 
follows: 
a. p. 
Dextra)S H.V. = whisper, 3 ft. W. = T.-F. C2, vertex best in A.S.M. =gg. M.A. = Jg. 
or (Hear- (Voice). (Watch). (Tuning-fork). (Mastoid). (Meatus 
R. E. ing). Auditorius). 
(Right Ear). 
A. S. 
(Auditus H_ v. = L. C. 6 ft. W.=y. T.-F. c2, M.=Jg. M. A. gg. 
or (Hearing). (Voice). (Loud Con- (Watch). (Tuning- (Mastoid). (Meatus 
L. E. versation). fork). Auditorius). 
(Left Ear). 
In the above record of the tests of the hearing power it will 
be noticed that bone-conduction, as tested by a C2 fork, is 
somewhat impaired for the right ear and apparently increased 
for the left, indicating that there exists in the right ear not only 
disease of the conducting apparatus, but also impairment of the 
receptive apparatus. For most cases one tuning-fork, pref- 
erably a large C2 fork, is all that is required; but the aurist 
should be provided with at least five forks-C, C, c2, C3, C4-• 
which should all be used in testing the hearing in certain cases. 
After the hearing has been tested, the aurist should inspect 
the parts of the ears made visible by means of otoscopy, care- 
fully noting the condition of the external auditory canal and EXAMINATION OF PATIENTS 
55 
drum-head; and if the membrane be wholly or partly destroyed 
as the result of disease or accident, noting the condition of the 
mucous membrane of the tympanum and other structures 
that may be visible. In most instances it is advisable to make 
a diagram or rude drawing of the condition of the tympanum, 
and in making notes as to the result of otoscopy to give to each 
ear one or more separate lines in the note-book in the same 
manner as when recording the results of the tests for hearing. 
The patency of the Eustachian tubes should next be tested 
by means of the Politzer method and the aural stethoscope 
or, if necessary, the Eustachian catheter should be used. 
In suitable cases the patient's equilibrium should now be 
examined and the functional reaction of the labyrinths to 
turning, caloric and galvanic tests. THE NOSE 
ANATOMY OF THE NOSE 
The external nose is an arch-shaped framework, bony 
above and cartilaginous below, covered by integument ex- 
ternally and lined within by mucous membrane. It is 
separated into two portions, practically two noses, by the nasal 
septum. 
The bony arch or bridge of the nose (Fig. 36) is composed of 
the nasal processes of the superior maxillary and the nasal bones. 
Fig. 35. 
Fig. 36. 
Figs. 35 and 36.-Bones and cartilages of the external nose. Fig. 35, Side view; 
a, Cartilage of septum; b, upper and (c) lower lateral cartilages; d, sesamoid carti- 
lages; e, cellular tissue; f, nasal bone; g, nasal process of superior maxillary bone. 
Fig. 36, View from below: a, Lower lateral cartilage; b, sesamoid cartilages; c, 
cellular tissue. 
The cartilaginous arch consists of the upper and lower lateral 
cartilages and the sesamoid cartilage, usually three on each side 
of the nose. The cartilages are bound together by strong con- 
nective tissue, and by the action of muscles upon them the 
opening into the nose can be dilated or narrowed. 
The aloe or wings of the nose contain no cartilage, but con- 
sist of a mass of cellular issue and fat. 
56 ANATOMY OF THE NOSE 
57 
The nasal septum consists of bone and cartilage covered by 
mucous membrane. Its cartilaginous portion is the so-called 
triangular cartilage, because it fits into a triangular space be- 
tween the perpendicular plate of the ethmoid and the. vomer 
(Fig. 37). However, the cartilage of the septum is quadri- 
lateral in shape. The perpendicular plate of the ethmoid and 
the vomer, the nasal crests of the superior maxillary, palate, 
Pig. 37.-Osseous and cartilaginous septum of the nose: 1, Triangular cartilage 
of the septum; 2, median plate of the lower lateral cartilage, sometimes called 
columnar cartilage and cartilage of the aperture; 3, cartilage of Jacobson; 4, sup- 
ravomerine cartilage sometimes present; 5, vomer; 6, perpendicular plate of 
ethmoid; 7, ethmovomerine suture; 8, sphenoidal sinus; 9, nasal bone; 10, palate 
bone (Arnold). 
and nasal bones, and the nasal spines of the frontal, enter into 
the formation of the septum. It is developed from a bilobed 
mass, the mesial nasal process; and when its lower portion 
ossifies to form the vomer this bilateral character is preserved 
to the extent that a deep groove is formed along the upper bor- 
der of the vomer between the plates. In this groove there is a 
strip of cartilage which frequently persists during the entire 
adult life and is called the vomerine or supravomerine cartilage. 58 
DISEASES OF THE NOSE, THROAT, AND EAR 
The groove, sometimes distorted into an imperfect tube or into 
other shapes, is called the vomerine crest. Ridges of bone and 
cartilage extending obliquely upward along this crest are the 
result of the distortion or over-growth of the vomerine crest 
or cartilage. The nasal septum is covered by mucous mem- 
brane, beneath which, near the nasal floor, is ill-developed erec- 
tile tissue. Specialized nerve-filaments of the sense of smell 
occupy a small area in the mucous membrane of the upper 
portion. 
The skin covering the external nose, especially at the tip, is 
rich in sebaceous glands, when diseased the contents form 
comedones. At the tip of the nose beneath the skin is a 
cushion of fat which when hypertrophied aids in the produc- 
tion of "pug nose." The skin extends into the nose nearly to 
the anterior extremities of the inferior turbinated bones, and 
at the entrance into the nares it is usually covered with short 
thick hairs, the vibrissae. 
The muscles of the external nose are the levator alae nasi, 
depressor alae nasi, levator alae nasi props, and the musculis 
apicis. These muscles by their action dilate and make narrow 
the anterior nares during respiration. 
The arteries of the external nose are the lateralis nasi, a 
branch of the facial, nasal branches of the ophthalmic and in- 
fra-orbital, and the septal artery from the superior coronary 
artery. 
The nerves of the external nose are branches from the facial, 
infra-orbital, infratrochlear, and- the nasal branch of the 
ophthalmic. 
The nasal cavities are the commencement of the upper 
respiratory tract. They extend from the anterior nares to the 
posterior wall of the pharynx, and consist of two chambers, 
divided from each other by the septum. The floor is separated 
from the roof of the mouth by comparatively thin structures 
and hence is parallel to it. The roof is formed by the nasal 
bones and nasal spines of the frontal bone, the horizontal plate 
of the ethmoid, and the anterior wall of the sphenoidal cells. ANATOMY OF THE NOSE 
59 
The lateral walls are formed by portions of the frontal, lacrimal, 
ethmoid, sphenoid, and superior maxillary bones. 
Upon the lateral walls of the nasal chambers are the superior, 
middle, and inferior turbinated bones (Fig. 38). The inferior 
turbinated is a separate bone, but the superior and middle turbin- 
ated are portions of the ethmoid: At birth this portion of 
the ethmoid is often divided into three or even four turbinated 
bones by grooves that disappear later in life. The agger nasi 
is a slight elevation at the junction of the anterior end of the 
middle turbinate with the superior maxillary and is the rudi- 
Fig. 38.-Nerves of nose and sphenopalatine ganglion, from inner side: 1, 
Network of external branches of olfactory nerve; 2, nasal nerve, giving its external 
branch to outer wall of nose; the septal branch is cut short; 3, sphenopalatine 
ganglion; 4, ramification of large palatine nerve; 5, small, and 6; external palatine 
nerve; 7, inferior nasal branch'; 8, superior nasal branch; 9, nasopalatine nerve 
cut short; 10, Vidian nerve; 11, great superficial petrosal nerve; 12,great deep 
petrosal nerve; 13, the sympathetic nerves ascending on internal carotid artery. 
ment of the nasal turbinate of the lower animals. Beneath 
the turbinated bodies are their respective meati: the superior, 
middle, and inferior meati. The inferior meatus extends back- 
ward and downward, and at the junction of its anterior third 
with the posterior two-thirds receives from beneath the inferior 
turbinated body the secretions of the eye through the nasal 
duct (Fig. 69). Its position upon the floor of the nose renders 
the inferior meatus the important drainage fossa of the nose, 
and along it the spray of an atomizer or the stream of a syringe 
should be directed if it is desired to wash secretions into the 60 
DISEASES OF THE NOSE, THROAT, AND EAR 
pharynx. Above the inferior turbinated body is the middle 
meatus, and because of the numerous ostea opening into it is 
an important fossa in nasal diseases. The superior turbinated 
body is a portion of the ethmoid separated from the middle 
turbinate by a groove, the superior meatus, closed in front, but 
opening posteriorly into the spheno-ethmoidal recess. 
The nasal cavities are divided into vestibular, respiratory, 
and olfactory regions, and the accessory cavities. 
The vestibular region is all that portion of the nose anterior 
to the turbinated bodies. The respiratory region is the inferior 
nasal chambers posterior to the vestibular region, bounded 
above by the inferior edge of the middle turbinated body. 
Through this region of the nose the respiratory air-currents 
arch on their way to and from the pharynx. The olfactory 
region lies above the inferior edge of the middle turbinated body 
and the space between the middle turbinate and the sep- 
tum is the olfactory slit. 
At birth the hard palate is on a level with the junction of the 
sphenoid and basilar process; at three years it is opposite the 
middle of the basilar process, and at six years, as in the adult, 
opposite the anterior edge of the foramen magnum. 
The mucous or Schneiderian membrane of the nose is a 
continuation of the external tegument, and is continuous with 
that of the pharynx, the Eustachian tubes, and the accessory 
sinuses. It is sometimes called the pituitary (meaning phlegm- 
producing) membrane or the Schneiderian, after Schneider, an 
anatomist, who first proved that the nasal secretions were pro- 
duced by it and not by the brain. In many portions of the nose 
it is thin and inseparable as a membrane from the periosteum 
or perichondrium beneath, but over the inferior turbinate and 
the adjacent portion of the septum, as well as the inferior edge 
of the middle turbinate, it is thick and vascular. In these 
regions is the so-called erectile tissue, somewhat similar to that 
of the sexual organs, consisting of cavernous blood-vessels im- 
bedded in cellular tissue. When this tissue erects itself, that 
is, when its vessels fill with blood, the bulk of the nasal mem- ANATOMY OF THE NOSE 
61 
brane enormously increases and may cause almost complete 
stenosis of the nasal chambers. 
The vestibular mucous membrane is covered by stratified 
pavement epithelium and contains sweat and sebaceous glands, 
and anteriorly vibrissae or short hairs that serve to prevent the 
entrance into the nostrils of coarse particles of dust and insects. 
The mucous membrane of the respiratory region is covered by 
pseudostratified ciliated epithelium and contains goblet-cells. 
Mucous, serous, and lymphatic glands are numerous. The 
mucous membrane of the olfactory region contains no erectile 
tissue and to it are distributed the specialized nerve-endings 
of the olfactory nerve. It is covered by a single layer of cy- 
lindric epithelium and contrasts by its yellow color with the 
bright pink of the parts below. In this thin pale membrane 
are the olfactory and sustentacular cells capable of receiving 
sensory impulses recognized as odors. 
The arteries of the nasal fossae are the anterior and posterior 
ethmoidal from the ophthalmic, the sphenopalatine branch of 
the internal maxillary, and the alveolar branch of the internal 
maxillary to the antrum. 
The nerves of the nasal fossae (Fig. 38) are the nasal branch 
of the ophthalmic to the septum and outer wall, anterior branch 
of the superior maxillary to the inferior turbinated body, and 
the floor of the nose. The sphenopalatine ganglion gives off the 
Vidian nerve to the septum and superior turbinated body and 
the superior nasal branch to the same regions, the nasopalatine 
to the middle of the septum, and the anterior palatine to the 
middle and lower turbinates. 
The olfactory or first cranial nerves from the olfactory bulb 
enter the nose through twelve or more openings in each side of 
the cribriform plate. They are distributed to the specialized 
nerve-endings in the mucous membrane of the superior turbi- 
nate and a corresponding small region of the septum. 
The lymphatics of the nose are numerous. The more an- 
terior terminate in the submaxillary glands, the posterior com- 
municate with the pharyngeal glands. Hence the not uncom- 62 
DISEASES OE THE NOSE, THROAT, AND EAR 
mon slight inflammation of the tonsils and cervical lymphatics 
after nasal operations. 
PHYSIOLOGY AND PATHOLOGY OF MUCOUS MEMBRANES 
During respiration through a normal nose the bulk of the air 
passes along the septum above the inferior turbinated body, 
describing a semicircle in its course, smaller currents extending 
upward nearly to the roof of the nose. However, a consider- 
able volume of air passes through the inferior meatus, eddying 
downward from the main current above the inferior turbinate 
and circling backward along the inferior meatus. The di- 
rection of the breath current is largely due to the horizontal 
position of the anterior nares, and because of the vertical po- 
sition of the posterior nares the expiratory current is by no 
means as complicated as the inspiratory. It simply spreads 
out like a fan in its passage through the nose and, hence, a 
larger volume of air passes through the olfactory region during 
expiration than inspiration, a fact that doubtless has an im- 
portant bearing on the appreciation of the flavor and odor of 
foods during mastication and swallowing. It is understood, 
of course, that the respiratory path changes with the shape 
of the nasal chambers. Abnormal dryness of the nasal mu- 
cous membrane, or nasal obstructions of a kind to interfere 
with the free access of air to the olfactory portion of the nose, 
interfere greatly with the acuteness of the sense of smell. 
The nose also serves as a resonant cavity during vocaliza- 
tions, so that obstruction of the nasal chambers produces a 
peculiar nasal intonation during speech. Perhaps the most 
important function of the nose is to warm, moisten, and free 
from the dust inspired air. In health exhaled air has a tem- 
perature of 98.5° F., and it has been proved experimentally 
that most of the heat supplied to inhaled air comes from the 
nose, the turbinated bodies being well adapted not only to warm 
the inspired air, but to moisten it and free it from particles of 
dust which adhere to its moist, sticky surface. ANATOMY OF THE NOSE 
63 
Dust particles removed from the skin of the face and from 
the vibrissae contain numerous bacteria from which cultures 
can be made. On the other hand, bacteria removed from the 
surface of the normal nasal mucous membrane evince little 
vitality and cultures are made from them with considerable 
difficulty. Hence it has been claimed that the nasal secretions 
possess sufficient antiseptic qualities to destroy some bacteria 
and inhibit the growth of others. The practical point from this 
is that irritating antiseptic sprays before an operation are un- 
called for, and by setting up what might be called a chemic 
rhinitis tend to promote the growth of bacteria rather than 
destroy them. This is particularly true of solutions of corro- 
sive sublimate. 
In inflammation of mucous membranes the secretions are 
either increased or decreased in quanity, so as to either flood 
the parts or leave them unnaturally dry. It should be borne 
in mind that the normal secretion of the nasal mucous mem- 
brane is over 16 ounces of clear watery mucous in twenty-four 
hours, a part of which in health passes unnoticed through the 
nasopharynx down into the esophagus and stomach. Only 
when by obstruction or irritation, due to any cause whatever, 
this easy outflow and abundant secretion is interfered with, 
do we perceive a thickening and an accumulation of mucus, 
which is composed largely of epithelial cells in a state of 
fatty degeneration, mucous corpuscles, and the impurities 
from the inspired air. When mixed with pus or blood the 
secretions become yellow, green, or brown in color; and if 
retained upon the mucous membrane for a sufficient length 
of time the secretions become offensive as the result of putre- 
factive changes. 
"Catching cold" is the result of a transient influence upon 
the vasomotor system of nerves, producing an uneven distri- 
bution of blood in the capillaries, especially manifesting itself as 
a congestion of the mucous membrane of the upper respiratory 
tract, followed in most instances by inflammation, swelling, 
and excessive secretion which then becomes infected by bac- 64 
DISEASES OF THE NOSE, THROAT, AND EAR 
teria. It is probable that the phenomena of "catching cold" 
is largely of a reflex nature in which the peripheral sensory 
nerve fibrillae of the skin and extremities perceive the abstrac- 
tion of heat as a shock, and being afferent in their conductive 
function, convey the impression to their respective ganglia, 
whence it is reflected by means of the efferent vasomotor fas- 
ciculi to the vessels, causing their dilatation'and congestion, 
and, finally, inflammation of the structures containing them. 
This theory not only explains the ordinary phenomena of a 
"cold in the head," but also the pain of neuralgia and rheu- 
matism suddenly produced by "catching cold." Dilatation 
of the vasonervorum, resulting perhaps in the effusion of serum, 
produces pressure upon a nerve within its sheath and conse- 
quent pain in the muscle or skin containing it. 
The reason why the mucous membrane of the upper air- 
passages is the most frequent seat of an inflammation due to 
cold or a chilling of the surface of the body is that the sudden 
change of temperature produces, in the first place, an effect 
upon the sensory nerve-fibers in the skin, which impression is 
communicated to the vasomotor centers, and consequently 
results secondarily in a contraction of the blood-vessels of that 
portion of the skin which has been affected with a correspond- 
ing dilatation at some portion of the vascular system least able 
to resist the pressure. Inasmuch as our variable climate, the 
impurities of the atmosphere, and our artificial way of living 
have a tendency to weaken the capillaries of the upper air- 
passages from early childhood, that portion of the human 
economy is, therefore, the region most liable to suffer from this 
unequal distribution of blood. There results, first, engorge- 
ment of the parts, increased secretion and, finally, inflammation. 
However, frequently recurrent coryza is often only one of 
the manifestions of the sluggish elimination of waste products 
and toxins which when excreted through the nose cause irri- 
tation and swelling of its mucous membrane. In certain in- 
dividuals an error in diet is promptly followed by an attack of 
coryza. Under such circumstances, local treatment should ANATOMY OF THE NOSE 
65 
be supplemented by a carefully ordered diet and more impor- 
tant still, salines in sufficient quantities to secure daily copious 
evacuations. 
INFLAMATION OF MUCOUS MEMBRANES 
The most common forms are acute and chronic catarrhal in- 
flammation, purulent, croupous, and diphtheritic inflammation. 
In acute catarrhal inflammation an increased blood-supply 
stimulates the epithelial layer of the mucous membrane to in- 
creased activity; new cells are rapidly formed and cast off, 
while the glands pour out their secretion in excessive quantities 
and an abundant liquor sanguinis transudes the vessels, the 
mucous membrane at the same time appearing red and swollen. 
Chronic catarrhal inflammation differs from acute catarrhal 
inflammation in that the subepithelial layer of the mucous mem- 
brane is more involved. Connective tissue is developed by a 
slow process of proliferation. Usually the mucous membrane 
is thickened and hypertrophied; but, in some instances, the 
new tissue may be so placed as to press upon the glands and 
follicles, giving rise to atrophy. Also in catarrhal inflammation 
of the mucous membrane there sometimes occurs increased 
activity in the lymphoid cells, finally producing hypertrophy 
of the tonsils or other adenoid structures. Activity of morbid 
processes, confined largely to epithelial and lymphoid structures, 
belongs essentially to the younger period of life; while morbid 
activity in the connective-tissue structures belongs essentially 
to later life, rendering it much more difficult to bring about a 
cure in the catarrh of an adult than in that of a child. 
Croupous inflammation is of a higher grade than catarrhal; 
for, while it commences in the same manner, with increased 
blood-supply, rapid cell-growth and proliferation, increased 
secretion, and a throwing off of immature cells, leukocytes, and 
liquor sanguinis, it differs from it in the fact that the exudate 
contains a large amount of fibrin and albumin, which coagulate 
upon the surface of the mucous membrane, forming a false mem- 66 
DISEASES OE THE NOSE, THROAT, AND EAR 
brane. This false membrane is at times so soft and almost 
granular in character as to be easily removed with a soft brush. 
At other times it is tougher and difficult of removal; but in 
either case, when removed, the mucous membrane is left intact 
or only deprived of some superficial epithelial cells. 
Diphtheritic inflammation is also characterized by the forma- 
tion of a false membrane, but its pseudomembrane permeates 
the mucous membrane so densely that it can only be removed 
by bringing away with it the entire thickness of the mucous 
membrane to which it is attached, thus leaving the parts below 
completely denuded. A diphtheritic pseudomembrane is of a 
dark grayish color, resembling somewhat an ordinary slough of 
the mucous membrane, in contradistinction from a croupous 
membrane, which is of a bluish-pearl color, with no appearance 
as of sloughing of the parts. 
DISEASES OF THE NOSE 
Effect of Diseases of the Nasal Passages on Other Parts of 
the Body.-Nasal disease may extend to the pharynx, ear, or 
larynx by continuity of structure, or affect the other respiratory 
organs by abeyance of the functions of warming, moistening, 
and filtering the inspired air, so that it enters the pharynx 
cold, dry, and dust-laden. Chronic pharyngitis and laryngitis 
frequently result from this cause; and while it is not easy to 
prove that pneumonic phthisis is indirectly the result of 
atrophic rhinitis, yet it is difficult not to suspect some such 
relationship. As the result of nasal disease there are often 
induced certain reflex phenomena, viz., nasal cough, nasal 
asthma, nasal vertigo, nasal epilepsy, nasal chorea, hay-fever, 
pareses of the palate and larynx, neuralgia and headache, 
reflex skin rashes, affections of the eye; both inflammatory, 
and muscular; amblyopia, suppuration of the orbit, and men- 
ingitis by infection from suppurating accessory nasal sinuses. 
The reflexes which originate in nasal or nasopharyngeal 
irritation and terminate in cough, laryngeal spasm, or asthma, DISEASES OF THE NOSE 
67 
follow much the same pathway as the reflex known as sneezing. 
The nasal branches of the ophthalmic division of the fifth nerve 
and the nasal branches of the anterior palatine descending from 
Meckel's ganglion, which is in connection with the superior 
maxillary division of the fifth nerve, conduct the sensory im- 
pressions to the medulla. It is there reflected to the respiratory, 
pneumogastric, and other centers; whence the deep inspiration, 
the forced expiration, and the coincident spasm of the pharyn- 
geal and laryngeal muscles, termed a sneeze. 
Acute rhinitis is an acute catarrhal inflammation of the nasal 
mucous membrane. 
Etiology.-It is generally the result of exposure to cold and 
wet when the body is overheated. It may, however, be pro- 
duced by breathing hot dry air or inhaling irritating vapors and 
dust, errors of diet, or come on apparently as the result of a ven- 
ereal debauch. Chronic catarrh, syphilis, rheumatism, dys- 
pepsia, or a debilitated state of the system renders an individual 
more liable to attack. The bacteria most commonly found in 
the discharges are: (i) Bacillus influenzae, (2) B. leptus, (3) B. 
of Friedlander, (4) Micrococcus cartarrhalis, (5) M. paratet- 
ragenus. The more chronic form of the disease has practically 
always the Bacillus of Friedlander in its discharges. Allen, by 
injecting appropriate doses of opsonic vaccines corresponding to 
the bacteria found in the discharges of acute rhinitis, succeeded 
in hastening convalescence; and in some cases apparently es- 
tablished an immunity from colds by the injection of opsonic 
vaccines. On the other hand, Rossbach observed that in 
rabbits, when the trachea was opened and ice applied to the 
abdomen, after a short period of pallor, the mucous membrane 
reddened and finally took on the dusky hue resulting from 
venous congestion. These appearances he attributed to the 
reflex from the skin acting on the vasomotor system in such 
a manner as to first produce contraction, then dilatation, and 
finally paralysis of the vessels of the mucous membrane with 
altered secretions and other symptoms of inflammation. He 
believes that only after the resistance of the mucous membrane 68 
DISEASES OF THE NOSE, THROAT, AND EAR 
is thus decreased do bacteria find a suitable culture media in 
the altered secretions; and hence are not the initial cause of the 
inflammation. 
Pathology.-At first the mucous membrane, though swollen 
and congested, is dry. As the disease progresses, there is an 
abundant serous discharge, which becomes more and more 
charged with broken-down epithelial cells, lymph-corpuscles, 
pus-globules, etc., until the discharge assumes the character of 
thick tenacious mucous or mucopus. The deeper lying tis- 
sues also participate in the process. The erectile tissue be- 
comes gorged with blood and swollen, in some instances com- 
pletely occluding the nares. 
Symptoms.-The onset may be simply an attack of sneezing, 
followed by increased and thickened discharges. In other cases 
the attack begins with chilly sensations and a general feeling of 
illness. There is a sensation of fulness and pain about the nose 
and forehead. The face may be flushed, the eyes suffused, and 
more or less fever be present. Sensations, almost suffocating 
in their character, may be present from occlusion of the nares, 
and the discharges be so irritating as to scald the skin of the alae 
and upper lip. A cold in the head lasts from two or three days 
to as many weeks. It generally ends in complete resolution, 
but frequently repeated, is a common source of chronic nasal 
catarrh. In nursing children the child takes nourishment 
only with difficulty, frequently pausing to breathe through the 
mouth. 
Treatment.-A cold in the head can often be aborted at its 
commencement by a hot bath and a bowl of hot lemonade at 
bedtime, with or without io gr. of Dover's powder, followed in 
the morning by a saline purge and the wearing of extra warm 
clothing. The turgescence of the nasal mucous membranes and 
discharges can always be abated by the application of a 2 per 
cent, solution of cocain. This effect of the cocain can be kept up 
for several hours by spraying the interior of the nose with a 2 per 
cent, solution of antipyrin immediately after the application 
of the cocain solution. If repeated every day this treatment DISEASES OF THE NOSE 
69 
gives great and immediate comfort to the patient and cuts 
short the course of the disease, while a soothing snuff (Formula 
115), used by the patient in the intervals between the applica- 
tions, adds much to the efficiency of the treatment. In severe 
cases the patient had better remain in bed, and the presence of 
fever requires the administration of aconite in small doses at 
frequent intervals. Many pill makers manufacture what they 
term rhinitis tablets, the active ingredient of which is atropin; 
gr. °f this drug, taken every two hours for four or five doses 
or until a sensation of dryness in the throat is produced and 
then at much longer intervals, yields decided relief in control- 
ling the nasal symptoms; but in some individuals produces 
headache, a hot dry skin and throat; and general discomfort. 
Simple chronic rhinitis, turgescent rhinitis, is a catarrhal 
inflammation of the nasal mucous membrane, exhibiting but a 
slight tendency to spontaneous recovery. Turgescent rhinitis 
is a recurrent swelling or turgescence of the erectile tissue at 
irregular intervals, mostly at night. The parts may appear 
nearly normal between attacks. 
Etiology.-It is generally the result of uncured rhinitis or 
frequent attacks of coryza. 
Pathology.-The mucous membrane of the nose presents pre- 
cisely the appearance seen in acute rhinitis, only it is less 
swollen and less red in color. The discharge is either watery, 
if the upper parts of the nose, especially the mucous membrane 
of the middle turbinated bodies are the parts most affected, or 
it approaches mucopus in character if the disease is mostly 
located in the lower parts of the nose. 
The symptoms are precisely those of acute rhinitis, only less 
pronounced. There is a feeling of fulness about the nose. 
There is alternating stenosis as the result of turgescence of 
first one nasal chamber and then the other, a continual dis- 
charge, and the sufferer is continually "catching cold," when, 
of course, all his symptoms are increased in severity. 
Prognosis.-'Untreated, chronic rhinitis may continue indefi- 
nitely, and finally result in hypertrophic rhinitis, the pharynx 70 
DISEASES OF THE NOSE, THROAT, AND EAR 
also gradually becoming affected. Under treatment a cure is 
frequently brought about in from three to six weeks. 
Treatment.-'Ordinarily the tone of the system is below par 
and a tonic is indicated. In such cases Formula 137 answers a 
useful purpose. If the bowels are sluggish, it is advisable to 
direct the occasional use of a saline cathartic. Cleanliness of 
the mucous membrane is of primary importance, and may be 
secured by the patient using at home, twice a day, a bland 
alkaline wash (Formulas 1, 2, 3, 4, 5) with an atomizer. 
The application of an alterative or an astringent to the nasal 
mucous membrane in these cases is of greatest value, and the 
following formula has long been popular for this purpose: 
1$. lodini, gr. v; 
Potassii iodidi, gr. xv; 
Glycerinae, f g ij.--M. 
The result of the application varies according to the amount of 
the solution used. When the nose is extremely sensitive, only 
a small amount of cotton should be wrapped about the applica- 
tor, so as to form a brush capable of absorbing but a small 
amount of the solution, which should be carefully applied to 
those portions of the nasal mucous membrane where the in- 
flammation seems greatest; the cotton brush should also be 
passed along the floor of the nose and the application painted 
upon the pharyngeal mucous membrane. After the appli- 
cation of the iodin solution the use of some protective upon the 
nasal mucous membrane is advisable. This indication may be 
secured by means of a spray of fluid albolene, applied until 
the mucous membrane of the nose and nasopharynx is thor- 
oughly coated with it. 
Instead of plain albolene, what is frequently referred to as 
menthol-camphor-albolene may be employed: 
Menthol, gr. v; 
Camphor, gr. xx; 
Albolene, fgij.-M. 
In certain cases either of the following formulas, when ap- 
plied to the nose, give quicker and better results than the iodin 
solution, espec ally in adults: DISEASES OF THE NOSE 
71 
1$. Argyrol. 10-25 Per cent. 
1$. Boroglycerid. 50 cer cent. 
I}. Zinci sulphates, 2-4 per cent. 
I|. Acidi tannici, gr. xl; 
Glycerinae, fgj.-M. 
A case of simple chronic rhinitis is, then, perhaps best treated 
in the following manner: The patient is ordered a tonic, in- 
structed to wash out his nose night and morning with either 
Dobell's solution or one of its modifications, and to present 
himself at the physician's office at least twice a week, but better 
every other day, for treatment. After first cleansing the nose 
with a spray from an atomizer filled with an alkaline solu- 
tion, the physician should make an application of the required 
solution and follow it with a spray of menthol-camphor-al- 
bolene. 
Purulent rhinitis is an inflammation of the Schneiderian 
membrane in which the discharge from the beginning is puru- 
lent. It is more common in children. 
Etiology.-'It probably always results from specific infection 
of some kind. It may occur during the course of one of the 
exanthemata, diphtheria, etc. Some cases occurring in young 
infants are due to gonorrheal infection from the vagina during 
birth. 
Pathology.-'The bacteria characteristic of the infection are 
found in the discharge or in the mucous membrane. When suf- 
ficiently virulent to cause actual destruction of tissue, deep 
ulcers occur, with final formation of scar-tissue. This disease 
in childhood is probably the most common cause of atrophic 
rhinitis in after life. The adherents of the "Herd" theory 
believe that a chronic bilateral sinusitis is produced, which 
is responsible for the formation of crusts in the upper portions 
of the nose. 
Symptoms.-The disease is most common in children and is 
characterized by a fetid, thin, purulent discharge, sometimes 
streaked with blood, which often excoriates the lip and alae of 72 
DISEASES OF THE NOSE, THROAT, AND EAR 
the nose. The nasal mucous membrane is red, swollen, and 
ulcerated. 
Treatment.-'The nasal mucous membrane should be cleansed 
at least twice a day with an alkaline spray. 
In infants the nose is more effectively cleansed by means of a 
syringe than by the spray from an atomizer, and the bulb 
rubber syringe (Fig. 28) is useful for this purpose. Extreme 
gentleness should be used in syringing, in order to prevent 
fluid entering the middle ear. In children who have not yet 
learned to blow their nose, it is best to blow it for them by in- 
serting the syringe tip into one nostril and forcibly compressing 
the syringe-bulb. By this means a current of air is forced into 
one nostril and out of the other, blowing the mucus and pus 
before it. After the nose has been cleansed of the secretion, 
with Dobell's solution, with a small quantity of gallic acid 
ointment, from 3 to 10 gr. to the ounce of vaselin, according 
to the age of the child, should then be placed within the 
nostrils with a brush. This home treatment should be car- 
ried out twice a day. 
The physician himself should treat the child two-or three 
times a week or oftener by cleansing the nasal mucous mem- 
brane as described above, using an air-douche either from a 
syringe or, in the case of larger children, the Politzer bag to 
blow mucus from the nose both before and after the use of 
the atomizer. When thoroughly cleansed, the nose should, 
be sprayed with albolene and dusted with powdered calomel 
or aristol by means of a powder-blower, care being taken that 
none of the powder reaches the pharynx and is swallowed. 
In scrofulous children hygienic measures are often as impor- 
tant as local treatment. Cod-liver oil, syrup of the hypophos- 
phates or iodid of iron being required in many instances. 
Membranous rhinitis is an acute inflammation of the nasal 
mucous membrane characterized by the formation of a pseudo- 
membrane involving the epithelial and sometimes the subepi- 
thelial structures. 
Etiology.-'The disease is most common among poorly DISEASES OF THE NOSE 
73 
nourished children living in unhygienic surroundings. Occa- 
sionally an adult is attacked. One of the writer's cases was 
a woman twenty-four years old. The disease is the result of 
inoculation of the nasal mucous membrane by a microorganism 
capable of generating in that locality a pseudomembrane; 
although it should be borne in mind that the sloughs resulting 
from galvanocautery wounds, either in the nose or on the tonsils, 
resemble very closely pseudomembranes; and the same is 
true to a certain extent of other nasal traumatisms. 
Pathology.-'The pseudomembrane is generally thick, pulpy, 
and grayish white, and during the earlier stages is removed 
with considerable difficulty, leaving a bleeding surface; later, 
it is more loosely attached and more easily removed. After 
each removal, if antiseptics are used, a smaller and smaller 
surface becomes again covered by exudate. The membrane 
is a meshwork of fibrin entangling leukocytes, degenerated 
epithelial cells, and microorganisms. Besides the Klebs- 
Lbffler bacillus, and that resembling it (Hoffman's bacillus), 
the streptococcus, staphylococcus, pneumococcus, and other 
microorganisms are capable of producing a pseudomembranous 
rhinitis. 
Symptoms.-The nasal mucous membrane is greatly swollen 
and that of the inferior turbinate and adjacent parts of the 
septum is covered by a pseudomembrane which sometimes 
involves other portions of the nose. The pharynx is usually 
almost completely free from pseudomembrane, or there may be 
one or more small patches, one of which may be on the tonsil. 
The sufferings of the patient are mostly those resulting from 
the occluded nostrils. However, the throat is generally some- 
what sore and the cervical glands, while not swollen, are tender 
to the touch and there is sometimes a slight elevation of tem- 
perature. Untreated the disease runs a course of from three 
to six weeks; under treatment, ten days to two weeks. 
Treatment.-'The pseudomembrane should be examined by 
a careful and competent bacteriologist for the presence of 
virulent Klebs-Lbffler bacilli, and if present, antitoxin should be 74 
DISEASES OF THE NOSE, THROAT, AND EAR 
injected, the case isolated and treated as diphtheria; although 
primary nasal diphtheria usually runs a mild course, and the 
danger of inoculating other individuals is probably less than 
in faucial and laryngeal diphtheria. The writer has never 
seen an instance in which membranous rhinitis was apparently 
contracted from an individual similarly affected, although in 
some instances cases before coming under his care had attended 
school, and played or even slept with one of their parents or 
other children. In some of these cases the report of the bacte- 
riologist stated that the Klebs-Loffler was present. However, 
it is possible that in all these instances the cause of the pseudo- 
membrane was not the Klebs-Loffler bacillus, but that of 
Hoffman, which is morphologically identical and not an un- 
common inhabitant of the nose. 
As in the present state of our knowledge it is impossible to 
make a reliable differentiation between the Klebs-Loffler 
bacillus and that of Hoffman, except by guinea-pig inocula- 
tions or some similar test, requiring several days, and as anti- 
toxin, to be most effective, should be used within the first 
forty-eight hours after the onset of diphtheria, it is possibly 
better in recent cases, where the bacteriologist reports that the 
microscopic examination of "smears" show the presence of a 
bacillus possibly that of diphtheria, to at once inject antitoxin 
without waiting several days to determine the result of guinea- 
pig inoculations. In cases not seen before the pseudomem- 
brane has existed for a week or more, it is better to wait the 
result of guinea-pig inoculations, as in such cases the proba- 
bility of antitoxin doing much good is somewhat remote. 
In cases where the pseudomembrane is the result of the pres- 
ence of some other microorganism than the Klebs-Loffler 
bacillus, the use of antitoxin is manifestly not indicated. If 
the cervical glands are inflamed the skin of the neck over them 
should be kept covered by a io per cent, ointment of ichthyol 
in lanolin until the inflammation subsides. The medical 
attendant should see his patient at least once a day, and in 
older children pledgets of cotton saturated with a 3 per cent. DISEASES OF THE NOSE 
75 
solution of cocain should be inserted into each nostril, and after 
the turbinates have contracted the pseudomembrane should 
be withdrawn from the nose by means of Politzer's ear forceps 
(Fig. 167). 
After the use of cocain this is usually readily accomplished, 
especially in the later stages of the disease. After the removal 
of the membrane the nasal cavities should be washed with 
Dobell's solution by means of an atomizer yielding a coarse 
spray, or with a syringe. In very young children it is sometimes 
impossible to cleanse the nares thoroughly and the operator 
will be obliged to content himself by irrigating the nose by 
means of a medicine dropper -with Dobell's solution or other 
alkaline wash, to which a small proportion of hydrogen dioxid 
has been added. After the nasal cavities have been as thor- 
oughly cleansed as can be done with gentleness, the Schneider- 
ian membrane should be sprayed with a 10 per cent, solution 
of argyrol. 
Between the physician's visits the treatment should consist 
either in spraying the nose every three hours with a 10 per cent, 
solution of argyrol or the insertion into each nostril of an oint- 
ment of gallic acid, 3 to 10 grains to the ounce of vaselin, 
according to the age of the child. 
During the attack the child is probably best confined to the 
house, even in summer, although this is sometimes hard to 
accomplish when the child's temperature is normal and it feels 
entirely well except for the discomfort of nasal stenosis. In 
the more severe cases the child's condition may require that it 
remain in bed, and in such cases tincture of the chlorid of iron-• 
5 to 10 drops in water every two hours-may be given with 
advantage, either with or without strychnin. 
The slight pharyngitis sometimes present yields to argyrol 
spraying, or the tonsils may be sufficiently inflamed to require 
one or more applications of a 10 or 15 per cent, aqueous solu- 
tion of nitrate of silver. 
Hyperplastic rhinitis and hypertrophic rhinitis are chronic 
inflammations, of the nasal mucous membrane and sub- 76 
DISEASES OF THE NOSE, THROAT, AND EAR 
mucous tissues with permanent dilatation of the blood-vessels. 
Hypertrophy of an organ is due to an increase in the size of 
the cells, while hyperplasia is an increase in the number of 
cells. Both conditions imply an increase in bulk. In the 
turbinated bodies of the nose the conditions can be differen- 
tiated from the fact that in hypertrophy the parts are soft to 
the touch and shrink greatly under the application of cocain 
or adrenalin, while in hyperplasia the parts are firm to the 
touch and do not shrink greatly under cocain. 
Etiology.-These diseases are invariably the result of long- 
continued simple chronic rhinitis or frequent attacks of coryza. 
Pathology.-While in long-continued simple chronic rhinitis 
there is already some thickening of the epithelial layer of the 
mucous membrane, yet the disease only becomes hypertrophic 
rhinitis when the thickening involves the other elements of the 
mucous membrane and the submucous structures. As the 
result of frequent attacks of inflammation the blood-vessels 
become permanently dilated and their walls thickened, glandu- 
lar tissue is hypertrophied, hyperplasia occurs in the connective 
tissue, so that the thickened turbinates cannot collapse as when 
normal, and remain permanently distended with blood. This 
thickening is most noticeable at the anterior and posterior 
parts of the middle turbinated bodies, where it is called an 
anterior or posterior hypertrophy. 
Symptoms.-The most prominent symptoms are those of 
nasal obstruction, want of proper drainage from the nasal 
cavities, and increased secretions. When the obstruction is 
great and constant the patient becomes a "mouth-breather." 
The inspired air, under such circumstances, not being properly 
warmed, moistened, and freed from dust in its passage through 
the mouth, causes dry lips, a coated tongue, follicular pharyn- 
gitis, and sometimes chronic laryngitis. When the nasal occlu- 
sion is complete, the face assumes a stupid expression on 
account of the constantly open mouth. Should the habit of 
mouth-breathing be acquired in early childhood and continued 
for some years, the shape of the bones of the face is altered and DISEASES OF THE NOSE 
77 
the habit of mouth-breathing retained long after the nasal 
obstruction has disappeared. Any position favoring the 
gravitation of blood into the hyperemic or hypertrophied parts 
is sufficient to cause their distention; hence, when the patient 
is in bed, first one nostril and then the other will become 
occluded, according to which side of the body is lain upon. 
This is especially true when large posterior hypertrophies are 
present. Obstruction and suppuration of the nasal duct not 
infrequently occur as the result of inflammation beginning at 
it nasal orifice. An anterior hypertroohv of the middle tur- 
Fig. 39.-Anterior hypertrophy of the inferior turbinate (Seiler). 
binated body pressing on the septal nerve, a branch of the 
ophthalmic, frequently causes reflex eye-symptoms, such as 
chronic conjunctivitis, slight paresis of accommodation; and 
irritable retina occurs as the result of involvement of the eth- 
moidal labyrinth. The olfactory slit may become closed from 
hyperplasia of the middle turbinated body, and thus interfere 
with the sense of smell and that of taste to a corresponding 
degree. Redness of the tip of the nose and acne are also in 
some cases apparently the result of interference with the blood 
supply of the skin. Hearing may be gravely compromised 
from the pressure of hypertrophies interfering with the blood 78 
DISEASES OF THE NOSE, THROAT, AND EAR 
supply of the Eustachian tubes, or the extension of the disease 
to their lining mucous membrane. Headaches are often com- 
plained of, and a feeling of pressure or even of pain at the root 
of the nose. 
The patient frequently complains thathehas "a bad breath." 
In many cases the offensive odor is due to decaying epithelium 
upon the tongue as the result of mouth-breathing or dyspepsia. 
At other times the "bad breath" of which the pa- 
tient complains is perceptible only to himself, and 
is probably due to irritation of the olfactory region 
of the nose, contrasting strongly in this respect with 
atrophic rhinitis. If any "catarrhal" odor " of the 
breath of an individual with hypertrophic rhinitis 
be present, it is always more annoying to himself than 
to a bystander. 
Treatment.-'Each case should be treated as one 
of simple chronic rhinitis until the inflammation of 
the Schneiderian membrane has disappeared, when 
operations should be undertaken for the removal of 
any tissue causing obstruction. 
Removal of Anterior Hypertrophies.-If large, especi- 
ally if the hypertrophy consists of hyperplastic tissue, 
that is, tissue that does not contract when cocain is 
applied, their removal with scissors or snare will be 
found most satisfactory. 
Another method of removing anterior hypertrophies 
is by the galvanocautery. A pledget of absorbent 
cotton, saturated with a 3 per cent, solution of co- 
cain, is introduced into the inferior meatus and al- 
lowed to remain in contact with the hypertrophy 
until it has shrunken as much as possible and the 
parts are thoroughly anesthetized. A metal specu- 
Fig. 40.-Jarvis' snare. The figure shows a small, light snare: what might be 
called the "standard" snare for nasal work. It should be forged from steel and not 
constructed of brass with a steel tip.. For ordinary nasal work it is threaded with 
No. 5 American steel piano wire, which, while not as strong, is somewhat more pli- 
able than the imported. _ However, many operators prefer Krause's snare or some 
similar type, which permits the same wire loop being used a number of times. DISEASES OF THE NOSE 
79 
lum is introduced after the removal of the cotton and the 
hypertrophy exposed. After the platinum wire of the cau- 
tery-knife is at a dull-red heat, it is placed upon the thick- 
est part of the hypertrophy, and by means of gentle to-and- 
fro movements is made to cut through to the bone, when it 
is carefully withdrawn, so as not to detach the eschar which 
it has formed. The operator should be careful to cut down 
to the periosteum before withdrawing his cautery-knife or the 
results of the operation will be far from satisfactory; for, 
although a superficial burn either with the galvanocautery 
or chromic acid heals very quickly and gives a certain 
amount of relief for a short time, yet the results are not as 
permanent as when the cautery-knife is made to penetrate 
the periosteum. 
No after-treatment is required beyond keeping the wound as 
dry as possible and endeavoring to avoid detaching the eschar 
before the healing process has been completed beneath it. 
Although nearly six weeks are sometimes required for the 
complete healing of a cautery wound, yet little inconvenience 
is usually experienced by the patient during the healing process, 
except that during the first week the nostril is sometimes more 
obstructed than ever as the result of swelling. At the end of 
about ten days the slough produced by the burning separates 
from the wound and decided advantage from the cauterization 
is then first experienced. The improved respiration becomes 
greater and greater until the wound is finally entirely healed. 
The anterior portion of the turbinate then presents a some- 
what pale appearance, with a depression indicating the seat of 
the cautery application. The turbinate not only is diminished 
in size, but sudden change in its volume, with consequent ob- 
struction of the nostril, is also prevented. The patient states 
he "does not 'catch cold' as readily as before the operation." 
The cautery should be used judiciously, as great and perma- 
nent injury may result from the work of a careless or brutal op- 
erator. Large tracts of mucous membrane may be destroyed 
by application of the flat side of the cautery-knife or the spread- 80 
DISEASES OF THE NOSE, THROAT, AND EAR 
ing over a moist mucous surface of a chemic caustic. Such 
wounds heal slowly and some time elapses before the scar be- 
comes covered by an epithelium that functionates properly. 
The galvanocautery should be used cautiously upon the mid- 
dle turbinated bone, only a very small knife being employed 
for the purpose. Its application to the posterior portion of 
the nose is best avoided. Because of the thinness of the car- 
Fig. 41.-Fusing chromic acid on an Allen probe: a, Heating probe to redness; b 
catching up a crystal; c, heating to round into a bead; d, finished probe. 
tilaginous septum and the low vitality of its cartilage deep 
cautery wounds generally result in a perforation. Because of 
the edema that sometimes results the cautery should not be 
used on the uvula, the anterior pillars of the fauces, the aryten- 
oids, or the glosso-epiglottic folds except with extreme caution. 
It is permissible to remove a little mass of mycosis by means of 
the galvanocautery from these regions, but a very small cau- DISEASES OF THE NOSE 
81 
tery-knife should be employed and the burn should be very 
superficial. 
Chromic acid is more frequently employed than any other 
chemic caustic in the treatment of anterior hypertrophies. It 
should be used in the following manner: The end of an Allen 
probe (Fig. 41) is heated and plunged into a bottle containing 
crystals of chromic acid, some of which will adhere to the probe 
and be withdrawn with it from the bottle. A further applica- 
tion of heat will fuse these crystals upon the probe, which is 
now ready for use. The probe may also be prepared for use as 
a cautery by wrapping a few fibers of absorbent cotton about its 
end and rubbing into it moist powdered crystals of chromic 
acid until the cotton is saturated with the paste. 
The parts having been cocainized, the end of the probe, 
covered with chromic acid, is pressed firmly into the hyper- 
trophy and pushed backward and forward over the line to be 
cauterized, and finally withdrawn. After the lapse of a few 
moments the nasal chamber is thoroughly washed with the 
spray from an atomizer containing an alkaline solution, care 
Fig. 42.-Galvanocautery handle. 
being taken that none of the resulting chromic salt reaches the 
pharynx and is swallowed, as it is poisonous. 
Chromic acid is more uncertain in its action than the galvano- 
cautery-knife, and the same is true of trichloracetic acid, which is 
used in practically the same manner, except that, being a liquid, 
it cannot be fused on to the end of a probe. 
When the rhinologist's office is lighted from the wires of an 
electric supply station some form of ''converter " may be used to 
secure a current suitable for the galvanocautery, snare, minia- 
ture lamps, and electric motor. Apparatus also may be pur- 
chased for obtaining from the company's wires both a suitable 
galvanic and faradic current for medicinal purposes. 82 
DISEASES OF THE NOSE, THROAT, AND EAR 
Removal of Posterior Hypertrophies-X Jarvis snare should be 
threaded with No. 5 steel piano wire. The loop of wire should 
be bent to one side before being introduced into the nostril, so 
that it may the more readily be passed around the hypertrophy 
and remain in position when the loop is tightened. Being 
made as small as possible without distorting it by pulling down 
the sliding tube upon the handle of the instrument, the loop is 
carefully intoduced along the floor of the nose until the poste- 
rior wall of the pharynx is reached when the loop is again en- 
Fig. 43.-Cautery-knives. 
larged by pushing upward the sliding tube, and the instrument 
at the same time is slowly withdrawn as its handle is carried 
toward the septum. By this means the wire is made to sur- 
round the hypertrophy and a resistance is finally felt as the 
instrument is withdrawn, caused by the bight of the loop 
coming in contact with the base of the hypertrophy. The wire 
loop is now quickly tightened around the hypertrophy by 
pushing forward the instrument within the sliding tube, and 
the milled nut is quickly screwed downward into place. Two 
or three additional turns are given to the milled nut to be 
certain that the wire is tight about the base of the growth DISEASES OF THE NOSE 
83 
and that the instrument is held firmly in place without danger 
of slipping, when the patient may be allowed to rest. The 
sudden tightening of the wire loop occasions the patient some 
pain, which, however, soon subsides, when the loop may be 
still further tightened by turning the milled nut until the pa- 
tient begins to again experience pain. In this way, proceeding 
slowly and carefully, the hypertrophy is finally squeezed off 
from its attachment, and is generally removed clinging to the 
end of the instrument by some fibers that have been drawn 
down into it with the wire. However, should the growth not 
be removed with the instrument, no attempt should be made to 
dislodge it from the nose, as it forms an efficient plug to pre- 
vent hemorrhage, and will probably drop into the fauces and 
be expectorated within twenty-four hours after the operation. 
Owing to the compression of the wire, the wound made by snar- 
ing a posterior hypertrophy is but small and generally heals rap- 
idly. Cocain should not be used as a local anesthetic for the 
removal of posterior hypertrophies, because it shrinks the tis- 
sues to such an extent that it is difficult to grasp the hyper- 
trophy with the snare. A io per cent, solution of stovain or 
alypin does not contract the tissues and hence is the preferable 
anesthetic for this operation. 
Turbinectomy, or removal of the whole or, at least, the greater 
portion of the inferior turbinated body, is performed to secure 
increased breathing space, for the removal of malignant growths, 
and for other reasons. Turbinotomy, or the removal of a por- 
tion of the inferior turbinate, by the snare, galvanocautery, 
and chemic caustics has been described already. When these 
methods are inadequate to remedy stenosis, a larger portion may 
be removed with a swivel knife (Fig. 63), which is applied as 
near the posterior extremity of the turbinate as deemed neces- 
sary and pushed upward through the tissues to the desired depth 
and then drawn forward parallel to the lower border of the 
turbinate, so that a long strip of tissue is cut away. The 
same result is accomplished with a "spoke shave," an instru- 84 
DISEASES OF THE NOSE, THROAT, AND EAR 
ment similar to Fig. 63, except that its cutting edge does 
not swing, but is fixed and immobile. 
When sufficient nasal respiration can be secured by operations 
on the septum, such as the removal of an exostosis or bringing 
a septal deviation into the median line, it is better not to re- 
move any large portion of the inferior turbinated body because 
of the great destruction of mucous membrane and erectile 
tissue. 
Fig. 44.-Struycken's nasal alligator cutting forceps, for removing turbinates. 
Moreover, a turbinectomy done to relieve the stenosis 
caused by a deviated septum would accomplish nothing toward 
improving the condition of the wider nostril. As a matter of 
fact, when middle-ear catarrh results from deviation of the 
nasal septum, it frequently begins in the ear of the same side as 
the wider naris. 
The operation of turbinectomy is best done in the following 
manner: The nasal mucous membrane is cleansed with spray 
from an atomizer containing Dobell's solution or some other 
suitable alkaline fluid. The upper and lower portion of the 
attachment of the inferior turbinate is now cocainized by rub- 
bing into them by means of a cotton-tipped applicator a io 
per cent, solution of cocain in i to 2000 adrenalin solution. DISEASES OF THE NOSE 
85 
One blade of Struycken's cutting forceps (Fig. 44) or, better, 
a stout pair of nasal scissors (Fig. 45) is inserted beneath the 
anterior extremity of the turbinate in a direction upward and 
somewhat backward and the anterior attachment of the bone 
severed. The cutting is continued backward in a direction 
parallel to the floor of the nose until the inferior turbinate is 
completely severed from its attachment to the lateral wall of 
the nose. It is then removed with a pair of forceps. The 
hemorrhage is frequently trifling. 
It should be remembered that while the anterior attachment 
of the middle turbinate is nearly vertical, that of the inferior 
is obliquely upward and backward. 
Fig. 45.-Beckmann's scissors. 
Simpson's tampon or a longer strip of Bernay's sponge (Fig. 
49) is inserted into the nostril, where it is allowed to remain for 
24 hours. 
Ecchondroses and Exostoses of the Septum.-A localized 
cartilaginous thickening or projection from the cartilaginous 
septum is called an ecchondrosis, while a similar bony growth 
upon the bony septum is referred to as an exostosis or hyper- 
plastic osteoma. Heteroplastic osteoma is a name given to 
rather a rare form of bony nasal growth which springs from the 
cellular tissue beneath the mucous membrane, is not continu- 
ous with the cartilaginous or bony framework of the nose, and 
is, therefore, movable. Frequently, ridges or shelves of carti- 
lage and bone are found extending along the septum nearly 
from the anterior to the posterior nares. Usually such growths 86 
DISEASES OF THE NOSE, THROAT, AND EAR 
follow the suture between the vomer and superior maxillary 
or that between the triangular cartilage and the vomer. (See 
Vomerine Crest, p. 86.) 
Etiology.-They are, doubtless, sometimes merely provisional 
callus that has escaped absorption and has been deposited 
upon an old traumatism of the septum, which may have been 
received during early childhood as the result of one of the num- 
erous "bumps upon the nose" that children are constantly 
receiving. 
Symptoms.-Frequent nasal obstruction. Atrophy of the 
turbinated body opposite them is not uncommon, nor neuralgia 
of the whole side of the face, as the result of intranasal pressure. 
Sometimes the crest of such growths is ulcerated, and a thin, 
irritating, sanious discharge results, impossible to cure except 
by the removal of the exostosis or ecchondrosis. The nostril 
being obstructed in front, the breath current is interfered with 
in such a way that there is a constant rarefaction of the air at 
the orifice of the Eustachian tube at each inspiration, and as the 
result of "vacuum congestion" tinnitus and, finally, otitis 
media and deafness result. 
Operations.-Localized thickenings of the cartilaginous sep- 
tum may be cut through and removed by means of a small 
probe-pointed tenotome. When the growth is hard and bony 
it is best removed by means of a chisel or saw. It should be 
borne in mind that only that portion of the growth should be 
removed which interferes with proper nasal respiration. This, 
of course, means, in most instances, the whole of the growth. 
In a roomy nostril, however, and in atrophic rhinitis the growth 
may in some instances be doing good by occupying a certain 
amount of space in a nostril already too large, and under 
such circumstances its removal would probably cause post- 
nasal catarrh and chronic pharyngitis. 
The parts to be operated upon should be exposed by means of 
a dilator (Fig. 17), which will be found convenient for operations 
within the nose, because when once in position it is not easily 
displaced by the struggles of the patient during an operation. DISEASES OF THE NOSE 
87 
The field of operation is then rubbed with a cotton-tipped 
probe which is moistened and dipped into coarsely powdered 
cocain. A i to 1000 solution of adrenalin is then applied 
in the same manner. 
When the saw is used, it should be entered below the growth 
and the sawing done in an upward direction, so as to obscure 
the field of operation as little as possible by blood, which, of 
course, flows downward from the wound. When the shelf of 
bone is large and hard the operation is necessarily tedious; 
but at any stage of the operation the saw may be withdrawn 
and both operator and patient rest, a plug of absorbent cotton 
saturated with a solution of adrenalin being inserted within 
the nostril. Under these circumstances the nostril will be 
found free from blood when the cotton is withdrawn, so that 
the operator can readily see to replace the saw in the cut al- 
ready made. It is possible in some instances to secure a prac- 
tically bloodless operation; but it should be borne in mind 
that adrenalin contracts only the more superficial vessels, and 
that if a large vessel is severed, especially one deeply im- 
bedded in bone, the hemorrhage may be severe. Under such 
circumstances the operation should be completed as speedily 
as possible and the severed mass of bone removed. A Simp- 
son nasal tampon (Fig. 49) should then be placed within the 
nose, but should this prove insufficient, the case should be 
treated as described in the section on Nasal Hemorrhage. 
A large variety of nasal saws are for sale in instrument stores. 
Those shown in Fig. 46 are typic as to arrangement of the teeth. 
The saw blades should be thin but rigid, and therefore some- 
what wide, especially near the handle. Occasionally a narrow 
saw is required to commence the sawing of an exostosis too 
close to the floor of the nose to permit the introduction of a 
wider instrument. To prevent binding in the tissues, the 
cutting edge of the saw should either be thicker than the back, 
as in metacarpal saws, or the teeth will require "setting," as in 
ordinary carpenters' saws. Clogging of the teeth with sawdust 
occurs in all saws, but is best prevented by the arrangement of 88 
DISEASES OE THE NOSE, THROAT, AND EAR 
the teeth in the Sajous saw. Hence this saw penetrates hard 
bone more rapidly than the others and is a preferable instru- 
ment when an exostosis is large or much sawing has to be done, 
as in the author's operation for deviated septum. Hall's saws 
and the beveled saw blades of Pynchon are excellent for small 
soft exostosis. To avoid leverage the sawing should be done as 
much as possible with the teeth nearest the operator's hand, 
and the saw teeth should extend up somewhat closely to the 
handle of the instrument (Fig. 46, e). 
Fig. 46.-Nasal saws: a, Bosworth's saw. The three varieties have teeth 
which are either "straight cutting," "back cutting," or "front cutting"; 6, Buck- 
lin's saw. The teeth are arranged like those of a metacarpal saw; c, d, Hall's saws, 
right and left, are beveled on the cutting edge, so that these saws may be sharp- 
ened on a stone in the same way as a knife; e, Sajous' saw. Has teeth arranged 
like the double-handled large cross-cut saws used by lumbermen to saw logs. This 
arrangement of the teeth prevents them from being clogged by sawdust, and hence 
Sajous' saw penetrates bone more rapidly than the others. 
Not infrequently, after the bone has been completely severed, 
it will be found difficult to cut with the saw the shreds of mu- 
cous membrane by which it is still attached to the septum. 
These shreds usually can be easily cut with the nasal scissors. 
However, in most instances the snare (Fig. 40) is by far the 
preferable instrument. It is especially useful in cases where a 
small exostosis has apparently been completely severed, but 
has disappeared from view in the blood within the nose. In 
some of these cases it is difficult to locate and grasp the mass 
with forceps, and impossible for the patient to blow it from the 
nostril because of a shred or two of uncut membrane; under DISEASES OF THE NOSE 
89 
these circumstances if the wire loop of a snare is passed beyond 
the position of the exostosis and then kept closely in contact 
with the septum, the loop will hardly fail to encircle any shreds 
that still connect the exostosis to the septum, and after these 
are severed by closing the loop the exostosis usually is with- 
drawn from the nose with the snare by means of fibers that 
have been drawn into the tube of the snare. 
Ecchondroses, occupying only the anterior portion of the 
septum, are best removed by a submucous operation, which is 
readily done by incising the mucous horizontally along the 
crest of the growth and elevating that above the crest with a 
probe-pointed tenotome. No attention need be paid to the 
mucous membrane below the crest, as that above is usually 
sufficient to cover the wound. The cartilage or bone is then 
removed with knife or saw and the mucous membrane re- 
placed over the wcund. Except that such wounds heal more 
quickly than when the mucous membrane has not been sacri- 
ficed, the method has no advantages except at the extreme 
anterior portion of the septum. In this locality the removal 
of much mucous membrane is often followed by annoying crust 
formations which may persist for many months or years. 
Drills.-The motive power for the drill is supplied through a 
flexible armpiece (such as is used by dentists) by a small electro- 
motor. 
The operation with the drill is performed in the following 
manner: After cocainization of the field of operation as already 
described, a trephine sufficiently large to remove at once the 
major portion of the exostosis is selected, and with its shield is 
adjusted to the armpiece of the electric motor in such a manner 
that the shield will protect all parts of the nose from injury 
except those to be cut away. The teeth of the trephine are now 
pressed into the anterior part of the growth, and as the instru- 
ment is pushed forward a piece of bone is cut from the exostosis, 
which enters the cavity of the trephine, where a knife set at an 
angle cuts it into pieces sufficiently small to pass through a 
fenestra made for this purpose. Should a sufficient amount 90 
DISEASES OF THE NOSE, THROAT, AND EAR 
of the growth not be removed by the first passage of the tre- 
p'hine through the nasal fossa, the trephine may be reapplied as 
often as may be necessary to remove the entire exostosis and 
leave a smooth, flat surface like that made by a saw. 
When an ecchondrosis or exostosis has attached itself to the 
inferior turbinated bone, so that a synechia or "bridge" 
extends from the septum to the opposite side of the nostril, it is 
perhaps best removed by first sawing through the portion next 
the septum, then snaring the attachment to the turbinate. 
Unfortunately, after such an operation the "bridge" is very 
liable to recur, owing to the granulations from the cut surfaces 
Fig. 47.-Gleason's electric-motor drill. 
of each side of the nostril approaching each other during the 
healing process until they finally unite. To prevent this dis- 
aster, a steel probe may be used to break down the adhesions, 
or a piece of tin-foil or gutta-percha may be worn inside the nose 
between the cut surfaces until the healing process is complete. 
Ordinarily, nasal operations, either with saw or chisel, reqiure 
no after-treatment beside the free use of an alkaline wash by 
the patient, in order to keep the wound clean. There is but 
little inflammatory reaction and the wounds heal promptly. 
Packing the nose with iodoform gauze or any other substance 
after a nasal operation should be avoided if possible. It is only 
permissible to check hemorrhage or when the patient has to 
travel a considerable distance after leaving the surgeon's office 
before reaching home. Under such circumstances a narrow 
strip of iodoform gauze, previously saturated with fluid albo- 
lene, should be placed in the nose in such a manner as to make 
gentle pressure upon the wound. Such a packing can generally 
be removed without hemorrhage, in from twelve to twenty-four 
hours, if care is taken to remove it gradually, so as not to 
remove the pressure from the wound too suddenly. 
When no dressing is used, which is by far the preferable DISEASES OF THE NOSE 
91 
method, blood-stained mucus is blown from the nose for some 
days after the operation. 
Atrophic rhinitis is an atrophic condition of the nasal mucous 
membrane, usually also of the submucous tissues, and the tur- 
binated bones and septum. In some cases because of a faulty 
development of the shape of the nose the nostrils look forward 
instead of downward. The disease is characterized by a les- 
sening in the size and thickness of the intranasal anatomy, a 
change in the color of the mucous membrane, a replacement of 
ciliated by squamous epithelium, and partial loss of function as 
the result of a decrease in the number of component cells, 
hence diminished secretion and the formation of crusts of inspis- 
sated and putrid mucus which emit a fetid and offensive odor. 
Etiology.-Atrophic rhinitis is said to result from long-con- 
tinued hypertrophic rhinitis, but the author never observed 
hypertrophic rhinitis assume the atrophic form except in a 
syphilitic; where, after the loss of the major portion of the 
septum, the nose presented a characteristic atrophic appear- 
ance, with loss of the sense of smell and fetid crust formation. 
Meissner states that atrophic rhinitis is the result of ^'primi- 
tive" or broad shallow nose, and to congenital development of 
pavement instead of columnar mucus-producing epithelium. 
An abnormal dryness of the atmosphere, like that produced 
by hot-air heaters, abnormal patulency of the nares, or any- 
thing else that causes a rapid evaporation of the nasal secre- 
tions, tend to produce atrophic rhinitis. In many instances 
the disease begins in childhood as a purulent rhinitis. Any 
infection with bacteria virulent enough to cause destruction 
of the nasal mucous membrane over comparatively large areas 
will produce atrophic rhinitis. Probably a majority of cases 
are the result of the destruction caused by pseudomembranous 
rhinitis and nasal diphtheria. Suppuration of the accessory 
sinuses may result from atrophic rhinitis or, according to Hurd 
and others, produce the disease. There is said to be present 
in most cases the bacillus fcetidus ozaenae, which was formerly 
thought the cause of the disease. Bacteria of various kinds 92 
DISEASES OF THE NOSE, THROAT, AND EAR 
swarm in the semi-putrid, half-dried secretions, and the stench 
is either directly the result of such masses, or may originate 
from the contents of suppurating accessory sinuses. 
Pathology.-As the result of the increased size of the nasal 
chambers the scanty secretions rapidly evaporate and, mixed 
with the inhaled dust, accumulate upon the mucous membrane, 
forming bad-smelling scabs and crusts. Owing to pressure from 
these scabs, shallow ulcers occur beneath them, while the 
atrophy progresses by the destruction of glands, nerves, blood- 
vessels, connective tissue, and bone until, in some cases, the tur- 
binates have nearly disappeared and the septum has become, 
at certain parts, almost as thin as a sheet of writing paper. 
It is not uncommon for individuals to present themselves to the 
surgeon with hypertrophic catarrh existing in one nasal cavity, 
while atrophic rhinitis is present in the other. In such cases 
there is usually deviation of the septum toward the hyper- 
trophic side. Cases are not infrequently seen with an inferior 
turbinated body and the adjacent mucous membrane atrophied, 
while the middle turbinated body immediately above is 
greatly hypertrophied. 
Concomitant disease of the ethmoid cells or of some one or 
more of the other accessory sinuses of the nose is not uncommon 
in atrophic rhinitis. When superficial necrosis results from 
bacterial infection the progress of the disease, after the forma- 
tion of ulcers, is similar to that described above. Retained 
secretions putrefy and produce a characteristic odor, horribly 
offensive, the disease being then termed ozena. Similar 
stenches occur in syphilitics, the stench resulting usually not 
from fetid semi-inspissated mucus, but from sequestra of dead 
bone within the nose. 
Somewhat numerous varieties of bacteria are found in the 
secretions of atrophic rhinitis, the saprophytes, or those 
causing putrefaction, naturally being the most numerous. 
The Klebs-Lbffler bacillus or that of Hoffman is frequently 
found. Attention has not infrequently been called to the large 
proportion of cases of pulmonary tuberculosis among patients DISEASES OF THE NOSE 
93 
with atrophic rhinitis; for instance, Theisen reports 14 cases 
of pulmonary tuberculosis among 40 cases of ozena examined. 
It has been suggested that the large proportion of consumptives 
is due to the fact that atrophic rhinitis deprives the nose of its 
power to arrest and destroy the bacteria of inspired air. 
Symptoms.-A sensation of dryness and irritation within the 
nose and pharyngeal vault, with almost constant efforts to re- 
move the accumulated secretions by hawking, spitting, and 
blowing the nose. The breath is usually fetid, but the patient, 
because of his defective sense of smell, is unaware that his 
breath is horrible offensive. Upon inspection, the mucous 
membrane is found dry and glazed, with scabs and pus adher- 
Fig. 48.-Allen's nasal applictor with Gottstein's cotton plug ready to be 
deposited inside the nose. After the cotton is within the nose the probe is detached 
from the cotton and withdrawn by turning it in a direction opposite to that by which 
the cotton was wrapped. 
ing to certain portions of it. Sometimes the nostrils are so 
patulos that the posterior pharyngeal wall can be plainly seen 
through them, and it also is usually in an atrophic condition. 
Yet, notwithstanding the patulos nares, patients usually com- 
plain of an inability to breathe through the nose. Reflex skin 
rashes, pharyngitis and laryngitis are very common as the 
result of this affection. Anemia frequently results from the 
obsorption of septic material and loss of the respiratory func- 
tions of the nose. 
Treatment.-The indications are to secure and maintain ab 
solute cleanliness of the nasal mucous membrane, and replace, 
if possible, the atrophied parts. Cleanliness may be secured by 
syringing with an alkaline wash. When the patient is wearing 
Gottstein's cotton cylinders within the nose there is usually no 
trouble in removing the secretions, as crusts usually cease to form. 
The best results are obtained in the treatment of atrophic 
rhinitis by the use of absorbent cotton, as first advocated by 
Gottstein (Fig. 48), so placed inside the nose as to perform the 94 
DISEASES OF THE NOSE, THROAT, AND EAR 
functions to a certain extent of the atrophied turbinated bodies. 
If pharyngitis sicca is present, the cotton cylinders should be of 
sufficient length to extend the entire length of the nasal floor 
and project somewhat from the posterior nares. The presence 
of the cotton cylinders excites the atrophied mucous membrane 
to renewed action, so that the dried secretions are washed away 
in the increased discharge and the fetor of the breath corrected. 
The cotton cylinders soon become soaked with mucus, so that 
the air passing around them is warmed, moistened, and freed 
from dust, and enters the pharynx and larynx as if it had passed 
through a healthy nose. This is the result partly of mechan- 
ical irritation and partly of the refraction of the inspired air- 
a factor that should not be overlooked in the treatment of atro- 
phic rhinitis, as irreparable damage results from the removal of 
an exostosis, especially if located well forward. 
A cotton cylinder is easily made by loosely wrapping absor- 
bent cotton about an applicator (Fig. 48) until it has assumed 
the desired bulk and shape. The cotton is then placed inside 
the nose and the applicator removed by turning it in a direction 
opposite to that by which the cotton was wrapped about it. 
The patient should be taught how to make and place these 
cotton cylinders inside his nose, and should insert fresh ones as 
soon as the old are removed by the use of the handkerchief. If 
worn constantly they cause an immediate change for the better 
in all the symptoms. However, a very large proportion of 
patients are unable to properly use this cotton. 
The condition of the accessory sinues should be carefully in- 
vestigated, and if diseased, should receive appropriate treat- 
ment. If practical, the patient should adopt an outdoor em- 
ployment away from dust and, if possible, near the seashore. 
Diphtheria antitoxin has been injected subcutaneously under 
the impression that the disease was due to the presence of the 
Klebs-Loffler bacillus in the nose or accessory sinuses. The 
temporarily good results reported were probably due to the stim- 
ulating effects of this substance on mucous membranes rather 
than to bactericidal action. DISEASES OF THE NOSE 
95 
So numerous are the drugs that have been used in the local 
treatment of atrophic rhinitis that a catalogue of their names 
and combinations would fill several pages. Among the best is 
sarlet red ointment. As most drugs and formula that are anti- 
septic and slightly stimulating afford at least temporary relief, 
the composition of the remedy is probably of much less impor- 
tance than the thoroughness with which it is applied to the 
angles beneath the remains of the middle turbinates and other 
not readily accessible parts of the nose. Nitrate of silver solu- 
tions have been used for many years in the treatment of atrophic 
rhinitis and at the present time there seems a tendency to return 
to their employment. After the nose has been cleansed of crusts, 
an applicator with a small, somewhat firmly wrapped piece of 
cotton is dipped into a solution of nitrate of silver and after 
being freed from drip is pressed into all accessible portions of 
the upper portion of the nose, especial attention being directed 
to locations in which accumulations occur. In such places 
the remedy is massaged, as it were, into the tissues by recur- 
rent pressure with the applicator; 2 up to 15 per cent, nitrate 
of silver may be used, but when the stronger solution is em- 
ployed, great care should be taken that there is no drip ex- 
pressed from the cotton to reach the pharynx and larynx. 
Attempts have been made with no great success to restore 
the original bulk of the turbinals by the injection of paraffin 
wax (Formula 85) underneath the nasal mucous membrane. 
The average case of atrophic rhinitis without disease of 
accessory sinues is best treated in the following manner: At 
the first office visit the nasal and nasopharyngeal mucous mem- 
brane is thoroughly cleansed and all adherent masses removed. 
Nitrate of silver solution (2 per cent.) is then thoroughly applied 
to the entire surface and carefully worked into all angles and 
spaces, such as those about the remains of the turbinated bodies. 
At the third or fourth office visit at intervals of three or four 
days the mucous membrane will have assumed a more normal 
appearance, and the patient should be taught to make and in- 
sert Gottstein's cotton cylinders. 96 
DISEASES OF THE NOSE, THROAT, AND EAR 
As soon as he has learned to do this properly and cleanse his 
nose efficiently the office visits should be made at less frequent 
intervals. 
He is ordered for home use a wash and instructed how to use 
it with a syringe. After cleansing the nose he should apply 
twice a day, by means of a brush, iodin, potassium-iodin-gly- 
cerin (Formula 112). If pharyngitis sicca and laryngeal symp- 
toms are very annoying small doses of iodid of potash (gr. ij to 
iv, t. i. d.) or syrup of hydriodic acid may be ordered with ad- 
vantage, to increase the secretions. 
Prognosis.-'Atrophic rhinitis is one of the most unsatisfactory 
and tedious of nasal diseases to treat. Fetor of the breath and 
the other more annoying of the patient's symptoms are easily 
and quickly corrected in the majority of cases by wearing 
Gottstein 's cotton cylinders, and something very like a cure of 
the disease after some years, will be finally brought about. 
The writer occasionally sees cases that he treated ten or more 
years ago. Some of these cases are cured to the extent that 
there is no fetor of the breath or retained secretions requiring 
removal, except during periods when the patient has caught 
cold. Others of these cases still wear the cotton cylinders, 
although not constantly, and by this method and by the use of 
nasal washes manage to maintain a fair degree of comfort. In 
some cases there has been a partial restoration of the sense of 
smell. 
Syphilitic rhinitis is a diseased condition of the interior of the 
nose dependent upon the presence of syphilitic virus. 
Pathology.-It is exceedingly rare to find the primary lesion 
of syphilis existing inside the nose, from the fact that the syph- 
ilitic virus is rarely introduced inside the nasal chambers, 
and that, should such an event occur, the secretions of the parts 
tend to wash away the morbid matter before inoculation takes 
place. Secondary lesions of the nasal mucous membrane are 
analogous to, and often coincide with, those appearing upon the 
skin. They vary from a mere erythema of the nasal mucous 
membrane with increased secretion to intense hyperemia and DISEASES OF THE NOSE 
97 
swelling, with the presence of mucous patches or shallow ulcers, 
secreting a sanious and offensive mucopus. During the tertiary 
period nasal gummata are by no means rare. They appear as 
irregular nodulated swellings distending the mucous membrane 
of any part of the interior of the nose. A nasal gumma may be 
absorbed, leaving in some instances a characteristic stellate 
cicatricial contraction, or it may break down and produce an 
ulcer, before which the cartilages and even the bony structures 
of the nose may melt away like wax as the ulceration rapidly 
extends, thus producing in a marvelously short time the most 
hideous deformity. Exuberant granulations may spring from 
the ulcerating gumma and completely fill the nasal chamber or 
even project from the nares, simulating a malignant growth. 
When the ethmoid has thus been necrosed and exfoliated, 
there may remain, after the healing process is complete, but 
a thin fibrous membrane between the interior of the nose 
and the brain. The lateral wall of the nose may be destroyed 
entirely, so that the antrum of Highmore and the affected side 
of the nose become one large cavity. In other instances the 
septum, nasal processes of the superior maxillary, and the nasal 
bones may be partly destroyed in such a manner that the nose be- 
comes flattened upon the face, producing a most serious deform- 
ity. In aggravated cases the soft parts may also be involved 
in the process, until finally the anterior nares are represented 
merely by an irregular hole in the face. During the ulcerative 
process of a gumma the breath is generally very offensive. 
Hereditary syphilis pursues the same course as the tertiary form 
of the acquired disease. 
Treatment.-Constitutional treatment is of primary impor- 
tance. Prompt amelioration of symptoms follows the injection 
of salvarsan. When for any reason this remedy cannot be 
employed, mercury and iodid of potassium yield, at least in 
tertiary lesions, almost as satisfactory results and in most cases 
a course of mercurial treatment should follow the salvarsan 
injection or injections. The primary and secondary lesions are 
probably best treated by the internal administration of a pill 98 
DISEASES OF THE NOSE, THROAT, AND EAR 
containing | gr. of the protoiodid of mercury (Formula 22). 
The patient may take from one to three of these pills three or 
four times a day, and, if necessary, a sufficient quantity of 
opium should be administered to prevent their producing diar- 
rhea. The pills are less likely to produce digestive derange- 
ments if taken after meals and at bedtime. Any ulceration upon 
the nasal mucous membrane should be touched every other day 
with the acid nitrate of mercury (1 to 4 parts of water) until 
they are healed; and the inflammation treated in the meanwhile 
as a case of simple chronic rhinitis. However, although the 
applications of acid nitrate of mercury are effectual in bringing 
about a rapid healing of the ulceration, they are somewhat pain- 
ful; and if the patient complains bitterly of the pain, a 12 per 
cent, solution of nitrate of silver should be substituted or the 
ulcerations merely may be dusted with powdered calomel. 
In tertiary syphilitic rhinitis the mixed treatment answers a 
very useful purpose, for, while the iodid of potassium is not a 
specific in syphilis in the sense that mercury is, yet it gives a 
much quicker result in controlling tertiary manifestations. One, 
two, or three teaspoonfuls of Formula 21 may be given three or 
four times a day, according to the emergencies of the case and the 
patient's susceptibility to mercury. Mercury may also at the 
same time be administered by inunctions, which are perhaps 
the most reliable and comfortable to the patient of any method 
of treating syphilis, as it rarely disturbs the digestion or causes 
ptyalism and can be used at any stage of the disease. How- 
ever, it stains the underclothing, and hence leads to the detection 
of the patient's condition by other members of the household. 
The patient prepares for a course of one week's inunctions by a 
preliminary hot bath and then each night rubs into the skin 
of the belly, chest, or back one dram of freshly prepared and 
scented mercurial ointment. The undershirt is not changed, 
but worn constantly during the week. At the end of this 
period the inunctions are either suspended for some days or 
weeks or continued at the discretion of the physician. Where 
the most speedy effect possible upon the syphilitic lesion is de- DISEASES OF THE NOSE 
99 
sired, mercury may be administered hypodermically. From 8 
to 20 minims of Formula 24 should be injected into the cellular 
tissue of the back every other day or at less frequent intervals. 
If thrown into the cellular tissue of the back, a solution of 
corrosive sublimate not stronger than that of Formula 24 
will not produce an abscess, but causes some pain. The first 
injection should be given deep into the cellular tissue beneath 
the skin under one shoulder-blade; the second injection 
beneath the skin of the other shoulder-blade; the third, 4 
inches below the first; the fourth, 4 inches below the second, 
and so on down the back. But a few hypodermic injections arc 
ordinarily required to limit the spreading of a gummatous ulcer, 
which speedily assumes a more healthy appearance. In cases 
where gummata are so situated as to cause obstruction to nasal 
respiration, pain, and intense headaches from pressure, the 
action of medicines upon the growth are too slow and operative 
procedures must be resorted to. A gumma may be removed 
from a turbinated bone with the snare or scraped from the 
septum with a large nasal curette. Such operations, however, 
should not be performed upon patients of debilitated constitu- 
tions, or those who are not, or cannot quickly be brought under 
the influence of mercury, as otherwise the wound made by 
the operation will not heal and may result in extensive ulcera- 
tion. When a nasal gumma has broken down and is ulcerating, 
the parts should be kept scrupulously clean by the use of an 
alkaline solution (Formulas 1 to 5), and the wound stimulated 
to heal by the daily application of acid nitrate of mercury di- 
luted with 4 parts of water. Wounds resulting from operations 
upon gummata should be treated in the same way until the 
healing process is complete. 
Goundou, henpue, or dog nose is a proliferating periostitis 
beginning in the nasal processes. It usually follows and is 
probably identical with frambesia or yaws which is a tropical, 
contagious skin disease due to constitutional infection with a 
spirillum. The primary sore is usually extragenital. The 
secondary skin lesions from their resemblance to raspberries 100 
DISEASES OF THE NOSE, THROAT, AND EAR 
give the name yaws to the disease. The lesions of the tertiary 
stage closely simulate those of syphilis but the Wassermann 
reaction is negative. It is most common and fatal in children. 
Adults seldom die from it. 
Treatment consists in the administration of iodid of potas- 
sium. Mercury is said to be useless. Nasal hyperosities 
may require removal by the chisel or rongeur forceps. 
Tubercular rhinitis is an inflammation of the interior of the 
nose characterized by the presence of tubercle bacilli. 
Etiology.-The disease is usually the result of the inoculation 
of the nasal mucous membrane by morbid material from an- 
other portion of the body of a tuberculous individual. 
Pathology.-'The most common lesion observed is a small 
ulceration, usually on the septum or floor of the nose. Occa- 
sionally hyperplastic nodules and papillomata, pale in color and 
either pedunculated or sessile, are observed. 
Symptoms.-'Crusts form upon the ulcerations and are blown 
from the nose. The ulceration may progress to perforation of 
the septum. The hyperplastic growths sometimes attain 
sufficient size to cause nasal obstruction. 
Diagnosis.-'The disease in its ulcerative form somewhat 
resembles syphilis; but as it rarely occurs except in individuals 
with advanced pulmonary tuberculosis, the diagnosis usually 
is easy. The surrounding mucous membrane is much paler 
than in syphilis; indeed, the whole mucous membrane of the 
nose is usually anemic. In doubtful cases, iodid of potassium 
exhibited for a few days in ro-gr. doses every three or four hours 
will usually decide as to whether syphilis is the cause of the 
ulceration. However, it should be remembered that tubercu- 
lous individuals frequently do badly under iodid of potash, and 
the "therapeutic test" should, therefore, be used with care to 
prevent irreparable damage. The Wassermann reaction, while 
only conclusive if positive, is preferable in advanced cases, and 
it is better in practically all cases when the diagnosis between 
syphilis and tuberculosis is doubtful to test for syphilis before 
resorting to the tuberculin test (see page 557). Papillomatous DISEASES OF THE NOSE 
101 
outgrowths examined microscopically show the presence of 
tubercle bacilli. 
Treatment.-The local treatment consists of cleanliness of the 
nasal cavities by the patient's use of an atomizer containing 
an alkaline wash, followed by spraying the nose with menthol- 
camphor-albolene. The physician may cleanse the ulcerations 
and touch them with solid nitrate of silver fused on the end of 
a probe (Fig. 41). Large papilloma may be snared, but it is 
advisable to do no unnecessary surgery in a tuberculous nose. 
As the disease rarely, if ever, occurs except in advanced pul- 
monary tuberculosis, the general treatment is more important 
than the local. 
Lupus.-The name lupus is applied somewhat loosely to 
various skin diseases: Lupus erythematosa, lupus congestiva, 
lupus superficialis, lupus sebaceus. Lupus erythematosa 
first appears as grouped red spots that ultimately coalesce 
into slightly raised patches. The initial lesion is always ery- 
thematous and, unlike lupus vulgaris, there is no tendency to- 
ward ulceration. 
Lupus vulgaris sometimes originates at the tip of the 
nose, either upon the mucous or, more often, on the skin 
surface. 
Etiology.-'The cause of the disease is tubercle bacilli. 
Pathology.-'The lesion manifests itself as reddish-brown 
nodules. These atrophy, leaving scars, or ulcerate, involving 
sometimes large areas of skin, mucous membrane, and carti- 
lage. A large portion of the tip of the nose and septum may be 
destroyed. The ulcer is often covered by a brownish scab; 
when this is removed the ulcer appears filled with a granular 
"applejelly''-like mass, which can be readily scraped away 
with a curette. Deep cicatrices and deformities result from the 
healing of the ulcer. It may cicatrize at one extremity, while 
the progress of the ulceration is active at the other. The dis- 
ease is uncommon in America. 
Diagnosis.-Lupus so much resembles syphilis that the diag- 
nosis usually has to be established by the Wassermann reac- 102 
DISEASES OF THE NOSE, THROAT, AND EAR 
tion, or the exhibition of iodid of potassium. From epithe- 
lioma it is differentiated by the microscopic findings. 
Treatment consists in the daily application of the x-ray. 
Rhinoscleroma is a disease of the mucous membrane of the 
nose extremely rare in North America, but occurring in Brazil, 
Russia, Italy, and other countries. 
Etiology.-According to some authorities the disease is the 
result of the presence of a characteristic bacillus. 
Pathology.-The disease produces nodular hypertrophies on 
the nose and sometimes within the nose, pharynx, and larynx. 
Ulcers appear upon the mucous surfaces resembling the lesions 
of tertiary syphilis. The contraction of dense cicatrices some- 
times results in deformities. 
Symptoms.-There is little or no pain at any stage of the dis- 
ease. The growth inside the nose may interfere with nasal 
respiration, and when the mouth and pharynx are involved it 
may be impossible for the patient to swallow solids. Involve- 
ment of the larynx may be sufficient to interfere with respira- 
tion as the result of cicatricial contraction. 
Treatment.-As the disease has a tendency to recur, operative 
interference is inadvisable, except tracheotomy when necessary 
to prevent death from stenosis of the larynx. Lang recom- 
mends salicylic acid locally and in xo-gr. doses internally. 
Leprosy of the Nose.-'According to Sticker and others the 
nose in the earlier stages of leprosy is the site of lesions dis- 
charging leprous bacilli, and while the statement that the 
initial lesion is usually upon the nasal septum has not been 
proved by clinical observation, yet, as stated by Brinkerhoff 
and Moor, "When it is not practicable to make a complete 
physical examination of all individuals of a class suspected 
of leprosy the examination of the nasal septum and the bac- 
teriologic examination of the nasal secretions will prove of 
value by permitting the recognition of the most dangerous 
type of the disease, and is therefore worth while even if it 
does not reveal all cases of the disease in those who come 
under observation." DISEASES OF THE NOSE 
103 
The theory that the initial lesion is usually nasal is prob- 
.ably untenable. H. T. Hollman, one of the physicians in 
the Kalanpapa Leper Colony, Hawaiian Islands, states that in 
an early stage of the disease the symptoms are those of hyper- 
trophic rhinitis, the nasal chambers being sometimes completely 
occluded by the swollen turbinates. Sometimes small tubercles 
are present that degenerate into small-sized ulcers, which, 
however, heal nicely under appropriate local treatment. In 
neglected cases the symptoms do not differ from those of ordi- 
nary atrophic rhinitis: there is atrophy, foul-smelling accumu- 
lations, and loss of the sense of smell. Perforations involving 
in some cases nearly the entire septum are common. Indeed, 
the appearance of the interior of the nose not infrequently re- 
sembles that of neglected tertiary syphilis. 
Treatment.-Improvement invariably resulted in Hollman's 
cases from the use of a 25 per cent, spray of eucalyptus oil 
in albolene. In the atrophic cases discharge and odor dis- 
appeared after the use of eucalyptus spray and rubbing into 
the parts ichthyol (20 per cent.) in glycerin. 
Nasal Myiasis.-Occasionally the larvae or maggots of the 
ordinary house fly are found in the nose or ear of individuals 
with foul discharges. However, their presence is incidental, 
and not a cause of the disease. As the result of the deposit of 
the eggs of the screw-worm fly (Campsomyia macellaria) 
within the nasal chambers of man and the domestic animals, 
there results severe symptoms often terminating fatally. In 
America the screw-worm fly is found from the Argentine Re- 
public to Canada, but the greatest amount of damage is done 
in tropical and subtropical sections. A single fly is capable of 
depositing hundreds of eggs which hatch in less than twenty- 
hour hours. The worm or maggot reaches maturity in about 
a week, during which time its ravages in animal tissue are most 
destructive. It then instinctively abandons its unwilling host 
and buries itself in the earth during the puparial state, which 
occupies about fourteen days, and emerges a mature fly. 
Symptoms.-'The initial symptom is a peculiar sensation at 104 
DISEASES OF THE NOSE, THROAT, AND EAR 
the base of the nose followed by inordinate sneezing and, finally, 
excruciating pain over the frontal sinuses and the maxillary 
antra, probably as a result of the penetration of maggots into 
these cavities. There is a temperature of about 1020 F. and in 
severe cases delirium may be present. Within a few days there 
is a foul-smelling discharge from the nose, which, however, 
does not contain maggots until, as already stated, after a 
week's sojourn in the tissues they instinctively seek the earth 
to undergo their transformation into mature flies. 
On inspection, the interior of the nose may present a necrotic 
or gangrenous appearance. The soft parts may be destroyed, 
exposing bone which may become necrosed. The palate is 
sometimes perforated and swallowing or speaking may be im- 
possible because of swelling or destruction of tissue; fetid odors 
then sometimes occur and pneumonia may result from in- 
spiration of septic discharges. 
Treatment.-'Pain is usually sufficient to require morphin. 
Chloroform is a specific to the extent that the maggots are either 
killed by its vapors or wriggle from the deeper tissues into a 
superficial position, whence they are readily removed. The 
inflamed tissue become remarkably tolerant to its local 
irritation and 25 per cent, in olive oil may be injected two or 
three times a day. 
Foreign Bodies in the Nose.-Children and insane persons 
occasionally insert into their noses buttons, cherry-stones, 
beads, beans, twigs, hair-pains, etc. Necrosed bones, when 
detached, act as foreign bodies and produce their character- 
istic symptoms. Rhinoliths, ascarides, and maggots are also 
found in the nose, and may be considered as foreign bodies. 
Symptoms.-Obstructed nasal respiration proportionate to 
the size of the foreign body. If the foreign body is large or 
causes pressure, headache and pain of a neuralgic character are 
complained of. At first the presence of a small foreign body 
in the nose of a child attracts but little attention unless the 
child tells its parent there is something in its nose. After a 
time a discharge of glairy mucus occurs, which excoriates the DISEASES OF THE NOSE 
105 
skin of the lips and alee, but the discharge soon becomes puru- 
lent and may be streaked with blood and be fetid. A one- 
sided discharge from a child's nose is almost pathognomonic of 
a foreign body, and under such circumstances the most care- 
ful and painstaking search should be undertaken to discover 
the offending particle. 
Rhinoliths generally contain as a nucleus a foreign body 
around which the nasal secretions accumulate and deposit a 
coating of earthy salts, gradually increasing in thickness. The 
presence of a rhinolith causes practically the same symptoms 
as that of a foreign body of similar size and shape. 
Treatment.-The foreign body or bodies should be removed 
by means of a pair of forceps or a blunt ear curette. 
Rhinoliths may sometimes be removed whole or may have 
to be broken up by means of a powerful pair of forceps in order 
to remove them from the nose. 
Neuroses of the Nose. Motor Neurosis.-'Twitching of the 
nose and eyelid is generally due to peripheral irritation of some 
branch of the facial nerve. It occasionally occurs as the re- 
sult of the application of the galvanocautery to an anterior 
hypertrophy. 
Paralysis of the dilatores nasi produces a collapse of the lat- 
eral walls of the anterior portion of the nose that decidedly in- 
terferes with nasal respiration. Unilateral paralysis of the 
dilator nasi occurring in childhood, according to some of 
the older writers, is one of the causes of deviation of the nasal 
septum. The partial stenosis in long thin noses, due to the 
valvular action of the anterior portion of the sides of the nose 
by which inspiration is impeded, can be entirely alleviated by 
cutting a strip of requisite length from a visiting card, bending 
it, and placing it with its ends up inside the vestibule of the 
nose in such a manner that it acts as a spring holding the ante- 
rior nares open. However, in such cases the valve-like action 
of the anterior portion of the sides of the nose disappears 
permanently in many instances by increasing the breathing 106 
DISEASES OF THE NOSE, THROAT, AND EAR 
space by the removal of a small ecchondrosis from the septum 
or cauterization of the inferior turbinate. 
Sensory Neuroses.-Anosmia, or loss of the sense of smell, 
may be congenital or acquired. If acquired, the condition 
may be due to syphilis, hysteria, or result from lesions of the 
olfactory bulbs produced by meningitis, tabes, or the pressure 
of a brain tumor. Disturbances of the sense of smell amount- 
ing to almost complete loss occur from any cause that prevents 
odorous particles reaching the portions of the nose where the 
peripheral nerve-endings of the olfactory nerves are distributed. 
An ordinary cold, hypertrophic rhinitis, or polypi frequently 
cause mechanically greater or -less loss of the sense of smell, 
which returns after the mechanical obstruction is removed. 
In atrophic rhinitis affecting the vaults of the nasal chambers 
there is generally great impairment of the sense of smell, which 
in some cases is partly restored when crusts and accumulations 
no longer form. In inflammation of the ethmoid cells, espe- 
cially in those cases where the middle turbinates are sufficiently 
swollen to press on the septum, great impairment of the sense 
of smell is usually present. 
Hyperosmia is an increased sensibility of the olfactory ap- 
paratus. The ability to detect odors, generally stenches, is 
intensified. The condition is sometimes observed in nervous 
women. 
Parosmia is a perversion of the sense of smell associated with 
local or systemic disturbances, insanity, etc. The sensation of 
a bad odor is sometimes a part of the aura of epilepsy. 
Hyperesthesia and anesthesia of the nasal mucous membrane 
are occasionally encountered. 
Paresthesia, or the sensation of imaginary stenosis or foreign 
bodies in the nose, occurs in a certain proportion of neurotics. 
It is not an unusual thing for such patients to complain of 
stenosis when the condition present is atrophic rhinitis with 
widely patulous nasal chambers. 
Reflex nasal neuroses are classified according to Jurasz into: 
i, Those with the initial point of the reflex circuit within the DISEASES OF THE NOSE 
107 
nose; 2. those in which the initial and end points of the circuit 
are within the nose; and 3. those in which the end point only 
is within the nose. To the first class belong asthma, reflex 
cough, spasm of the pharynx and glottis, and rarely epilepsy, etc. 
To the second group belong hay fever, and nasal hydrorrhea. 
The third group consists of cases where there are nasal symp- 
toms or changes as the result of abnormalities of the genital 
tract. Examples are the violent fits of sneezing produced 
in some males by sexual excitement and congestion of the nasal 
mucous membranes in either sex during the period of court- 
ship, control of the pain of dysmenorrhea by applications of 
cocain to the so-called nasal genital spots of Fliess which are 
the tuberculum septe and the anterior portion of the inferior 
turbinate. These are spots of great susceptibility to irri- 
tants on the lateral wall of the nose above the anterior end 
of the middle turbinate and on the septum anterior to this 
locality. In asthmatics, touching one of these spots will 
sometimes bring on an attack which subsides when cocain 
is applied. Light cauterization is sometimes of value in the 
treatment of such cases. 
Hay-fever, or coryza vasomotoria periodica, is a chronic 
nasal affection depending upon disturbance of the nervous 
system, and particularly of the various nerves supplying the 
nasal mucous membranes, and characterized by periodic ex- 
acerbations caused by inhaling dust or other irritants. 
The synonyms-hay-asthma, autumnal catarrh, rose cold, 
horse cold, cow cold, peach cold, snow cold, miller's asthma- 
are names given to the affection and supposed to indicate the 
irritant which is the direct cause of the attack of the disease. 
Etiology.-'There are three factors in the causation of an 
attack of hay-fever, viz.: First, a pathologic condition of the 
nasal chambers; this may comprise anterior or posterior hyper- 
trophies, exostoses, ethmoiditis; but more especially the pres- 
ence of hypersensitive areas, distinguished by their heightened 
color and slight elevation above the surrounding mucous mem- 
brane. Irritation of one of these spots with the end of a probe 108 
DISEASES OF THE NOSE, THROAT, AND EAR 
even during the winter time will bring on an attack of hay-fever 
lasting from an hour to several days; second, a diseased or, at 
least, an irritable condition of certain nerve-centers, giving rise 
to a train of near and remote symptoms by reflex action; third, 
the presence of an external irritant. The absence of any one 
of these factors is sufficient to prevent an attack. 
Symptoms of an attack of vasomotor coryza are those of 
coryza-a sense of dryness and itching in the nose, violent 
sneezing, occlusion of the nares, and profuse watery discharge. 
These symptoms are usually followed by conjunctivitis, lacri- 
mation, photophobia, headache-often of a neuralgic character 
-a hacking cough, asthma, and a general feeling of malaise. 
Treatment.-The most effective treatment of periodical 
hyperesthetic rhinitis is a sea-voyage lasting through the entire 
hay-fever season or residence in a region free from the presence 
of irritating pollens and dust, like that of the White Mountains 
of New Hampshire. (See Climatology.) 
For professional and business men, however, such a treat- 
ment involves hardships and loss of business opportunities 
that render it acceptable only as a last resort. Therefore any 
treatment that will enable the sufferer to remain at home in 
comparative comfort and attend to business is eagerly sought 
by the majority of workers suffering from hay-fever. 
The attention of the profession, chiefly through the writings 
of Seth Scott Bishop of Chicago, has been directed to the fact 
that the neurotic condition of the patient and the hypersensi- 
tiveness of the nasal passages were often due to an excess of uric 
acid in the blood, and that this excess could be eliminated by 
the ingestion of mineral acids. 
Probably any mineral acid would prove efficacious, but there 
are two which suggest themselves as peculiarly efficacious: 
hydrobromic acid, because of its sedative qualities, and nitro- 
muriatic acid, because it is thought to limit the production 
of uric acid. 
The writer's experience has been limited to the effects of 
nitromuriatic acid, which has been prescribed in doses of 5 to 10 DISEASES OF THE NOSE 
109 
drops of the freshly prepared concentrated acid after meals and 
sometimes also at bedtime. The dose should be diluted with a 
tumblerful of water, and the patient, after taking the medicine, 
should rinse out his mouth and swallow another half-tumberful 
of water. 
When effective, the results of the remedy are apparent within 
forty-eight hours, and the relief of all hay-fever symptoms is 
usually sufficient to enable the patient to remain at home and 
attend to his ordinary business engagements in comparative 
comfort. If, however, a single dose is omitted, some symp- 
toms of hay-fever will appear within a few hours. This is 
especially true if the remedy is not taken after the evening 
meal, as, under such circumstances, the patient usually wakes 
up the next morning with occluded nares and suffused eyes. 
Between the attacks of hay-fever measures should be adopted 
to improve the patient's general health and correct any abnor- 
mality of the interior of his nose. The practitioner, however, 
should not be too sanguine as to the beneficial results to be 
obtained by such measures, for it should be borne in mind that 
hay-fever not infrequently occurs in vigorous individuals the 
interior of whose noses present no gross abnormality except 
during the hay-fever season. 
There is, however, one condition of the nose that is appar- 
ently present in all individuals suffering from hay-fever, and 
that is the presence of hyperesthetic areas upon the respiratory 
portion of the nasal mucous membrane, which when touched 
with a probe cause sneezing and lacrimation. 
The hypersensitive condition of such areas may be destroyed 
one or two at a time, even during the hay-fever season, without 
adding to the discomfort of the patient by either palliative or 
radical methods. 
The palliative method consists of cocainizing the nose and 
touching the sensitive area with a io per cent, solution of 
chromic acid applied by means of a cotton-tipped probe. The 
radical method consists in destroying the sensitive area with the 
galvano-cautery. A small cautery-knife should be selected, 110 
DISEASES OF THE NOSE, THROAT, AND EAR 
and the current should be sufficiently strong to instantly bring 
its tip to a white heat. After cocainizing the nose, the cautery- 
tip is moved over the mucous membrane until a sensitive area is 
discovered. The current is then turned on for an instant and 
the cautery-knife withdrawn. Very little destruction of the 
membrane results, and should hemorrhage occur, no undue 
haste should be used in controlling it, as the local depletion is 
beneficial rather than otherwise. 
Temporary relief may be obtained during the worst stages of 
the attack by spraying the nose with a weak alkaline i per cent, 
solution of cocain, and afterward with fluid vaselin as a pro- 
tective. It is, of course, justifiable to use cocain during an 
office treatment, but cocain should not be prescribed for the 
patient's home use, as hay-fever victims are often, because of 
the neurotic temperament, the class of people most liable to 
contract the cocain-habit. 
As a home treatment the patient may spray the nose every 
hour or two, if necessary, with a solution of adrenalin hydro- 
chlorate in the strength of i: 10,000 or 1:20,000. The solution 
should be freshly made and free from antiseptics, and for these 
reasons the drug is best prescribed for patients' use in the form 
of a small tablet which when dissolved in the proper amount of 
water forms a solution of the required strength. However, in 
many instances oily preparations are more efficient than watery 
solutions, and an ointment made up with lanolin and vaselin of 
a strength of 1:10,000 is of decided value. It is conveniently 
dispensed in collapsible tubes, so that the patient can carry it 
about in his pocket and squeeze out from the tube from time 
to time the amount of ointment required. A piece the size of a 
pea may be inserted into each side of the nose every two hours 
by a brush or simply with the tip of the little finger. The head 
is then thrown back until the ointment melts and distributes 
itself over the nasal mucous membrane. Adrenalin (1:1000) 
in oil may be applied by means of a nebulizer. This form of 
medication, because of the minute amount of adrenalin actually 
deposited in the nose, is most successful in the mild cases. DISEASES OF THE NOSE 
111 
After the attack has subsided, all pathologic conditions of the 
nose should be removed, and the sensitive areas cauterized with 
a small galvanocautery-knife. 
Professor Dunbar, of Hamburg, has prepared hay-fever 
antitoxin by the inoculation of horses with the toxins obtained 
from the albuminoid body found in the starch particles of 
pollen. The serum obtained from the horse is dispensed either 
in a liquid or dry form, and is designated to be applied to the 
mucous membranes of the nose and that of the eyes when 
required. 
The serum has been named Pollantin, and two forms are on 
the market, one prepared from rye pollen, especially used for 
spring and summer hay-fevers or "rose cold," and the other, 
prepared fron ragweed pollen, designed as a remedy for the 
hay-fever occurring in the late summer and fall. 
Dunbar believes that hay-fever is the result of a specific 
poison found in pollens, and his antitoxin is designed to immu- 
nize patients against pollen toxins when used previous to the 
hay-fever season, and also to palliate the symptoms in cases 
where the disease has already made its appearance. 
When applied to the inflamed mucous membrane of the nose 
or eye, pollantin produces a sensation of ease and comfort which 
persists for some time. 
There are a number of drugs which when taken internally are 
capable of at least mitigating the severity of the local symptoms 
of hay-fever. The more important are atropin, hyoscyamus, 
heroin, quinin, monobromate of camphor, and strychnin, and 
in cases where nitromuriatic acid fails to afford relief, a com- 
bination of two or more of these drugs may be prescribed (For- 
mulas 53-59). 
In cases where there is manifestly an excess of uric acid in 
the tissue, a course of salines (Formula 52) and restricted diet 
should be prescribed at least during the period immediately 
preceding the expected attack. 
Prognosis.-It is not unfavorable. Many cases completely 
recover. The patient should be kept under observation and DISEASES OF THE NOSE, THROAT, AND EAR 
112 
occasionally treated for at least three years after an apparent 
cure to prevent the danger of a relapse. 
Nasal hydrorrhea is a disease characterized by a clear watery 
discharge from one or both nostrils as the result of some irrita- 
tion or disturbance, either peripheral or central, of the vaso- 
motor supply of the nasal mucous membrane. 
Ecology.-In one class of cases the flow of fluid from the nose 
is perfectly passive and causes no inflammation. The phe- 
nomenon is probably due in such cases to a paresis of the nasal 
branches of the trifacial nerve, which exercises an inhibitory 
action upon the normal exosmosis of serum in the nasal mucous 
membrane. 
In a second class of cases the flow of serum is accompanied by 
great congestion and swelling of the Schneiderian membrane, 
and the phenomena are the result of an irritation of the vaso- 
motor nerves. In this second class of cases the congestion and 
inflammation of the nasal mucous membrane and the conse- 
quent watery discharge are greatly increased by cold and by 
inhaling dust and other irritants. Indeed, the symptoms are 
somewhat similar to those of hay-fever. 
Symptoms.-In the first class of cases there is an almost 
constant dropping of a clear watery fluid from one or both nos- 
trils. In the second class of cases the discharge is more remit- 
tent in character, according to the amount of irritation of the 
Schneiderian membrane. 
Treatment.-'Richard Lake claims that the blood is the source 
of trouble in many instances and successfully treated severa, 
cases with calcium chloride 35 to 45 grains a day for two weeks. 
The rhinorrhea was not only completely relieved but recurred, 
if at all, only at long intervals easily remediable by treatment. 
Disease of the ethmoid cells (page 181) sometimes produces 
rhinorrhea which ceases when the ethmoidal condition receives 
appropriate treatment. In some cases adrenalin acts as a 
specific. A solution of the strength of 1:20,000 up to 1:1000 
should be sprayed upon the nasal mucous membrane sufficiently 
often to control the symptoms. From 2 to 5 gr. of the extract DISEASES OF THE NOSE 
113 
of suprarenal capsule also should be taken every three hours, 
the patient being instructed to cease taking the remedy should 
disagreeable heart symptoms manifest themselves. In some 
cases a cessation of the discharge occurs within a few days, and 
the use of the remedy should then be discontinued. 
Sometimes astringents applied locally answer a useful pur- 
pose, and an ointment of gallic acid (io gr. to the ounce of vase- 
lin with i or 2 gr. of menthol) may be prescribed with benefit. 
Cerebrospinal rhinorrhea is a discharge of cerebro-spinal 
fluid through the nose and should be carefully differentiated 
from nasal hydrorrhea which is simply a discharge from the 
nasal mucous membrane. The amount of cerebro-spinal 
fluid discharged in 24 hours may reach 12 to 16 ounces. 
The diagnosis of such cases rests upon an analysis of the 
fluid. Normal cerebro-spinal fluid is transparent and colorless 
and may deposit cells from the cerebro-spinal cavity. It is 
alkaline, with a faint reaction for sodium chlorid. Heat and 
nitric acid yield no deposit, but on cooling a slight white cloudi- 
ness indicates the presence of albumose. It usually reacts with 
an orange-red deposit to Fehling's test. The prognosis as to 
cessation of the discharge is not good, yet patients have lived 
for many years without fatal infection of the meninges, but 
about 75 per cent, of the cases reported suffered from optic 
neuritis, atrophy, or hemiopia. No treatment is effective, but 
headache, drowsiness and other cerebral symptoms improve 
when the flow is free. Occasionally the discharge ceased 
abruptly. 
Nasal Hemorrhage. Etiology.-It is an old saying that re- 
current hemorrhage from the nose may be a warning, a remedy, 
or a disease. 
The bleeding may be the result of some disease of the blood, 
of which the most common are plethora, purpura, hemophilia, 
and the condition of the blood brought about by typhoid and 
the eruptive fevers. Diseases of the blood-vessels, the result 
of atheroma or syphilis, are predisposing causes, while the in- 
creased blood-pressure resulting from Bright's disease and 114 
DISEASES OF THE NOSE, THROAT, AND EAR 
organic disease of the liver, heart, lungs, or kidneys are fre- 
quently early manifested by bleeding from the nose. 
No good observer probably has failed to be impressed with 
the very evident correlation existing in most of our domestic 
animals between the nose and the sexual organs exhibited 
during the rutting season. Similar phenomena occasionally are 
observed in the human race, and many amusing stories are 
told in illustration. 
Erectile tissue occurs in but three portions of the human 
body: the nose and throat, the nipples, and the sexual organs. 
In the male, puberty is accompanied by a change of voice, and 
nosebleed is not uncommon at this time in either sex; in the 
female, sometimes as a vicarious menstruation. Recurrent 
nosebleed is said to be aggravated by masturbation. 
Ulcerations and neoplastic growths within the nose are some- 
times hemorrhagic. Angiomata, carcinomata, sarcomata, and 
especially fibromata frequently bleed at the slightest touch. 
Severe and repeated nasal hemorrhage, when .it occurs in a 
youth with a nasopharyngeal tumor, is almost diagnostic of 
fibroma. 
Traumatism is a frequent cause of hemorrhagia narium. If 
the blood flows from each side of the nose in equal amounts, it 
is somewhat suggestive of injury to the vault of the pharynx or 
even fracture of the base of the skull, because hemorrhage from 
injury to the nose alone is usually unilateral. However, blood 
from the nose may be swallowed or drawn into the bronchi and 
afterward coughed up or vomited in a manner suggestive of a 
pneumonic or stomachic origin of the hemorrhage. It is not 
always easy to make a diagnosis between bleeding from the vault 
of the pharynx and hemoptysis. 
The nasal vessels are not supported by a muscular cushion 
into which they may be crushed by a blow, but lie in more or 
less intimate contact with bone or cartilage, and are only pro- 
tected by extremely delicate mucous membrane, and hence a 
slight injury is sufficient to cause hemorrhage, which is profuse 
and long continued because the proximity of bone or cartilage DISEASES OF THE NOSE 
115 
prevents the ends of the severed vessels from contracting aS 
readily as if they were imbedded in soft tissue. When sawing 
exostoses from the septum an artery within the bone is occa- 
sionly encountered, and because the end of the vessel is held 
wide open by its attachments to the bone, hemorrhage is in- 
variably profuse and long continued. Such cases require rad- 
ical measures to control the flow. Fortunately, however, ar- 
teries within such growths are comparatively rare. Since the 
use of adrenalin solutions before nasal operations it is said that 
secondary hemorrhages after nasal operations are more com- 
mon. The usefulness of this drug has its limitations. Its ef- 
fects only penetrate a certain depth into the tissues and it, of 
course, has no effect on a vessel deeply imbedded in bone. The 
reaction after its use as a therapeutic agent to control conges- 
tion is much greater than that of cocain, and therefore, it 
must be used for this purpose only in dilute solutions. 
The prognosis of all forms of nasal hemorrhage is generally 
favorable, but few fatal cases having been reported. 
Pathology.-The great vascularity of the nasal mucous mem- 
brane readily explains the great frequency of nasal hemorrhage. 
In most cases of spontaneous origin the bleeding is from the 
neighborhood of the septal artery-i. e., from the anterior part 
of the septum. Wounds resulting from surgical operations 
upon this portion of the nose frequently bleed profusely, al- 
though an artery is sometimes observed to " spurt " in the wound 
of an operation done further back upon the septum, while spon- 
taneous bleeding may occur from posterior hypertrophies or 
adenoid vegetations. In such cases the blood flowing down- 
ward into the fauces is expectorated and is frequently mistaken 
for a hemorrhage from the lungs. 
Treatment.-If after an operation severe hemorrhage has oc- 
curred, and it is known from what spot the bleeding occurs, a 
small mass of absorbent cotton or "Bernays' sponge" (Fig. 49) 
should be placed within the nose over the bleeding vessel. 
Bleeding may occur from any portion of the nose, but it is 
most common from the anterior portions of the septum. In 116 
DISEASES OF THE NOSE, THROAT, AND EAR 
cases of recurrent nosebleed, after an attack, a small clot, a 
yellow spot, or a varicose condition of the veins upon the sep- 
tum will mark the seat of the hemorrhage. Under such circum- 
stances the patient should be directed to apply daily, by means 
of a brush, an ointment of gallic acid (io gr. to an ounce of vase- 
lin), and to avoid violently blowing the nose. Should the 
vessels be very numerous and varicose, this treatment will 
hardly suffice, and it will be necessary to destroy the vessels by 
a touch of the galvanocautery or chromic acid. It is not well to 
apply the galvanocautery or chromic acid too vigorously, as 
the cartilage of the septum has not much vitality, and too vig- 
orous application of either caustic may result in perforation. 
Simply singe the mucous membrane lightly with the flat side of a 
small cautery-knife. A whitish spot upon the mucous mem- 
Fig. 49.-Simpson's intranasal tampon shaped from "Bernays' sponge" or 
compressed cotton. When inserted within the nose, the cotton rapidly absorbs 
moisture and swells to many times its original thickness, thus exerting sufficient 
lateral pressure to control nasal hemorrhage. In wide noses two or even three 
tampons may be inserted side by side, although this is seldom necessary to con- 
trol hemorrhage. If too large, the tampon may be cut into the required shape 
with scissors. Strips of Bernays' sponge about 3 inches long and 12, 14 or 16 M. M. 
wide are often more convenient than Simpson's tampons. 
brane and the disappearance of the outline of the vessel indi- 
cates that the burn will be effective. 
Occasionally recurrent nosebleed is the result of a small ul- 
ceration or erosion of the mucous membrane of the anterior 
portion of the septum, generally in a hollow caused by a slight 
deviation of the septum or a cartilaginous spur within the nose. 
Because of the hollow upon the septal wall, mucus dries until 
the bulk becomes sufficient to extend above the hollow into the 
air-current, when it is dislodged by violently blowing the nose 
or by sneezing. Under such circumstances a minute portion of 
mucous membrane is carried away with the inspissated mucous 
and hemorrhage occurs. Sometimes the hemorrhage occurs DISEASES OF THE NOSE 
117 
from dislodging such masses of mucus with the finger-nail. 
The patient should be cautioned against picking his nose, as 
under such circumstances the resulting ulceration becomes 
deeper, until finally it extends entirely through the septum and 
a perforation results. 
Generally the formation of crusts and scabs can be prevented 
by frequent applications of carbolized vaselin, but should this 
not suffice, the hollow in the septum must be eradicated by 
suitable operative procedure. The usually slight bleeding from 
anterior ulcerations, as it occurs from time to time, can be 
controlled by grasping the tip of the nose firmly between the 
thumb and finger, the insertion of a small piece of ice within the 
naris, by applying an ointment of adrenalin on absorbent cot- 
ton, or by inserting a Simpson's tampon which when saturated 
with blood swells to the original bulk of the cotton before it was 
compressed (Fig. 49). 
In most cases such remedies as adrenalin are useless, because 
the flow of blood prevents their coming into contact with the 
mucous membrane and exerting their effects; not is it possible, 
in most instances, to accurately locate the bleeding spot and 
apply pressure to its directly. Usually the patient is found 
bending over a bowl upon his lap or he may be resting upon the 
bed in such a position that his head leans over its side so as to 
allow the blood to drip into a receptacle upon the floor. Have 
him at once sit erect, with his head neither thrown back nor 
forward, and instruct him to hold a finger-bowl under his chin 
(not nose) to catch the flow of blood. 
This change of position takes off pressure from the veins in 
the neck and may be all that is necessary to stop the hemor- 
rhage. If this be the case, a little pledget of absorbent cotton, 
saturated with vaselin, should be inserted loosely within the 
naris to support the clot and prevent the patient breathing 
through that side of the nose. 
If in spite of the change of the patient's posture the blood 
should continue to flow, it will be necessary to apply pressure 
to the bleeding vessel. This is most expeditiously, painlessly, 118 
DISEASES OF THE NOSE, THROAT, AND EAR 
and effectually accomplished by inserting a Simpson tampon 
into the nose, which usually controls the bleeding as soon as 
the cotton is saturated with blood. In cases where the 
bleeding spot is far back in the nose, it is better to insert a 
strip of Bernays' sponge (Fig. 49) | inch wide and about 2^ 
long through the inferior meatus into the nasopharynx, and 
cut off with stout scissors any redundant portion projecting 
from the anterior naris. Such a strip when saturated with blood 
will completely occlude both the posterior and anterior nares. 
When Bernays' sponge is not available the bleeding is readily 
controlled by adding hydrogen peroxid to the clot within the 
nose which causes an increase of many times its original bulk. 
Wrap a piece of absorbent cotton loosely about an Allen probe 
Fig. 50.-Method of making pressure-cone of cotton for the control of nasa 
hemorrhage. A piece of absorbent cotton (a) is frayed at each end into a thin 
edge, folded through the middle (dotted line a), and loosely wrapped about a nasal 
applicator in such a manner as to form a cone. This is dipped into hydrogen per- 
oxid and placed within the nose. 
so that it forms a cone 3 inches in length and 1 inch in diameter 
at its proximal extremity (Fig. 50) Thrust this dripping 
with hydrogen peroxid along the floor of the nose until the 
pharynx is reached. Place the forefinger-tip against the cotton 
within the nose and withdraw the probe, leaving the cotton in 
position supported by the finger-tip until the pressurecaused 
by he ebullition of gas has somewhat subsided, then withdraw 
the finger and support the first pledget by means of asecond 
plug of cotton saturated with hydrogen peroxid. This is 
pressed firmly into the naris, especial care being taken that it 
firmly fills the space within the extreme tip of the nose, or DISEASES OF THE NOSE 
119 
blood will escape over the cotton plug. If required, a third or 
even a fourth plug of cotton may be used. It is well to smear 
the whole of the presenting surface of the cotton with a solution 
of perchlorid of iron, which dries with a little blood into a 
black impenetrable varnish, and allows no blood to trickle. 
Never apply any of the iron salts inside the nose to control 
hemorrhage, as they are extremely irritating and form a sort 
of sticky black sand difficult to remove. 
This method of controlling nasal hemorrhage is much less 
irritating than most others employed; but at the end of five or 
six hours swelling of the mucous membrane will have occurred 
to a sufficient degree to render the packing within the nose 
somewhat uncomfortable, and it is generally advisable and 
safe to remove the outer plug. This should be done with 
extreme gentleness, avoiding any sudden pull or jerk. At the 
end of twelve or twenty-four hours the larger mass of cotton 
can often be removed with safety if done in a proper manner. 
Avoid removing pressure too suddenly or the hemorrhage will 
certainly recur and the packing will have to be replaced. It is 
well to have at hand a smaller cone of cotton saturated with 
peroxid to instantly replace that removed should this accident 
occur. Grasp the end of the mass of cotton to be removed 
with a pair of dressing-forceps and draw it forward | inch, then 
wait five minutes. Repeat this procedure at intervals of five 
minutes until the mass is coaxed, as it were, from the nose. If, 
during this process, a drop of blood shows itself, cut off with a 
pair of bandage-scissors that portion of the cotton already out- 
side of the nose and press into the vestibule a little mass of fresh 
cotton saturated with peroxid. Be content to wait for an 
hour or so before again trying to remove the packing; for, at any 
rate, you have diminished the pressure within the nose and 
rendered your patient more comfortable. If, however, you 
have succeeded in removing the whole of the cotton without the 
hemorrhage recurring, place a little cotton in the vestibule of 
the naris and allow your patient to rest for a half-hour or so 
before permitting him to blow out the clot--which should be 120 
DISEASES OF THE NOSE, THROAT, AND EAR 
done with great gentleness. It is advisable in all cases to re- 
move the packing from the nose at the end of forty-eight hours, 
as by that time it will be extremely foul smelling and there is 
danger of sepsis. If necessary to check the recurrent hem- 
orrhage, the nose can be packed again with cotton saturated 
either with peroxid or alboline, which, next to peroxid, is 
probably the best hemostatic for use within the nose. 
In most works on surgery an instrument called Bellocq's 
cannula is figured, by means of which the posterior nares may 
be plugged by drawing a mass of gauze through the mouth 
behind the soft palate; if at hand, this instrument may be used. 
A simpler plan is to insert a Eustachian catheter through the 
nose and pass a catgut suture, string or well-waxed piece of 
stiff silk or linen suture through it until its end appears in the 
fauces, when it may be seized by a pair of forceps and drawn 
out through the mouth. A piece of iodoform gauze should then 
be tied to the middle of the catgut string or waxed cord, and 
drawn up behind the palate into the vault of the pharynx in 
such a manner that one end of the string projects from the 
nose and the other from the mouth. The ends of the suture 
material may now be tied together, so that the plug is firmly 
held in position. If a Eustachian catheter is not available, 
a silk suture may be tied around the eyelet of an ordinary soft- 
rubber urethral catheter, which is then passed through the 
inferior nasal chamber until the suture and catheter appear 
in the pharynx. However, plugging the posterior nares is 
seldom, if ever, necessary to check hemorrhage from the nose, 
but may be used where ether is administered to prevent blood 
flowing into the pharynx during an operation upon the interior 
of the nose. 
In hemophilia or purpura, after the nose has been packed 
with absorbent cotton and peroxid, calcium chlorid or lactate 
(Formula 47), 5 to 10 gr. every two hours, may be given in cap- 
sule or dissolved in a little water. However, human blood or 
horse serum by supplying "fibrin ferment" to the patient's blood 
sometimes quickly controls hemorrhage in these cases. From DISEASES OF THE NOSE 
121 
io to 30 c.c. should be injected subcutaneously. "Coagu- 
lose or desiccated serum disolved in normal salt solution 
may be used in the same manner as the fresh serum. 
TUMORS 
Nasal Polypus.-The most common growths to be found 
within the nose are mucous polypus, fibroma, or fibrous poly- 
pus, cyst, ecchondroma, exostosis, osteoma, papilloma, an- 
gioma, sarcoma, and carcinoma. 
Fibrous polypi differ from the soft or mucous polypi simply 
because of the proportion of fibrous material each contains. 
Instead of being soft, gelatinous, and highly hygrometric, fi- 
brous polypi are hard and fibrous. They usually have their 
attachment in the upper posterior portion of the nasal cham- 
bers but sometimes within the antrum. When attached to the 
junction of the nose and pharynx the fibrous tissue is so abun- 
Fig. 51.-A, Mucous polypi in the nose; B, anterior view of same, normal size 
(Sajous). 
dant that the resulting tumor is a true fibroma almost as hard 
as bone. Nasopharyngeal fibroma are extremely vascular, 
bleeding sometimes at the slightest touch. Fibrous polypi are 
probably local hypertrophies of the mucous membrane and sub- 
mucous tissues that have undergone fibrous change in pro- 
portion to the amount of connective tissue involved. 
Mucous polypi most frequently originate from the middle 
turbinated region of the nose. Here the mucous membrane 122 
DISEASES OF THE NOSE, THROAT, AND EAR 
possesses low folds. It is thin, the subepithelial tissue loose and 
abundant, and the erectile tissues scanty. The mucous glands 
on the lateral surface of the middle turbinates are numerous. 
As the result of chronic inflammation from any cause the 
normal folds of the mucous membrane become edematous. 
This edema is favored by the dependent position of the parts 
until it is sufficient to develop into mucous polypi. The nor- 
mal active glands of the middle turbinated region prevent the 
occurrence of edema, but when the glands cease to act as the 
result of degenerative changes, edema results. 
Etiology.-Any long-continued irritation of the nasal mucous 
membrane may result in polypi. The most common causes are 
ethmoiditis or defective nasal drainage, as the result either of 
bony ridges on the septum, a deviated septum, or of hyper 
trophies of the lower turbinated bone. 
Treatment.-Removal of the nasal polypi and adequate 
treatment of the cause that produced them, in the manner 
described in the sections upon Ethmoiditis and Hypertrophic 
Rhinitis. The mere removal of the polypi is usually only the 
first step toward bringing about a cure of the nasal disease. 
Simple removal is usually followed by a relapse into the former 
condition. Therefore after the removal of the growth the 
surgeon should not be content until the parts from which they 
grew have firmly cicatrized. 
Operations.-The nasal chamber is cocainized with a pledget 
of cotton saturated with a 3 per cent, solution of cocain, 
and the parts sprayed with a 1 : 5000 solution of adrenalin. 
The operative speculum (Fig. 17) is then inserted into the nos- 
tril and the size and attachment of the most anterior of the 
polypi determined by a probe and by pulling it forward with 
forceps. The loop of a snare (Fig. 40) is then slipped over the 
polyp and manipulated until the loop encircles its base, the 
loop quickly tightened, and the polyp severed from its attach- 
ment by a little jerk. The parts are again sprayed with 
adrenalin and the next polyp removed by the snare, and so on 
until the nasal chamber is completely free from the growths. DISEASES OF THE NOSE 
123 
Spraying with adrenalin solution after the removal of each 
polyp usually prevents excessive hemorrhage and secures a 
satisfactory view of the middle turbinate region from which 
they grow. Should the inferior border of the turbinate be 
covered by stumps of polypi that have escaped the snare, it is 
better to remove this diseased tissue at once with a swivel- 
knife to prevent a return of the growths. 
There is no after-treatment except that the patient should 
cleanse the nasal chambers by spraying with Dobell's solution 
or some similar alkaline wash. The surgeon should inspect the 
surfaces from which polypi have been removed at sufficiently 
frequent intervals for about six months and remove small 
polypi (''buds") or any suspicious spot upon the middle tur- 
binate with a swivel-knife or punch forceps in order to secure 
a firm cicatrix. However, when instead of multiple polypi, the 
contents of a nasal chamber consists of a single large polypus, 
its removal is ordinarily followed by cure without further 
treatment. 
Nasal cyst usually occurs as a large sessile bladder, filled 
with a thin, watery, mucous fluid, attached to the inferior 
turbinated bone. 
N asopharyngeal fibromata consist of fibrous tissue containing 
numerous large blood-vessels which when severed bleed 
profusely because of the hardness of the tissue in which they 
are imbedded. These growths usually originate from the 
thick, fibrous aponeurosis covering the basilar process, but 
sometimes a pedicle extends from one of the accessory sinuses, 
especially the maxillary. They often hang down from the 
vault of the pharynx so as to be plainly visible through the 
mouth, and may send prolongations into the nose and all of 
the adjacent cavities, either bending around obstacles or 
eroding their way through them, enlarging the nasal chambers, 
thinning the bones, and broadening the bridge of the nose as 
they grow, causing great deformity or what is sometimes called 
"frog face." Such tumors cannot readily be removed by an 
ordinary snare. The best imported steel piano wire usually 124 
DISEASES OF THE NOSE, THROAT, AND EAR 
snaps during the attempt, or the snare may be twisted into a 
cork-screw shape if an attempt is made to tighten the wire 
by turning the screw of the instrument with a wrench. The 
growth is, however, readily removed by means of a galvano- 
cautery snare with its red-hot wire. Relapses are common, 
although the disease generally attacks children; and there 
is a distinct tendency toward slower growth of the tumor or 
even retrograde changes as the individual advances in years. 
When the galvanocautery snare cannot be used, a pointed 
cautery-knife (Fig. 43) may be pushed through the tumor 
toward the center of the growth and heated while in situ. The 
current of electricity should be turned off as soon as the patient 
complains greatly of the heat and after an interval turned on 
again. This may be repeated several times before the cautery- 
knife is finally withdrawn from the growth, which should be 
done with gentleness and care while the current is turned on in 
order to avoid hemorrhage. The procedure is less painful than 
electrolysis and results in a greater amount of shrinking of the 
growth. 
Radical operations for the removal of nasopharyngeal fibro- 
mata with the knife have been successfully performed, but 
the fatalities have been somewhat numerous. 
Nasal papillomata are wart-like growths most frequently 
attached to the septum or inferior turbinated bodies. They 
are generally abundantly supplied with capillaries and some of 
them bleed at the slightest touch. 
Treatment.-They should be removed with the snare and the 
place of their implantation touched with the galvanocautery 
to prevent a recurrence. 
Nasal Sarcoma.-Sarcoma within the nose presents the same 
pathologic characteristics as when present elsewhere. It may 
occur as a primary growth or result from the degeneration of 
fibrous polypi or papillomata. Nasal sarcomata are generally 
sessile and of a light reddish color. In children they grow very 
rapidly and are prone to ulcerate, with the result of producing a 
fetid greenish or bloody discharge. Penetrating the surround- DISEASES OF THE NOSE 
125 
ing structures, great deformity of the face often results. If 
growths occur in an upward and backward direction, tinnitus, 
deafness, and severe pain are usually present, while death may 
occur from final involvement of the brain by the disease. 
Prognosis.-In children the growth ordinarily occurs so rap- 
idly that an early fatal issue is to be expected, while in adults 
a slower growth makes early and complete evulsion practic- 
able. The tumor will, however, return with increased malig- 
nancy if imperfectly removed. 
Nasal Carcinoma.-Carcinoma of the nose is of rare occur- 
rence as a primary affection, but may invade the nasal cavities 
from surrounding parts. It is usually of the epitheliomatous or 
encephaloid type. 
Treatment.-The varieties of sarcomata and carcinomata 
differ greatly in their malignancy. Nearly all recur after the 
most complete operation while apparent spontaneous cureshave 
been reported. The x-ray in many cases at least retards the 
progress of the disease and should always be employed after 
an operation before recurrence occurs. Even when the antrum 
is involved, the complete removal of the upper jaw is rarely 
necessary as access to the growth is readily obtained by the 
Jansen operation supplemented by an incision along the side 
and beneath the nose and through the center of the lip so that a 
greater exposure of the field of operation is obtained when the 
flap is dissected back. 
DISEASES OF THE NASAL SEPTUM 
Deviation.-Normally, the septum is vertical, but after the 
seventh year deviations generally toward the left are somewhat 
frequent. Such deviations from the vertical only are consid- 
ered pathologic when they interfere decidedly with nasal 
respiration or, by pressure upon the middle turbinated body, 
cause pain or disease. 
Etiology.-Traumatism is by far the most common cause 
of the pathologic deviations, the most frequent traumatism being 126 
DISEASES OE THE NOSE, THROAT, AND EAR 
a dislocation of the triangular cartilage and the anterior por- 
tion of the vomer from each other and their attachment to 
the nasal crests of the superior maxillaries. Under such cir- 
cumstances the deviation is of the so-called angular variety, 
because the dislocated horizontal edge of the septum projects 
into the obstructed nares as a sharp edge or ridge running back 
as far as the dislocation extends. The dislocation rarely 
involves the whole septum, because the posterior portion of 
the septum is defended from the effects of traumatism by 
bony walls. Rarely is more than the anterior third of the 
septum involved in a deviation, and it is, therefore, more 
exact to speak of a deflected area of a septum rather than a 
deviated septum. 
Between the edges of the dislocated bones and cartilage 
"provisional callus" is thrown out, which finally unites the 
separated edges with a firm bony or cartilaginous union, usu- 
ally thicker than the normal septum, and hence the so-called 
"hypertrophied angle" of a septal deviation. It will be seen 
that after the organization of the "provisional callus" the sep- 
tum has notably increased in size, is redundant or too large to 
occupy a vertical position within the nose. 
According to the extent posteriorly of the dislocation of the 
septum from the superior maxillary may the deviation be 
described as vertical or horizontal. In comparatively rare 
cases a vertical deviation of the septum will involve so little of 
the septum anteroposteriorly as scarcely to admit the blunt end 
of a lead-pencil into the deflected area at the base of the septum. 
Such a deflection probably would result from a very rapid and 
violent bending of the tip of the nose to one side. 
Probably the larger number of deviations, so slight as not to 
be considered pathologic, are the result of a faulty develop- 
ment of the bones of the face. It is stated that adenoids and 
other causes of defective nasal respiration cause an arching of 
the palate, and the septum, crushed between this abnormally 
narrow arching of the palate and the nasal bones, is bowed, as 
it were, out of the median position. DISEASES OF THE NOSE 
127 
As a matter of fact, a comparatively large proportion of de- 
flected septa are encountered, associated with a narrow arch 
of the palate, and the deviation is due to incoordination in the 
development of the bones of the face, including those of the 
nose, and evidently not traumatic. Such deviations are curvi- 
linear instead of angular, sometimes S shaped, and there is 
usually little or no thickening of the sutural lines. However, 
they rarely, if ever, involve the whole septum. 
By artificially occluding one side of the nose of pupies and 
other young animals Ziem proved that under such circum- 
stances the occluded nostril and adjacent bones and accessory 
cavities remained undeveloped. 
Asymmetric development of the two sides of the face, if 
it involved the nasal septum, would result in the bowing or 
deviation of the septum toward the larger side of the face, be- 
cause the concave surface of a deviated septum is, of course, 
smaller than the convex surface. 
Pathology.-Septal deviations occur in almost endless variety. 
A simple classification is physiologic and pathologic, angular, 
with or without hypertrophied tissue at the angle, round and S 
shaped, vertical and horizontal. 
Symptoms.-There is sometimes some deformity of the 
external nose, the tip of the nose being turned to one side of the 
bridge flattened. The degree of obstruction in the narrowed 
nostril is in proportion to the deviation of the septum and may 
amount to occlusion. Usually in such cases there is complete 
obstruction to inspiration from a valve-like action of the ala of 
the affected side, while expiration is somewhat free as the re- 
sult of the blowing outward of the ala by the expired air. 
Nasopharyngeal catarrh is usually present and is the direct 
result of the deviation. It will be observed that during in- 
spiration a partial vacuum occurs posterior to the obstruction, 
and consequent vacuum congestion, that is, the decreased 
atmospheric pressure behind the obstruction engorges the 
blood-vessels of the mucous membrane by a species of suction. 
The vacuum congestion and consequent catarrhal inflammation 128 
DISEASES OE THE NOSE, THROAT, AND EAR 
frequently extend backward to the nasopharynx. Vacuum 
congestion also occurs within the dilated portion of the un- 
obstructed nostril, and when chronic catarrh of the middle ear 
results, it is often the ear upon the side of the unobstructed 
nostril that first is affected. It might be objected to this me- 
chanical theory of the causation of vacuum congestion back of a 
deflected area upon the septum that any partial vacuum result- 
ing during inspiration would be counteracted by increased 
pressure during expiration. That this is not the case is due 
to the fact that expiration is more deliberate and passive than 
inspiration and the valve-like action of the ala referred to 
above. 
The amount of obstruction to nasal respiration resulting 
from a deflected septum is precisely the same as if the obstruc- 
tion resulted from an exostosis. When the obstruction is com- 
plete from inspiration the individual loses one-half his nasal 
breathing space; for what breathing space is lost in one nostril 
is not compensated for by increased breathing space in the 
other, because the unobstructed nostril is not larger, either 
anterior or posterior to the obstruction, and hence will not 
transmit more air than if the septum were not deflected. 
In the dilated area of the unobstructed nostril the inferior 
and sometimes the middle turbinated bodies are frequently 
hypertrophied, probably as the result of the increased blood 
supply resulting from the decreased atmospheric pressure in the 
dilated area referred to above. As the result of such hyper- 
trophy the breathing space within the dilated area may be 
reduced to normal limits. In the obstructed nostril the tur- 
binated body may become atrophied from the pressure of the 
deflected septum. Should the deflection be so located as to 
cause pressure upon the middle turbinated body, pain and 
nasal reflexes are usually present, and sometimes disease of the 
ethmoid and frontal sinus. Fortunately, great deviation 
of the septum in this region is comparatively rare, and if present 
without obstruction to respiration the removal of a portion of 
the middle turbinal will prove an easier and more satisfactory DISEASES OF THE NOSE 
129 
operation than an attempt to restore the septum to a vertical 
position by a submucous resection. 
In some cases when the deflection is slight as scarcely to be 
Considered pathologic, erosions occur upon the septum. The 
inspissated secretions of such erosions being in a hollow of the 
septum, and hence not in the direct breath-current, are usually 
removed by the finger-tip or by violently blowing the nose. 
Usually some of the septal tissue is removed w th the ac- 
cumulation and hemorrhage results. The condition is a com- 
mon cause of recurrent nasal hemorrhage. When such ac- 
cumulations are removed by the finger-nail the erosion usually 
becomes deeper and deeper, until the individual literally picks 
a hole through his septum. 
The two factors interfering with the success of operations for the 
correction of deviation of the nasal septum are redundancy and 
resiliency. The septum is too large to occupy a vertical posi- 
tion within the nose, and hence any operation, to be successful, 
must provide for the redundancy of the septum, both in the 
horizontal and vertical direction. The simplest method would 
seem to be a rectangular crucial incision through the center 
of the deviation. After such an incision, if the deviated area 
of the septum is brought into the median position, the edges of 
the four triangular flaps overlap, and thus the redundancy of 
the septum in both the horizontal and vertical directions is 
provided for. Redundancy of the septum is equally well 
provided for by multiple incisions through the septum, cross- 
ing each other at a common center, and by L, JL, U, and W 
incisions through the septum. This is far from being true 
as regards the resiliency of the septum. Septal resiliency of 
the deviated area is best counteracted by means of a long, 
narrow, quadrilateral flap but, of course, is completely de- 
stroyed by submucous complete removal of the cartilage and 
bone from the deviated area. 
It must not be supposed that because the deviated area of a 
septum is too large to be crowded into a position on a plane 
every point of which is equidistant from the lateral walls of the 130 
DISEASES OF THE NOSE, THROAT, AND EAR 
nose .that, therefore, the tissues of the deviated septum are 
subjected to tension, which, if released, would result in the de- 
viated area of septum assuming a normal vertical position as 
the result of its resiliency. On the contrary, if a deviated sep- 
tum be dissected out from the nose, its deviated area does not 
change its shape, and if pressed into a position parallel to the 
rest of the septum, it immediately springs back into its original 
deflected position as soon as the pressure is released. It must 
not be imagined, as stated by some 
authors, that the resiliency of the sep- 
tum is destroyed by incisions of any 
shape, mentioned above, as the result- 
ing flaps when bent all tend to spring 
back into their former position. 
Resiliency is an inherent quality 
of both the bony and cartilaginous 
septum. However, if the bony por- 
tion be fractured, the broken bone re- 
mains in the position in which it is 
placed and the resiliency at the line 
of fracture is destroyed. The carti- 
lage of the septum, on the other hand, 
is not readily fractured, but when bent at a right angle or 
more, its resiliency is greatly lessened for a considerable time. 
Operations for Correction of Deviation of the Nasal Septum.-• 
Bosworth's Operation.-'The simplest operation is that intro- 
duced by Bosworth (Fig. 52)-'the removal of the hyper- 
trophied angle of the deviation with a saw. The operation 
is successful to the extent that it secures increased breathing 
space in the obstructed nostril. 
Gleason's Operation.-The writer's method of operating 
for deflection of nasal septum is as follows: A U-shaped incision 
(Fig. 53) is made around the deviated area (a), which then 
becomes a quadrilateral flap, covering a hole in the septum; a 
sort of trap-door with a spring hinge holding it in a deviated 
position. This quadrilateral flap is then, with the finger-tip, 
Fig. 52.-Vertical, trans- 
verse section through the an- 
terior portion of the nose; an- 
gular deviation of the septum, 
with hypertrophy of the tissues 
at the angle of the deviation. 
The dotted line indicates the 
direction of the saw-cut for 
the removal of the obstruction. DISEASES OF THE NOSE 
131 
pushed through the hole in the septum which it covers, and its 
neck (c) is bent at the same time at a right angle. The 
success of the operation depends almost entirely on a thorough 
bending of the flap. If the deviated area is of the horizontal 
type and extends far back along the septum the neck of the 
quadrilateral flap will contain a considerable amount of bone. 
When the neck of the flap is bent at a right angle this bone will 
be fractured with a snap, often audible at a considerable dis- 
tance. The resiliency of the bony portion of the flap is then 
as completely destroyed as if a submucous resection had been 
performed because fractured bone remains in the position in 
which it is placed. As a matter of fact it, to a certain extent, 
acts as a splint to retain the cartilaginous portion in a vertical 
plane, as it is impossible to fracture it even by bending to a 
right angle. 
However, by the thorough bending of the cartilage the re- 
siliency of the flap is diminished, for the time being, to the ex- 
tent that it hangs without support in the vertical position, its 
redundant edge overlapping, without pressure, the edge of the 
hole in the septum, in front, below, and behind. 
The quadrilateral shape of the flap has much to do with its 
remaining in a vertical plane. In any cartilaginous septal 
flap the resiliency tending to reproduce the original deformity 
is proportionate to the width of the base (c) of the flap. In the 
triangular flaps used by Asch, Roberts, Watson, and others 
the width of the base of the flap rapidly increases with the size 
of the flap. In the quadrilateral flap the base of the flap (Fig. 
53, c) is always of. the same width as its edge (b), and conse- 
quently, because of constantly increasing leverage proportion- 
ate to the length of the flap, in long, narrow, cartilaginous flaps, 
but very little support at its lower edge (b) is required to main- 
tain such a flap in the vertical plane. This very important 
factor in the success of operations for the correction of septal 
deflections may be demonstrated by cutting flaps of various 
shapes in the side of a rubber ball, the resiliency of which may be 
compared to that of the cartilaginous septum. The main idea DISEASES OF THE NOSE, THROAT, AND EAR 
132 
in devising this operation was to provide a better method of 
overcoming the resiliency of the septum than those then in 
vogue, and all other considerations were sacrificed to this idea. 
In most operations it is not septal redundancy, but the neglect 
or the impossibility of providing for septal resiliency that causes 
failure. The resiliency of the septum is exerted for months 
upon septal flaps after apparent healing, and often gradually 
reproduces, in part at least, the original deviation. It is 
Fig. 53.-Diagram of author's operation. The traumatism originally caus- 
ing the deflection is practically reproduced by converting the deflected area of the 
septum into a quadrilateral flap: a, Deviated area of the septum, surrounded by 
a U-shaped incision; c, neck or base of the resulting quadrilateral flap; b, its in- 
ferior edge. 
impossible to judge of the success of an operation for septal 
deviation until at least six months have elapsed. Therefore 
it is best in most instances to slightly overcorrect the deviation. 
The technic of the writer's operation is as follows: Both 
sides of the septum are anesthetized by packing the nose with 
pledgets of absorbent cotton saturated with a 3 to 4 per cent, 
solution of cocain. This is allowed to remain in contact with 
the parts for one-half hour in order that the weak solution of 
cocain may penetrate deeply into the tissues. The nostrils are DISEASES OF THE NOSE 
133 
sprayed with a 1 : 1000 solution of adrenalin. The line of 
incision is then rubbed by means of a cotton-tipped probe with 
a saturated solution of cocain in order to produce profound su- 
perficial anesthesia. 
The field of operation is brought into view by means of the 
self-retaining speculum (Fig. 17), and a straight Sajous saw is 
introduced into the obstructed nostril, close to and parallel 
to the floor of the nose. The septum is sawed transversely 
until the saw has obtained a firm hold upon the tissues; the 
direction of the sawing is then somewhat rapidly changed until 
it becomes nearly vertical, the saw meanwhile being carefully 
maintained in a posi tionexactly parallel to the septum. A gush 
of blood from the unobstructed nostril indicates that the 
sawing has extended through the septum. The saw is now 
partly withdrawn and its tip pushed through the cut into the 
unobstructed nostril. The anterior crus of the U-shaped 
Fig. 54.-Seiler's septum knife. 
incision is made by sawing upward with the tip of the saw or a 
probe-pointed tenotome may be used for the purpose. The 
posterior crus is most quickly made by introducing a probe- 
pointed, double-edged knife, curved on the flat (Fig. 54), 
from the left nostril through the saw-cut. The index finger- 
tip is then introduced into the right nostril. Finger and knife 
together reach the posterior limit of the deviated area, and the 
posterior crus of the U-shaped incision is quickly and easily 
made. 
If the deviation is toward the right nostril, the operator wets 
his left forefinger in sterile water, while, if the deviation is 
toward the patient's left nostril, the right forefinger, after being 
wetted, is introduced into the obstructed nostril, pushing and, 
if necessary, lifting up the deflected area until it has been thrust 
through the hole in the septum which it covers. The operator's 134 
DISEASES OF THE NOSE, THROAT, AND EAR 
forefinger-tip is then carried up along the anterior and posterior 
crura of the U-shaped incision to make sure that the flap has 
completely cleared them; the finger-tip is then thrust through 
the hole in the septum beneath the quadrilateral flap until the 
lateral wall of the nose in the unobstructed nares is touched. 
The finger is then pressed upward until the flap is bent at a right 
angle and any bone in the neck (Fig. 53, c) of the flap breaks 
with an audible snap. This is of the utmost importance, and in 
horizontal deflections the success of the operation depends 
entirely upon the bending of the flap being thoroughly done. 
Fig. 55. 
Fig. 56. 
Pigs. 55 and 56 show the overlapping which occurs in the Sajous, Roberts, 
Seiler, Gleason, and Watson operations after the upper or movable portion of 
the septum is pushed into the median line-a feeble and unreliable amount of 
support is given by this overlap-insufficient in most instances to prevent the 
reproduction of the deformity. In the Gleason operation success depends on 
three factors-the quadrilateral shape of the flap; that there is only one flap to bend, 
and a bending of this one flap so thoroughly as to completely destroy its resiliency. 
At the beginning both operator and patient are seated; but 
to more thoroughly bend and kneed the neck of the flap, the 
operator rises and places his disengaged hand on the patient's 
head. In vertical deflections too narrow to permit of the 
forefinger being used, the little finger should be employed. 
After the thorough bending of the flap it should hang in the 
formerly unobstructed naris without resiliency (Fig. 56); and 
either Allen's tube or the writer's modification of the same 
should be dropped into the formerly obstructed nostril. Should 
any impediment to its free entrance into the nostril be encount- 
ered, it is probable that the U-shaped incision has been im- 
properly made and has passed through instead of around some DISEASES OF THE NOSE 
135 
portion of the deviated area. This is usually the posterior 
portion of the deflected area, the posterior crus of the U-shaped 
incision being made too far forward. An effort should be made 
to bring this deflected posterior edge of the incision into line 
with the finger-tip in order to admit of the easy introduction 
of the tube, and, failing in this, the end of the tube should be 
compressed by the fingers in such a manner as to permit of its 
easily being passed beyond the obstruction. The tube should 
always fit loosely. Any great amount of pressure exerted by 
the tube becomes well-nigh intolerable within twenty-four 
hours. The tube serves to control the usually trifling hemor- 
rhage. It is worn over night and the next day it is decided 
if its support is longer necessary. In rather more than 80 
Fig. 57.--Gleason's nasal tubes, made of soft malleable metal (pewter)._ These 
tubes may be readily cut with a pen knife to any desired length, and their shape 
considerably altered by bending and burnishing the edges. 
per cent, of cases of deviation of the nasal septum operated 
upon by the method described above no support whatever 
was necessary. 
The after-treatment consists in the patient presenting him- 
self at the surgeon's office daily, in the meantime attending to 
his usual avocation if not too laborious. At each daily visit 
the parts are inspected and, if necessary, cleansed. At first 
the overlapping of the edges of the flaps resulting from its 
redundancy will appear excessive because of the swelling. 
Within a week or two this swelling will have disappeared 
and also, apparently, much of the redundancy, because in 
traumatic cases the redundancy is newly formed tissue, 
"provisional callus," and hence is usually absorbed. At any 
time any redundant thickening can readily be removed, but 136 
DISEASES OF THE NOSE, THROAT, AND EAR 
unless the obstruction is so large in the formerly unobstructed 
nostril as to produce a decided impediment to respiration it is 
best to defer "trimming up" the redundant septal thickening 
until several months have elapsed after the operation. 
Modifications. -In large horizontal deviations in large prom- 
inent noses the major portion of the flap will be cartilaginous, 
and the incision, instead of being U shaped, as in narrow verti- 
cal deviations described above, will be | | shaped. In such 
flaps the most thorough bending is not always sufficient to 
destroy its resiliency, and the operator has the misfortune to 
find the deviation reproduced within a few days after the tube 
is discarded. Ballenger has modified the author's operation 
by curving the upper ends of the U-shaped incision toward 
each other, thus C-> , so as to narrow the neck of the flap and 
decrease its resiliency. The same result can be accomplished 
by inserting a blunt-pointed tenotome beneath the perichon- 
drium and incising the neck of the flap. This can be done a 
week or more after the operation, when perhaps for the first 
time it is discovered that the deviation, at least at its anterior 
portion, is likely to be reproduced; or the operator can wait a 
month or more until healing is complete and then do a partial 
submucous resection, which is then comparatively easy, be- 
cause the bone at the lower border of the flap will be found un- 
united with that below. Fortunately, cases requiring second- 
ary operations are rare. 
Very infrequently horizontalCX) -shaped deviations are en- 
countered, where one nostril is occluded by the anterior devia- 
tion and the other by the deviation further back. In a case of 
this kind operated on by the author a successful result was 
secured by correcting the anterior deviation by the author's 
method and then bringing the posterior deviation into the 
median line with Adams' forceps and the forefinger. 
A modification of the author's method to the extent that 
quadrilateral flaps are used is the K incision through the devi- 
ated area, described by Price and Brown. Such quadri- 
lateral flaps, of course, have the abvantages already described DISEASES OF THE NOSE 
137 
over the triangular flaps of Asch, Watson, and others; but, 
theoretically at least, two quadrilateral flaps are inferior to one 
for overcoming the resiliency of the deviated area. However, 
it has often occurred to the author that in some horizontal 
deviations it would be an advantage to point his U-shaped in- 
cision forward instead of downward, because bone would then 
be encountered at the neck of the flap, which, when broken, 
would completely destroy the resiliency of the flap. 
Kyle's Operation.-Kyle, of Philadelphia, makes horizontal 
parallel incisions through the deflected area on opposite sides of 
Fig. 58.-Fetterolf's sharp-edged triangular file. 
the septum by means of Fetterolf's triangular file (Fig. 58), and 
brings the enclosed area into the median line by means of fin- 
ger or forceps. The operator's finger is inserted into the unob- 
structed nostril and a parallel incision is made with the sharp- 
edged file (Fig. 58) at the apex of the convex surface of the 
septum, the finger of the operator readily detecting when 
the cartilage has been cut through to the mucous membrane. 
If desirable, more cartilage can be removed by means of a 
file truncated on its edge (Fig.59), in order to avoid wounding 
Fig. 59--Fetterolf's truncate-edged triangular file. 
the mucous membrane of the convex side of the septum. 
Through the concave side of the septum two parallel incisions 
are made with the file; one above and the other below that 
from the convex surface. These incisions do not involve the 
mucous membrane of the convex surface. The deviated area 
is practically bounded above and below by these later inci- 
sions. Its resiliency is destroyed in the vertical direction and 
redundancy disappears as the result of the removal of the tri- 
angular strips with the file. The deviated area is now pushed 138 
DISEASES OF THE NOSE, THROAT, AND EAR 
into the median line with the finger-tip and manipulated in 
such a manner as to destroy its resiliency. A tube (Fig. 57) 
is inserted into the formerly obstructed naris and the after- 
treatment is similar to other operations for deviations of the 
nasal septum. 
In submucous resection, the cartilage and bone of the entire 
deviated area is removed, the mucoperiosteum of both sides 
of the septum being preserved. 
An incision is made within the left nostril at the junction 
of the skin and mucous membrane extending from a point 
high up upon the septum downward well into the floor of the 
Fig. 6o.-Ballenger's septum knife. 
nose. Freer in certain cases also makes an incision extending 
backward from the vertical incision. It is better in most 
instances to carry the primary incision at once transversely 
through the cartilage to the mucoperiosteum of the right side 
in such a manner that the membrane is lifted on the knife 
point without being cut; the depth of the incision being directed 
Fig. 61.-Freer's septum knife 
by a finger tip inserted into the patient's right nostril. The 
posterior cut edge of cartilage is now bent into the left nostril 
where the lines of union between it and the mucoperiosteum 
of each side are plainly in view. The perichondrium is sepa- 
rated without difficulty on the right side by simply thrusting 
the dull end of Ballenger's elevator (Fig. 62) between it and 
the cartilage and sweeping the instrument downward. On the 
left side the periosteum is elevated with greater difficulty, 
for at first the point of the elevator (Figs. 62, 63) used as a 
curette is usually required to start the separation sufficiently 
to permit the introduction of elevator (Fig. 62 or 63). This is DISEASES OF THE NOSE 
139 
thrust between the cartilage and the perichondrium in the direc- 
tion of least resistance, which is usually upward and backward 
from the upper angle of the wound where 
the perichondrium is less firmly attached 
to the cartilage. The perichondrium is 
separated by sweeping the instrument 
downward. It is not necessary to rotate 
the instrument on its long axis and the dull 
end of the instrument (Fig. 62) is better for 
this part of the work. 
If there is any great difficulty experi- 
enced in denuding the cartilage it is prob- 
ably because the operator is inadvertently 
trying to separate the mucous membrane 
from the perichondrium, a matter of con- 
siderable difficulty, -and this mistake 
should be corrected. 
When the angle of the deviation is very 
sharp, the separation of the perichondrium 
from the cartilage in this locality is facili- 
tated by pushing the cartilage into the 
median line with the Ballenger instrument 
or a finger tip or it is sometimes helpful to 
grasp the portion of septal cartilage already 
denuded between long broad-jawed forceps 
and straighten such localities by closing 
them. The mucoperiosteum is then lifted 
up and separated on both sides of the 
septum at once by partly opening the 
forceps. 
The triangular cartilage is completely 
surrounded by its own perichondrium, 
which should be remembered when denud- 
ing at sutural lines where it is necessary 
to cut with a sharp knife the perichondrium extending through 
the suture. 
Fig. 62.-Ballenger's 
double elevator: a, Semi- 
sharp end; b, dull end. 140 
DISEASES OF THE NOSE, THROAT, AND EAR 
If it is found impossible to denude the septum without 
making large tears in the mucous membrane, the operator 
should abandon the attempt and do a Gleason operation. 
The septal cartilage being now cleared on both sides, and 
its perichondrium held out of the way with a long-bladed 
speculum (Fig. 64), is readily removed in one large piece by the 
Fig. 63.-Freer's sharp and blunt elevators. 
swivel knife (Fig. 65). Up to this point the operation has been 
nearly painless and should not occupy more than five or ten 
minutes. However, when there is an additional bony deform- 
ity, that portion of the perpendicular plate involved should be 
cut away with septal bone-clipping forceps. The attachment 
of the vomer to the anterior nasal spine is now cut through 
with a chisel or clipped with for- 
ceps. Adams' forceps (Fig. 67) 
is now applied, with one blade in 
each nostril, and the anterior por- 
tion of the vomer grasped through 
the mucous membrane, and by a 
turn of the wrist cracked from its 
inferior attachment, when it can 
be removed readily with dressing 
forceps, leaving the mucous mem- 
brane untorn. 
No after-treatment is ordinarily 
required, except a Simpson's intranasal tampon, Fig. 49, worn 
in each nostril over night to hold the two raw surfaces of 
mucoperiosteum together and prevent the accumulation of 
blood between them. 
As the resiliency is certainly and completely destroyed by 
the removal of the septal cartilage and bone, this operation 
Fig. 64.-Foster's speculum. DISEASES OF THE NOSE 
141 
should yield, when successful, absolutely perfect results. The 
objections to it are its difficulties: 
The length of time frequently re- 
quired to perform it, the danger of 
septal perforations, and occasionally 
flattening of the tip of the nose. 
Therefore, it would seem that an 
operation requiring less time would 
be often preferable, except where the 
deviation extends sufficiently high 
upon the septum to involve the re- 
gions opposite the middle turbinates. 
This is especially true in the case of 
children; because a submucous resec- 
tion interferes with the future devel- 
opment of the nose, in most cases of 
atrophic rhinitis, in cases operated 
under ether, and in cases where be- 
cause of collapse of the patient or 
excessive hemorrhage it is necessary 
to finish the operation quick. The 
Gleason operation can always be done 
in less than 2 minutes and because the 
resulting scar is entirely outside the 
deviated area, does not interfere with 
a subsequent submucous resection 
should it prove unsuccessful. 
Congenital Occlusion of the Nares. 
-Congenital occlusion of either the 
anterior or posterior nares, usually 
unilateral, is a somewhat rare con- 
dition. When the posterior nares are 
occluded, generally it is the result of 
a bony outgrowth from the floor of 
the nose. The anterior naris may 
Fig. 65.-Ballenger's swivel 
knife. There are several sizes of 
this instrument. It is conve- 
nient for the removal of the sep- 
tal cartilage and many other pur- 
poses because its movable blade 
may be made to cut either up- 
ward or downward, backward or 
forward. 142 
DISEASES OF THE NOSE, THROAT, AND EAR 
be occluded as the result of faulty development or adhesions 
during embryonic life. 
Symptoms.-The symptoms are those of occlusion from any 
other cause. When the occlusion is posterior, there is a dis- 
charge of mucus from the nose upon the lip and the patient 
is unable to cleanse the nostril by blowing the nose. Aural 
symptoms are sometimes present when the obstruction is 
anterior. 
Diagnosis is made by inspection. Anterior obstructions are 
readily seen, and those which are posterior may be observed in 
the rhinoscopic mirror. A rough estimate of the thickness of a 
posterior obstruction can be made with an Allen's probe, the 
end of which is wrapped with cotton and saturated with a 4 per 
cent, solution of cocain. This is introduced into the obstructed 
naris until the obstruction is reached, and the distance com- 
pared with that to the posterior edge of the septum on the un- 
obstructed side. 
Anterior obstructions are usually thin and web-like. Pos- 
terior obstructions usually have a thickness of not over | inch. 
Treatment.-It is comparatively easy to break down nasal 
obstructions, either anteriorly or posteriorly; but as they almost 
invariably recur unless prevented from doing so by a somewhat 
tedious after-treatment, the wisdom of operating in young 
children unless very docile is worth considering. When only 
one side is affected and causes but little inconvenience, the 
operation in young children should be postponed until the 
child has arrived at an age to appreciate the advantage to be 
derived from the after-treatment. 
Anterior obstructions are excised with a knife or scissors and 
a pewter tube (Fig. 57) of suitable size and shape inserted. 
This is removed and cleansed daily after the operation until the 
parts have completely cicatrized. 
Posterior bony obstruction are removed with the guarded 
electric drill or burr (Fig. 47), either under ether or, as the opera- 
tion is not very painful, under cocain anesthesia. If ether is 
employed, the tip of the forefinger of the operator's left hand is DISEASES OF THE NOSE 
143 
inserted into the posterior naris from the pharynx, to serve as a 
guide to the parts to be removed by the drill and to prevent 
injury to the surrounding structures. 
The after-treatment consists in daily cleansing the parts and 
the passage of bougies until cicatrization is complete. How- 
ever, in spite of every precaution, the posterior naris at the site 
of the operation frequently becomes again occluded by a thin 
cicatricial membrane. Should such a membrane form, it pos- 
sesses but little vitality, and in 2 cases observed by the 
writer was destroyed by piercing 
it in two or three places with a 
small galvanocautery-knife, after 
which it did not recur. 
Dislocation of the Columnar 
Cartilage.-The so-called colum- 
nar cartilage is the inner plate of 
the lower lateral cartilage of the 
nose (Fig. 36), a small strip of car- 
tilage lying parallel with the lower 
border of the septum, the purpose 
of which is to act as a support tc 
the columna. 
Dislocation of the columnar car- 
tilage, as ordinarily seen, consists of the displacement laterally 
of the distal extremity of the septum in such a manner as 
nearly to occlude the affected nostril (Fig. 66). 
Treatment.-The mucous membrane should be incised over 
the most prominent part of the deformity and the perichon- 
drium elevated in such a manner as to allow the excision of a 
sufficient amount of the septal cartilage to restore the patency 
of the affected nostril. It is not generally necessary to suture 
the edges of the incision after the excision of the cartilage. 
No after-treatment is required. 
Hematoma of the septum is an extravasation of blood be- 
neath the mucous membrane of the septum, generally the result 
Fig. 66.-Dislocation of the 
columnar cartilage of the nose into 
the right nostril (Bosworth). 144 
DISEASES OF THE NOSE, THROAT, AND EAR 
of traumatism. It presents itself as a blood-red tumor, some- 
times large enough to obstruct nasal respiration. 
Prognosis.-The blood may be absorbed, or inflammation 
may occur and an abscess result. 
Treatment.-If the amount of blood is large, an incision 
should be made to allow it to escape. Should hematoma 
follow a submucous resection the wound should be reopened 
and the clot pressed out. 
Abscess of the Septum.-Etiology.-Abscess of the septum 
may result from traumatism, syphilis, or phlegmonous inflam- 
mation of the septum. 
Symptoms.-There may be the history of a chill, followed by 
fever, as in abscess elsewhere. Upon inspection the nose is 
found to be obstructed by a soft, fluctuating tumor of the sep- 
tum. Generally the cartilage is soon perforated, so that the 
tumor becomes bilateral. 
Treatment.-Early evacuation of the pus, to prevent exten- 
sive destruction of the parts involved in the inflammation and 
hasten resolution. The incision through the abscess should be 
sufficiently free to allow of syringing with sublimate solution if 
deemed necessary, and the patency of the opening should be 
maintained by the daily passage of a probe or the introduction 
of a drain of a few strands of chromatized gut or horse-hair. If 
a sequestrum of cartilage or bone form, it should not be re- 
moved until completely separated, and extreme care should 
be exercised to prevent injuring the mucous membrane of both 
sides of the septum, or a perforation of the septum will be 
present when the healing process is complete. 
Septal perforations occur from traumatism or follow the re- 
moval of an exostosis or other septal operation. Extensive 
destruction of the septum sometimes results from tertiary 
syphilis, or a perforation may result at the anterior portion of 
the septal cartilage from simple ulceration. 
Symptoms.-Posterior perforations present no symptoms. 
Anterior perforations of oblong shape sometimes cause whist- 
ling respiration, which disappears either wholly or in part if the DISEASES OF THE NOSE 
145 
perforation is made round. In this locality the edges of the 
perforation are not infrequently covered with crusts which 
cause slight hemorrhages when removed. 
Treatment.-Posterior perforations are best left alone. Gold- 
stein has pointed out that crusts only occur at portions of the 
perforation covered by cicatrice, and that if the mucous mem- 
brane is dissected back on both sides from the edge of the per- 
foration and a portion of cartilage removed with a swivel 
knife, so that after healing the edge of the perforation is 
covered by normal mucous membrane, crusts cease to occur. 
For this reason crusts do not occur in perforations following 
submucous resections. In fact even large perforations cause 
apparently no inconvenience and the patient's condition is 
infinitely better than if no operation had been done. Burton 
Haseltine has devised an operation in which a flap of mucous 
membrane is pulled forward over the aperture on one side and 
a similar flap pulled back on the other, thereby providing an 
intact membrane opposite each seam. The few stitches that 
are inserted must not produce tension. 
Submucous infiltration of the septum is a comparatively 
frequent accompaniment of chronic rhinitis, consisting of an 
edematous tumefaction situated on each side of the septum, 
generally at its posterior portion. 
Treatment.-If nasal respiration is obstructed, the masses 
may be scraped from the septum with the nasal curette or cau- 
terized with the galvanocautery. 
Injuries and Deformities of the Bony Framework of the 
Nose.-By far the most common result of nasal traumatism is 
dislocation of a portion of the septum from its attachment to 
the nasal processes of the superior maxillary bones. The dislo- 
cation is often overlooked at the time the injury is received 
because of the profuse hemorrhage. If a surgeon is consulted, 
his efforts usually are directed to controlling the flow of blood; 
and often he does not again see his patient for some days or 
weeks. Then the patient states that he can breathe only 
through one nostril. 146 
plSEASES OF THE NOSE, THROAT, AND EAR 
Inspection of the nasal cavities shows a bulging area of sep- 
tum in the obstructed nostril corresponding to a concavity 
upon the septum in the opposite nostril. If seen within a week 
or two of the injury, the parts should be cocainized. The sur- 
geon then wets with sterile water the forefinger of his right 
hand if the patient's left nostril is obstructed, or the left fore- 
Fig. 67.-Adams' septum forceps. 
finger if the obstruction is in the patient's right nostril. With 
the palmar surface toward the septum and a slight boring 
motion the surgeon's finger is guided along the floor of the 
patient's nose. As the finger advances, pressure from the fin- 
ger-tip readily forces the dislocated septum into a position 
median to both sides of the nose, after which the tube (Fig. 57) 
is inserted to act as a splint. 
Flattening of the Bridge of the Nose or 
Saddle-back Nose.-A common result of 
nasal traumatism is fracture of the nasal 
bones at the root of the nose. The distal 
fragments are rotated outward on their long 
axes and depressed, producing a broaden- 
ing and flattening of the bridge of the nose. 
When only one nasal bone is fractured, the 
tip of the nose is usually turned to one side 
as the result of dislocation of both lateral 
upper shield cartilages and the septum. 
If the case is seen soon after the injury the displaced nasal 
bones are brought into position one after the other by means of 
Adams' forceps (Fig. 67), one blade of which is inserted into 
the nostril, so that the nasal bone can be grasped between the 
blades and lifted and turned into the normal position. When 
Fig. 68.-Carter's bridge 
and intranasal splint. DISEASES OF THE NOSE 
147 
both nasal bones are in place they are supported by a splint 
fashioned from gauze and collodion placed on the outside of 
the nose, or the nasal splint devised by Dr. W. W. Carter, of 
New York, may be used (Fig. 68). The instrument is held in 
place by two sutures passed from within out through the bridge 
of the nose. If the septum is deviated at the time of the injury 
it is brought into the median line and the tube (Fig. 57) inserted 
into the formerly obstructed nostril. 
Paraffin Prothesis.-When the bones of the bridge of the 
nose are destroyed or greatly distorted as the result of syphilis 
or other cause, satisfactory results follow the injection of paraf- 
fin beneath the skin into the cellular tissue of the nose. A 
special paraffin is prepared by mixing with ordinary paraffin 
white vaselin until the mixture melts at about 1 io° F. (Formula 
Fig. 69.-Harmon Smith's screw-syringe for the subcutaneous injection of paraffin. 
85). This special paraffin is readily injected at ordinary tem- 
peratures through a needle but little larger than an ordinary 
hypodermic needle by means of the screw-syringe (Fig. 69). 
As the screw is turned the paraffin exudes from the end of the 
needle in a worm-like thread, readily compressible between 
the thumb and finger. The paraffin, having been melted, is 
drawn into the barrel of the syringe, which it completely fills. 
The end of the syringe where the needle is screwed on is then 
closed with a screw-cap to prevent the escape of the paraffin, 
and the syringe with the paraffin it contains and the needle to 
be used are dropped into the sterilizer and most carefully 
sterilized in boiling water. The syringe is then allowed to 
cool and the needle screwed into place ready to use. 
The patient requires no special preparation other than wash- 148 
DISEASES OF THE NOSE, THROAT, AND EAR 
ing the skin of the nose with green soap, alcohol, and, finally, 
corrosive sublimate solution (1:1000). 
The end of the needle is inserted near the tip of the nose 
and thrust through the subcutaneous cellular tissue slightly 
beyond the deformity. Before beginning the injection the 
operator should assure himself that the point of the syringe- 
needle lies in the cellular tissue and hence is freely movable. 
The screw of the instrument is slowly turned and as the 
paraffin is pushed out through the needle it presses aside the 
cellular tissue and infiltrates it. The paraffin is molded into 
shape by the thumb and finger of the operator to the exact 
shape desired. The syringe-needle is then withdrawn a short 
distance, and more paraffin thrown into the cellular tissue, 
which is molded into shape; and so on, until the needle is 
finally withdrawn from beneath the skin of the nose. Before 
this is done care should be taken to break the thread of paraffin 
at the needle's point, so that paraffin will not be drawn into 
the skin as the point of the needle is withdrawn through it. 
The thread of paraffin is readily broken by grasping the point 
of the needle through the skin and rotating the instrument 
immediately before the needle is withdrawn. 
Not more than 20 minims of paraffin should be injected at 
one sitting, in order to avoid injurious pressure and the cut- 
ting off of the circulation sufficiently to cause sloughing. It 
should be borne in mind that the operation is so simple and 
painless that it can be repeated as often as necessary to accom- 
plish the desired result, so that it is foolish to attempt too much 
at one sitting. 
Little or no swelling follows the injection, and the after- 
treatment consists in confining the patient to bed for twenty- 
four hours as a precaution and keeping him under observation 
for some days. Iced cloths or a 25 per cent, solution of alu- 
minum acetate on cloths may be applied if edema or inflamma- 
tion seem to require it. 
Paraffin injections not only push the cellular tissue aside, 
but infiltrate it to a greater or less extent, so that if too much DISEASES OF THE NOSE 
149 
paraffin is injected it is impossible to remove it without re- 
moving the cellular tissue in which it is imbedded. After all 
inflammation has subsided the paraffin feels somewhat like a 
little mass of fat beneath the skin, and is readily movable 
upon the bone beneath. 
Unfavorable results from subcutaneous injections of paraf- 
fin have been reported as follows: 
Infection followed by slough or abscess. Infection can be 
avoided by careful sterilization and by care to avoid leaving a 
cylinder of paraffin extending through the skin to the mass 
beneath. 
Pressure necrosis, produced by injecting too much paraffin 
at one sitting or beneath the skin, where it is tightly bound 
down by adhesions. 
Deformity from hyperinjection or depositing the paraffin 
in the wrong place. Ordinary skill, prudence, and the proper 
technic will prevent such a disaster from occurring. 
Several cases of embolism have been reported from the in- 
jection of paraffin. When the paraffin is injected as a solid 
the danger is less imminent. It will, however, be well to have 
an assistant compress the sides of the root of the nose between 
his thumb and forefinger while the injection is being made. 
Paraffin remains only for some years beneath the skin, as it 
is finally completely absorbed, leaving behind it cellular tissue 
of the same shape and size as the paraffin. 
Congenital Deformities of the Nose.-The most common 
of the congenital deformities of the nose are a bulbous condi- 
tion of the end of the nose and extreme prominence of the 
bridge. The latter is readily removed in the following manner: 
An incision is made through the skin and periosteum down to 
the bone. The periosteum is then stripped from the bone and 
the parts exposed. It is now a comparatively simple matter 
to remove the redundant bone and cartilage by means of a 
chisel. The skin and periosteum are then placed in their 
former position and the wound brought together by buried 150 
DISEASES OF THE NOSE, THROAT, AND EAR 
sutures, which leave no stitch-marks and a linear scar, which, 
in a year or two, becomes practically invisible. 
When bulbous enlargement of the tip of the nose is excessive 
the redundant skin and fat is best treated by the method of 
Rodman of Philadelphia, who removes a pear-shaped piece of 
skin and subcutaneous structures, being careful not to disturb 
the cartilaginous framework of the nose. In cases where the 
deformity is less pronounced, the operation devised by Roe of 
Rochester serves every purpose. 
The end of the nose is turned upward and backward and held 
with ? retractor by an assistant; then sufficient of the super- 
fluous tissue is removed or dissected out from the inside of the 
nose to allow the nose to conform to the desired shape. How- 
ever, great care must be exercised not to cut through into the 
skin, or a scar or dent in the external surface of the nose will 
result. 
DISEASES OF THE ACCESSORY SINUSES OF THE NOSE 
The cavities found in the bones of the skull communicating 
with the nasal chambers are the frontal sinuses, the antra of 
Highmore or the maxillary sinuses; the anterior and posterior 
ethmoid cells; the sphenoid sinuses and the lacrimal canals. 
The relative position of these sinuses in the face is shown in 
Fig. 70. 
All of tnese except the sphenoidal and frontal sinuses exist 
at birth. The frontal begins as a slight depression extending 
up from the nasal fossa in the third fetal month. The eth- 
moid cells appear in early fetal life as depressions which enlarge 
by the absorption of bone. The sphenoidal sinuses are pri- 
marily a constriction of the primitive nasal fossa which occurs 
in the third fetal month; but neither the frontal nor the sphe- 
noid are well-marked cavities before the age of seven nor fully 
developed before the twentieth year. Experiments upon pup- 
pies and other young animals indicates that full development 
of the accessory sinuses is dependent upon unobstructed nasal DISEASES OF THE NOSE 
151 
respiration. In a young animal occlusion of both nostrils 
causes death. Occlusion of one nostril is followed by imper- 
fect development of that side of the face including the accessory 
sinuses. 
As the result of senile changes the accessory sinuses increase 
in size after the age of fifty and the frontals of the aged some- 
times are enormous. 
Because of the conical shape of the orbits, the lateral masses 
of the ethmoids are narrower in front than behind and consist 
Fig. 70.-Relation of accessory sinuses, nasal'bones and cartilages, canaliculi 
and nasal ducts, and sac to surface. Projection upon surface of outei margins 
of orbital cavity of conjunctival sac, and of globus oculi upon surface: A, Antra of 
Highmore; F, frontal sinuses (the white cross above the right upper lid shows 
the relation of the supraorbital nerve to the frontal sinus; the black cross just 
beneath the lower lid indicates the relation of the infraorbital nerve to the antrum); 
N, nasal bones; 1, projection of margin of orbit upon surface; 2, projection of 
eyeball (globus oculi) on surface; 3, projection of conjunctival sac upon surface; 
4, lacrimal sac; 5, nasal duct (from the lacrimal sac to the inner ends of both eye- 
lids the lacrimal canals can be seen terminating at the eyelids in the puncta lacri- 
malia); 6, lateral cartilage of nose (between the cartilage of each side is the carti- 
laginous portion of the septum, upon which they rest); 7, alar cartilages (Modi- 
fied after Eisendrath). 
of cells between nearly vertical walls: the os planum of the 
orbit and the ethmoidal portion of the lateral nasal wall. 
Above, the ethmoidal cells are capped by the frontal bone into 
which they partly extend; which is comparatively thick and 
contrasts strongly with the thin, fragile cribriform plate uniting 
the lateral masses of the ethmoid capsule, the os planum, the 152 
DISEASES OF THE NOSE, THROAT, AND EAR 
lateral nasal wall, and the bony partitions between the cells 
and between them and the sphenoid antrum. 
The capsules are divided into anterior and posterior eth- 
moidal cells by the lamina of the middle turbinate (Fig. 78). 
Anterior to this lamina are the laminae of the bula ethmoidalis 
and that of the unciform process; while posterior are the lam- 
inae of the superior turbinate and of the partition between the 
ethmoid cells and the sphenoid antrum. The cells formed 
upon these laminae vary in size and shape and occasionally 
protrude beyond the normal limits of the labyrinthine capsule. 
For example an anterior ethmoidal cell may extend laterally 
over the orbit and anteriorly into the frontal bone. In cases 
where there is no frontal sinus, such an orbital cell may readily 
be mistaken for the sinus or lying in the frontal bone laterally 
to the sinus, for a double frontal sinus. One or more ethmoid 
cells sometimes occur between the orbit and the maxillary 
sinus and sometimes a cell develops above the sphenoid antrum. 
The appearance is that of an antrum divided into an upper and 
lower compartment by a complete partition. Such an ethmoid 
cell is always in intimate relation with the optic nerve which in 
some cases actually passes through it. 
The key to the understanding of the relationship of the 
ethmoid cells and the accessory sinuses is the position of their 
ostea. Those of the anterior ethmoidal cells invariably open 
into the nose beneath the middle turbinate and those of 
the posterior cells above it although because of the great 
variation in the shape and size of individual cells an anterior 
cell may extend back among the posterior cells or a posterior 
cell may extend forward among the anterior cells. In about 
60 per cent, of cases the inferior bulla cell pierces the lamina of 
the middle turbinate to open above it and hence becomes a 
posterior ethmoid cell. 
The septum between the frontal sinuses at its anterior point 
of origin upon the floor of the sinus is almost invariably in the 
central line; but the septum instead of being in the median line 
and vertical, may extend laterally backward and upward in DISEASES OF THE NOSE 
153 
either direction and thus cause the sinuses to differ from each 
other greatly in size and shape; but both ostrea are invariably 
present and in the usual position. Both sinuses may be ab- 
sent, or only one exist, which may extend completely across 
the forehead. In such cases there is only one ostium and 
that in the usual position. Incomplete partitions may partly 
divide the frontal sinuses into several chambers but a 
"double" frontal sinus in the strict sense of the word does 
not exist as these partitions are never complete and there is 
always only one osteum to such sinuses. 
The sphenoid antrum also is sometimes partly divided into 
several chambers by incomplete lamina; but it invariably has 
but one osteum which is always located in the upper one-half, 
generally in the upper one-third of its anterior nasal wall 
posterior to a groove (spheno-ethmoidal sulcus); between the 
ethmoid and sphenoid and laterally to the posterior border of 
the superior turbinate. 
The septum of the sphenoidal sinus like that of the frontal 
at its base anteriorly is almost invariably in the median line; 
but as it extends upward and backward may be so distorted 
as to render the sinuses not only different in shape and size 
but one may actually extend beyond and back of the other. 
The posterior and inferior walls of the sinus are composed of 
thick bone. The anterior wall comprises an exposed or nasal 
portion in the upper half of which is the ostium and the thin 
partition between the posterior ethmoid cells and the antrum, 
which is a part of the ethmoid so that when a skull is disarticu- 
lated this partition comes away with the ethmoid, leaving a 
wide opening into the sphenoid antrum. Upon the superior 
wall of the antrum lies the optic nerve. Because of a dehiscence 
in the bone the nerve sometimes lies directly on the antral muc- 
ous membrane. Upon the external wall is the cavernous sinus 
with the internal carotid running through it. Because of not 
infrequent dehiscence in this location, the cavernous sinus may 
lie directly upon the mucous membrane resembling in this 
respect the intimate relation sometimes existing in the middle 154 
DISEASES OF THE NOSE, THROAT, AND EAR 
ear between the mucous membrane and the bulb of the jugular 
vein; hence curetting the sphenoidal sinuses should be done 
only with the greatest caution if at all. 
The ostium of the maxillary sinus lies at the bottom of the 
infundibulum beneath the bula ethmoidalis. Unlike the other 
accessory nasal cavities there are not unfrequently one or more 
other openings into the antrum through the so-called "mem- 
branous" portion of the median wall, Fig. 77. 
The mucous membrane of all the sinuses is covered by ciliated 
epithelium so arranged that secretions, dust or bacteria are 
swept from the sinuses through the ostea into the nose and hence 
the comparative rarity of sinus infection in spite of the fact 
that congestion and mild catarrhal inflammation of one or 
more of the sinuses is not uncommon in acute coryza; and is 
manifested by characteristic headaches, which quickly subside 
providing the virulence of the infection is not sufficient to 
destroy the epithelium and the ostea remain patulous. Chronic 
purulent inflammation is usually the result of prolonged 
occlusion of an ostium or some focus of infection discharging 
into a sinus, as for example, a gangrenous tooth pulp into the 
maxillary antrum. 
Much can be learned of the topography of the accessory 
sinuses by sectioning dried preparations, but better results 
are obtained by hardening the specimen in formalin solution 
and then clipping away the bone piecemeal from the mucous 
membrane, which has become hard and resilient and perfectly 
retains the original shape of the accessory cavities. 
The accessory sinuses are phylogenetically ancient structures 
and, like the appendix, are residual organs, although their 
presence in the skull adds lightness without greatly diminishing 
the strength of the bones of the face and nose. The antrum 
of Highmore has its prototype in the amphibian accessory 
nasal chamber, which is an organ of smell. It is suggested 
that the sinuses become active when the individual is forced 
to breathe dry air and help supply the deficiency of moisture. 
The accessory sinuses are all supplied by the trifacial nerve, DISEASES OF THE NOSE 
155 
and this fact should be borne in mind in tracing the route of 
reflex phenomena. While the postmortem examinations of 
general hospitals upon cadavers dead from all causes show 
the presence of mucopus in about 33 per cent.; yet micro- 
scopic examination of the lining mucous membrane of the 
sinuses show pathological changes in only about 2 per cent, 
which corresponds more nearly with clinical observations upon 
the living. 
Differential Diagnosis between Diseases of the Accessory 
Cavities.-In disease of the antrum, the frontal sinus, and the 
anterior ethmoid cells the discharge appears anteriorly beneath 
the middle turbinate. That from the posterior ethmoids and 
sphenoid antrum in the olfactory slit or flows into the pharynx 
from the upper surface of the middle turbinate. If pus under 
the middle turbinate continuously reappears after being wiped 
away, it is not a local secretion but is the overflow from one or 
all of the first series of cavities mentioned above. The 
presence or absence of pus in the antrum is readily ascertained 
by needle puncture (see maxillary sinus). If after thorough 
lavage of this cavity, pus reappears beneath the middle tur- 
binate within an hour, its source is either the frontal sinus or 
the anterior ethmoid cells. If air is now blown into the frontal 
sinus by means of a cannula (see frontal sinus) and pus is 
forced out, its source is of course the frontal sinus. The ante- 
rior ethmoid cells are almost invariably diseased in frontal 
sinus suppuration. However, secretions from them may flow 
downward into the antrum but cannot flow upward into the 
frontal sinus. When the antrum is not infected but simply 
is a reservoir for the secretions of the frontal or anterior eth- 
moid cells, removal of the anterior end of the middle turbinate 
and if necessary the uncinate process prevents the entrance of 
pus through its ostium and this absence of pus can be demon- 
strated by needle puncture. 
Pus from the posterior ethmoids and sphenoid (second 
series of cells) appears in the olfactory slit or upper surface of 
the middle turbinate. Its source can usually be traced with 156 
DISEASES OF THE NOSE, THROAT, AND EAR 
the nasopharyngoscope (Fig. 19). After cocainization it is 
sometimes possible to expose the ostium of the sphenoid with a 
long Killian speculum (Fig. 14) and see a pulsating bead of pus 
exuding from its ostium. In other cases it will be necessary to 
remove the posterior part of the middle turbinate to bring the 
Fig. 71.- 1, Frontal sinus, with probe entering it through the adnasal duct; 
2, sphenoid antrum, with probe entering it through its ostium; 3, pharyngeal 
orifice of the Eustachian tube, with catheter in position; 4, Bowman's probe passed 
through the nasal duct into the nose, a portion of the inferior turbinated body 
has been cut away in order to show the point at which the probe enters the nose; 
s, m, i, superior, middle, and inferior turbinated bodies; o, ostium of the posterior 
ethmoid cells opening into the superior meatus; v, posterior portion of the Vomer; 
the rest of the septum has been cut away (from a dried preparation). 
sphenoid ostium into view. If, after washing out its sinus, pus 
reappears upon its anterior surface within half an hour, the 
source of the pus is the posterior ethmoid cells. If under these 
circumstances no pus can now be washed out from the sinus, 
it is probably not suppurating and any pus removed by the 
former lavage was seepage from the posterior ethmoids. DISEASES OF THE NOSE 
157 
Orbital abscess with consequent exophthalmos is most fre- 
quently the result of ethmoiditis but may result from disease 
of the sphenoid or frontal. From ethmoiditis the direction 
of the exophthalmos is outward and forward: from the sphenoid 
directly forward and from the frontal downward and forward. 
The pus is usually at first between the periosteum and the 
bone. The periosteum of the lamina papyracea may be dis- 
sected forward from the bone until it approaches the inner 
canthus or backward to the optic nerve. Ocular symptoms 
result either from the absorption of toxins, arterial or venous 
congestion or actual thrombosis of intercommunicating veins 
between the sinuses and orbit. The larger quantity of blood 
from the nose is carried into the ophthalmic veins; but there are 
no communications between the lymphatics of the accessory 
cells and orbit. In mild cases there is simply congestion of the 
conjunctiva and possibly epiphora and edema of the lids. 
Paralysis of the internal rectus and superior oblique sometimes 
result from ethmoid disease and ptosis from frontal sinus sup- 
puration. Only in rare instances does disturbance of vision 
occur from disease of the frontal or maxillary sinuses but the 
field of vision may be greatly restricted from sphenoid disease. 
There may be papillitis, neuroretinitis, choroiditis, or irido- 
cyclitis. Blindness results sometimes from direct pressure of 
inflammatory products upon the trunk of the optic nerve. 
Intracranial complications are phlebitis and thrombosis of 
the sinuses, meningitis, extradural, intradural and cerebral 
abscess. Facial neuralgia is most commonly caused by disease 
of the maxillary antrum. Crust formations on the middle 
turbinate are most common in ethmoidal suppuration, but 
may be present when there is a scanty discharge from either 
the maxillary or frontal sinus. 
Nasal polypi are most frequently the result not the cause of 
ethmoiditis and polypi may be present not only in the ethmoid 
cells but in any accessory cavity of the nose. Pain in max- 
illary or frontal sinus disease is usually referred to the sinus 
involved; but in the case of the ethmoid or sphenoid, headache 158 
DISEASES OF THE NOSE, THROAT, AND EAR 
is vaguely deep seated or referred to the vertex or sides of the 
head. Supraorbital pain may result from suppuration of 
either the maxillary or frontal sinuses. Sinus headaches are 
increased by bending forward. Pain is not usually proportion- 
ate to the amount of fluid in a sinus but is often the result of 
"vacuum congestion," that is the negative pressure caused by 
the absorption of oxygen from the air contained in a sinus 
whose ostium is occluded. "Pressure pain" can .usually be 
elicited in disease of the frontal sinus by pressing with the tip 
of the forefinger upon the anterior wall just above the supra- 
orbital ridge, or more frequently by pressing upward upon the 
floor of the sinus at the inner angle of the orbit. Pressure in 
this position toward the orbital plate of the ethmoid sometimes 
causes pain when the anterior ethmoid cells are inflamed. 
Pressure in the canine fossa over a diseased antrum usually 
causes pain but in unilateral diseases of any nasal accessory 
cavity the degree of pressure tenderness should be compared 
with that of the opposite side. 
Vertigo and momentarily blurred vision when stooping 
forward may be present in disease of any of the accessory 
sinuses. 
The sense of smell may be perverted {parosmia) so that the 
individual imagines he smells a bad odor or may be impaired or 
entirely lost {anosmia). The latter is usually due to swelling 
of the ethmoidal mucous membrane or polypi preventing 
ventilation of the olfactory fissure. 
Inflammation of the antrum of Highmore may be divided 
clinically into: Acute and chronic catarrhal inflammation and 
acute and chronic purulent inflammation. 
Etiology.-The fangs of the first and second molar teeth 
usually extend into the floor of the antrum, the apex of the fangs 
not infrequently reaching a level above that of the rest of the 
floor of the antrum (Fig. 72). Under these circumstances it is 
easy to understand how caries of these molar teeth would in- 
fect the antrum, and undoubtedly gangrene of the molar pulp- 
cavities is a frequent cause of chronic suppuration. However, DISEASES OE THE NOSE 
159 
closure of the ostium maxillare as the result of hypertrophic 
rhinitis and polypoid degeneration of the mucous membrane 
about this opening preponderates in the etiology of empyema. 
Some acute cases can be traced directly to the effects of influ- 
enza. The antrum may also be infected from disease of the 
ethmoid cells, the frontal sinuses, the sphenoidal sinuses, 
syphilitic necrosis, etc. In some instances the frontal sinus 
Fig. 72.-Transverse section of the maxillary sinuses (Zuckerkandl). 
and the anterior ethmoid cells drain almost directly into the 
antrum; because the ostium maxillare is at the bottom of the 
infundibulum. 
Pathology. Soon after the onset of acute inflammation the 
mucous membrane of the antrum becomes greatly swollen and 
edematous and a large amount of seromucus is poured out. 
The inflammation may gradually subside at this stage provided 
the ostium is patulous or the secretion may become purulent. 
In old cases the cavity may be filled with foul, cheesy pus. 
The mucous membrane in some cases becomes enormously hy- 160 
DISEASES OF THE NOSE, THROAT, AND EAR 
pertrophiecl, pulpy, and covered with granulations and polypi, 
with areas of exposed bone. 
Symptoms.-At the beginning of the attack there is a sense 
of fulness and pressure beneath the orbit, and pain, sometimes 
agonizing in character, involving the whole side of the face. 
In the more acute cases heat, swelling and redness occur 
over the affected cavities in inflammation of either the antrum 
or frontal sinus. 
Mastication is generally painful, the teeth of the affected 
side feeling as if elongated and crowded out of their sockets. 
These symptoms when due to a collection of fluid within the 
antrum and closure of the ostium maxillare may last for sev- 
eral days, when the fluid is either evacuated through the os- 
tium maxillare or by an opening through the thin median wall; 
in rare cases, the alveolus, the cheek, or the orbit. After this 
spontaneous evacuation the pus flows for a time, the course of 
the disease being marked by periods of retention, during which 
there is more or less pain, terminating by a discharge of some- 
what fetid pus from the nostril. Some cases, however, pursue 
a chronic course from the commencement, there being at no 
time complete closure of the ostium maxillare and retention, 
nor any well-marked symptoms, except a unilateral catarrh, 
general ill health, with perhaps evening rise in temperature, 
which may, perhaps, occasion the erroneous diagnosis of "com- 
mencing tuberculosis," and the possibility of antral inflamma- 
tion as a factor in the causation of acute articular rheumatism, 
pneumonia and asthma is worth consideration. 
Diagnosis.-A discharge of pus from one nostril, especially 
if periodic in character, which smells and tastes fetid to the 
patient, should always excite the suspicion of disease of the 
antrum. Upon inspection the pus will be found flowing from 
beneath the middle turbinated body. This pus should be 
carefully wiped away with absorbent cotton and the patient be 
directed to lie down upon the unaffected side for ten or fifteen 
minutes, when, if pus reappears beneath the middle turbinated 
body it is probable that its source is the maxillary antrum. DISEASES OF THE NOSE 
161 
If, while the patient is in a dark room, a 3-candle-power electric 
lamp is placed within his mouth, the face will be lit up by trans- 
mitted light, and the outlines of each antrum can be mapped out 
if both are empty. If one is inflammed that side of the face 
will appear darker. This is not due to the presence of pus; 
because the shadow will remain the same after this is removed, 
but to inflammatory thickening of the lining mucousmembrane. 
The observer should also observe the manner in which the light 
is transmitted into each nasal chamber, and more especially 
through the eyeballs. In some cases both sides of the face will 
be equally illuminated by the transmitted light; but if the pupil 
of each eye be observed, that of the unaffected side will be the 
brighter, and also a half-moon shaped portion of the lower eye- 
lid immediately below the eyeball will be more brightly illumi- 
nated. X-ray photographs often give valuable information as 
to the extent and size of the adnasal sinuses and presence or 
absence of disease; and in cases where it is suspected that dis- 
ease not only of the antrum but also of other accessory cavities 
exists, this means of information should not be neglected; 
but pathological conditions cannot be determined with 
certainty until the sinus has been opened, so that probably 
the simplest and most certain method of diagnosing the pres- 
ence of pus is the introduction of a Lichtwitz needle into the 
antrum. After thorough cocainization beneath the turbinate 
and the tip of the septum, the point of the needle is intro- 
duced beneath the lower border of the inferior turbinate and 
passed upward and backward until the middle of the attach- 
ment of the turbinate to the nasal wall is reached Fig. 74. 
In this position is the so-called "soft spot" where the wall of 
the antrum is usually so thin that no more force is required 
to penetrate it than to push a hypodermic needle through skin. 
However should hard bone be encountered in this locality, a 
few blows with a small mallet on the shank of the needle will 
overcome the difficulty. Before making the puncture the 
proximal end of the septum on which the shank of the needle 
rests is strongly bent toward the opposite side of the face so 162 
DISEASES OF THE NOSE, THROAT, AND EAR 
that the point of the needle will penetrate the bone as nearly 
vertical to its surface as possible and the bevel of the needle 
point should be directed backward so that it will tend to 
penetrate the bone and not to slip along its surface beneath 
the mucous membrane. The thrusting of the small needle 
through the nasal wall should give no more pain than a hy- 
podermic injection. Air forced through the needle with a 
large syringe will bubble through the contents of the antrum 
if it is filled with mucopus producing a loud and character- 
istic bubbling noise. However it should be born in mind that 
in some acute cases the mucous lining of the antrum may be so 
swollen as to almost completely obliterate its cavity, so that 
the operator should be certain before blowing air with much 
force through the needle, that its point has completely pene- 
trated the lining mucous membrane. Because the floor of the 
antrum is rarely as high as that of the nose (Fig. 72) the needle 
will enter at a considerable distance above the floor of the 
antrum and if the fluid within does not reach this level, there 
will be no characteristic bubbling sounds produced by blowing 
air through the needle. Under these circumstances the 
antrum should be cleansed by syringing, normal salt solution 
into the antrum through the needle. If the patient's head is 
bent forward, the fluid will escape through the ostium and out 
of the nose and may be collected for examination in a bowl 
held by the patient. The salt solution is thrown into the 
antrum until no pus is washed out. The fluid remaining in 
the antrum is then removed by blowing air through the 
needle with the syringe. 
If it is impossible to syringe through the needle without 
undue force, the needle may not have entered the antrum, Fig. 
74; it may be stopped up by a little spicule of bone, the ostium 
may be occluded, or the lining mucous membrane may 
be so swollen as to nearly fill its cavity. When its ostium 
is occluded, the pus should be asperated from its cavity. If 
the needle is stopped up, it should be withdrawn cleansed and 
reintroduced. DISEASES OF THE NOSE 
163 
Prognosis.-Resolution generally occurs in acute catarrhal 
cases, the result of transient closure of the ostium maxillare 
from simply taking cold. Chronic suppuration of the antrum 
rarely if ever gets well without operation. 
Treatment.-'Success in all acute cases of accessory sinus 
disease depends largely upon the restoration of ventilation and 
drainage. An effort should be made to restore the patency of 
the ostium maxillare in the following manner: The parts about 
the middle turbinated body should be thoroughly cocainized 
by means of pieces of absorbent cotton saturated with a 4 
per cent, solution of cocain placed within the middle meatus, 
after which the parts should be sprayed first with a 10 per cent, 
solution of antipyrin and next with a 3 per cent, solution of 
menthol in olive oil, the parts are then covered with powdered 
calomel. These applications should be made daily at the physi- 
cian's office, the patient in the meanwhile using at home every 
hour or two a spray of adrenalin of the strength of 1:10,000. 
This treatment is curative in some mild catarrhal cases. 
However, if much muco-pus is washed from the antrum with 
a Lichtwitz needle when used for diagnosis, it will be necessary 
to repeat this irrigation daily: but if after twelve days pus is 
still washed from the antrum, the disease is probably an acute 
exacerbation of a chronic suppuration and more radical 
procedures will be required to bring about a cure. 
The accessory sinuses can be inflated with a Politzer bag 
or by Valsalva's method, that is, closing the nose and blow- 
ing violently into it. They may be aspirated by inserting 
the nozzle of a Politzer bag into the patient's nose and allowing 
the empty bag to expand while the patient is blowing out 
this cheeks. Closing the nostrils and sniffing violently has a 
tendency to aspirate the accessory sinuses. In some cases the 
rarefaction of the air by this method in an inflamed antrum is 
sufficient to cause pain, and in certain cases is sufficient to 
enable a patient to aspirate fluid from this antrum when in the 
horizontal position with the affected antrum uppermost. 
Formerly chronic suppuration of the antrum was treated 164 
DISEASES OF THE NOSE, THROAT, AND EAR 
almost exclusively by the Cowper method. A molar tooth was 
drawn and the antrum entered through the inner root socket by 
means of a conical drill. Generally a carious tooth could be 
selected but when a sound tooth was sacrificed, the second molar 
was chosen. Occasionally the opening was made through 
the canine fossa and Fig. 73 shows a condition where it would 
be very difficult to enter the antrum through the alveolus. 
Fig. 73.-Illustrating the difficulty of opening the antrum through the root-cavi- 
ties when the antrum is small or abnormal in location. 
The antrum was washed out daily either by the surgeon or the 
patient. This method is still justifiable in necrosis when, after 
removal of one or more of the molars and surrounding necrosed 
bone, a large opening into the antrum results. It is astonishing 
in some such cases how quickly a cure of the suppuration results 
from a few daily irrigations. However openings from the 
mouth into the antrum quickly close if a plug of vulcanite or DISEASES OF THE NOSE 
165 
metal is not constantly worn to keep them open; and daily 
irrigation for years is sometimes unsuccessful in bringing about 
a cure. 
An opening through the nasal wall beneath the inferior 
turbinate closes more slowly because the bone is not very thick 
and if large sometimes remains open sufficiently long to bring 
about a cure of a chronic suppuration; because even without 
irrigation the antrum is cleansed by its secretions constantly 
escaping into the nose. 
Such openings are readily made either with or without the 
previous removal of the anterior third of the inferior turbinate, 
Fig. 74.-Section through the nose, showing needle (B) entering the orbita 
cavity through the middle meatus when the lateral wall slopes outward; A shows 
needle entering the antrum through the inferior meatus. Outline: Zuckerkandl, 
Anatomie der Nasenhohle (Coffin). 
with Wagner's punch, Weil's saw, Welaminsky's perforator' 
Well's rasp cannula, Gleason's perforator and rasp and by other 
methods. Should such an opening close prematurely, it is 
readily reproduced; because it is closed, not by the bone, but 
by thin cicatricial tissue which is easily penetrated and removed. 
The parts are cocainized as for an ordinary needle puncture. 
The triangular sharp end of Gleason's perforator is then 
placed upon the "soft spot" and a few half turns caused it 
to cut its way into the antrum. As it is withdrawn the bone 
is rasped away sufficiently to permit the introduction of the 
blunt end of the instrument and a sufficiently large opening 
quickly rasped from the antral wall into the nose. The opera- 166 
DISEASES OF THE NOSE, THROAT, AND EAR 
tion is comparatively painless if the parts have been sufficiently 
cocainized. The antrum is irrigated each day 
either by the surgeon or the patient with an Eusta- 
chian catheter as long as there is any discharge, 
when the opening is allowed to close. Should ex- 
uberant granulations from the edge of the wound 
obstruct drainage from the antrum, they should 
be scraped away by introducing the blunt end of 
the instrument through the wound. The instru- 
ment is smooth on two sides so that it can be used 
without wounding any part of the edge of the 
opening which has cicatrized. 
For cleansing the antrum sterile norma salt 
solution is probably the most convenient, Ibut a 
saturated solution of boric acid may be employed. 
To either of these solutions a small proportion of 
hydrogen dioxide may be added. Foul odor is 
best overcome by syringing with i to 1000 permanga- 
nate of potash or i per cent, silver nitrate may be 
thrown into the antrum and after a few moments 
removed by syringing with normal salt solution. 
However in most chronic cases, alcohol gives the 
best results. After cleansing with normal salt solu- 
tion, the antrum is filled with 50% alcohol which 
is allowed to remain. Should this cause only mo- 
mentary discomfort the strength of alcohol is in- 
creased at subsequent sittings until 95 per cent, 
is used. When the secretions instead of being 
purulent and rendering the irrigation fluid flocculent 
become mucoid so as to form a jelly-like mass float- 
ing in clear irrigation fluid, the case is rapidly ad- 
vancing toward a cure. The permanency of the 
cure will depend largely upon the patency of the 
ostium maxillare and the condition of the struc- 
tures about this opening should receive careful attention. 
Radical Operations.-In some cases intranasal treatment 
Fig. 75.- 
Gleason's 
antrum 
rasp. DISEASES OF THE NOSE 
167 
is insufficient to bring about a cure of chronic suppuration. 
Radical or as sometimes called external operations have been 
devised by Kfister, Janson, Caldwell-Luc and Denker. 
Janson claims that when one sinus is involved, all the sinuses 
of that side of the head are probably more or less affected. 
In America the operation is employed mostly for the removal 
of malignant growths involving the antrum and nose. A post- 
nasal tampon is first placed in the nasopharynx. An inci- 
sion is made along side the nose, then below the nose to the 
columna and then through the lip into the mouth. The flap 
is dissected back to expose the anterior bony wall of the antrum. 
This together with the nasal process of the superior maxillary 
is removed as in the Denker operation. . The growth is then 
rapidly excised, the ethmoidal labyrinth is torn away with 
alligator forceps, the thin wall between the posterior cells and 
the sphenoid antrum is broken down and its cavity widely 
opened. In a number of cases of malignant growths operated 
by this method, the hemorrhage was easily controlled by 
packing with iodoform gauze and there was ample opportunity 
to carefully inspect the parts and remove all tissue that seemed 
infected. 
Caldwell-Luc Operation.-'The patient is etherized and the 
foot of the operating table slightly elevated. To prevent 
blood reaching the pharynx a strip of gauze is packed between 
the jaw and the cheek beyond the wound and removed from 
time to time as it becomes saturated with clots. In spite of 
this very important precaution a certain amount of blood usu- 
ally reaches the pharynx; especially during the later part of 
the operation and a mouth gag, tongue-depressor and long 
Kocher's hemostats for sponge holders should be at hand 
for its removal. 
The cheek and upper lip are elevated by means of blunt 
retractors and an incision made at the junction of the cheek 
and jaw from the posterior border of the alveolus to just below 
the nasal septum through the mucous membrane and perios- 
teum. The anterior and lateral walls of the antrum are now 168 
DISEASES OF THE NOSE, THROAT, AND EAR 
uncovered by means of a periosteum elevator and the bone 
removed with chisel and rongeur forceps as far forward as the 
nasal wall and backward to the anterior border of the masseter 
muscle and vertically from the floor of the antrum to near the 
infraorbital canal. If the lining membrane is not wounded, 
the operation up to this point will be nearly bloodless. 
The mucous membrane is incised and the cavity of the an- 
trum examined with the finger and after hemorrhage has ceased, 
inspected. The hemorrhage which follows incision of the red 
and swollen mucous membrane will be profuse. It is con- 
trolled by packing the antrum with iodoform gauze, at least the 
mucous membrane of the floor of the antrum will probably be 
diseased beyond repair and require removing. This now is done 
by separating the mucous membrane from the bone by inserting 
a curette between them. When greatly inflamed and swollen 
Fig. 76.-Killian's frontal sinus chisel. 
it peels off readily and is often easily removed in one piece. 
The antrum is freed from blood, bony septa broken down and 
removed with the curette, and a larger opening made in the 
nasal wall. This is best started by making two rectangular 
cuts through the thin bone of the nasal wall with Killian's an- 
gular chisels (Fig. 76) care being taken not to penetrate the 
nasal mucous membrane if it can be avoided. The square 
plate of bone inclosed by the chisel cuts is carefully lifted off 
the nasal mucous membrane and the rest of the nasal bony wall 
cut away with curette and rongeur forceps. If possible the 
nasal mucous membrane is preserved and at the conclusion of 
the operation turned into the antrum to cover its floor. It 
adheres to the floor and shortens somewhat the time required 
for healing. The preservation of the nasal mucous membrane 
will be facilitated by placing the little finger within the nose 
from time to time while the bony nasal wall is being removed. 
However, if most of it is sacrificed during the operation, it DISEASES OF THE NOSE 
169 
need cause no anxiety as it does no harm except to lengthen 
the time required for healing. 
The lacrimal duct enters the nose beneath the inferior 
turbinate at the angle formed by its oblique and horizontal 
attachment to the antral wall. It is about on a level and not 
far from the infraorbital foramen, and is situated so high up 
that the greater portion of the nasal wall can be removed 
without injuring it. However, whether the duct is injured or 
not the patient generally has epiphora which after a time 
subsides. It is better to remove at least the anterior third of 
the inferior turbinate. The lower portion of the nasal wall 
should be removed so completely that there will be no ridge of 
bone between the nasal floor and that of the antrum. The 
operation is completed by inspecting all angles within the 
antrum for necrotic areas or diseased mucous membrane, 
which if found are removed. The remains of the nasal mucous 
membrane of the nasal wall of the antrum is now turned into 
the antrum to replace as far as possible its own mucous mem- 
brane and if necessary held in place with a stitch. The end of 
a strip of gauze is passed through the antrum into the anterior 
nares and the rest of the strip packed loosely into the antrum. 
The oral wound should not be stitched as it heals readily. 
The iodoform gauze is partly removed on the second day 
through the nose and the rest of strip on the third day. The 
after-treatment consists in syringing through the nose normal 
salt solution as long as there is secretion. During the healing, 
the antrum becomes greatly reduced in size. 
Denker's operation differs from the Caldwell-Luc to the 
extent that the anterior inferior angle of the antrum is obliter- 
ated by removing with chisel and rongeur the nasal process of 
the superior maxilla from the floor of the nose to the level of 
the infraorbital foramen. 
Diseases of the frontal sinus are acute catarrh or suppura- 
tion, chronic catarrh or suppuration, confined suppurations, 
mucocele, tumors, foreign bodies and local manifestations of 
syphilis, tuberculosis or some other systemic infection. Acute 170 
DISEASES OF THE NOSE, THROAT, AND EAR 
catarrh of the frontal sinus probably is more common than 
similar disease of any of the other accessory sinuses. The 
disease, however, more rarely goes on to suppuration because 
the ostium often affords ample drainage from the most de- 
pendent portion of the cavity. 
Fig. 77.-This section shows part of the frontal sinus, the hiatus semi-lunaris, an 
accessory opening into the antrum, the inferior turbinal body, the Eustachian tube 
opening behind this and the sphenoidal sinus, with a partial septum near its center. 
In front of this sphenoid are the posterior ethmoid cells (not opened) and between 
these two is the sphenoethmoidal sulcus. The middle turbinal body has been lifted 
upward to show the structures beneath it. It remains attached by part of its upper 
edge to the ethmoid body (Douglass). 
The symptoms of acute sinus inflammation are frontal 
headache, sometimes severe pain, with nausea and vomiting. 
Redness and swelling over the sinus and edema of the eye 
lids. The infection extends to the meninges with characteristic 
symptoms, according to some authors more frequently in 
accessory sinus disease than in otitis. When a transilluminator 
is placed beneath the brow, the light is transmitted better by a DISEASES OE THE NOSE 
171 
large normal sinus than by one containing pus or a tumor. 
However, the size and shape of the frontal sinus varies so greatly 
in different individuals that a much more satisfactory result 
can be obtained by an x-ray photograph than by transillumi- 
nation. It is usually possible, by means of a good photograph, 
to not only determine whether the sinus contains pus or a 
tumor, but also secure valuable information as to its size, 
the presence or absence of septa, the condition and size of the 
ethmoid cells, the antra of Highmore, etc. It should be borne 
in mind that headache and even tenderness on pressure be- 
neath the eyebrow over the sinus sometimes results from 
pressure of a hypertrophied middle turbinate on the nasal 
septum. 
Treatment.-'The headache and pain can sometimes be re- 
lieved by cocainizing the parts and inflating the frontal sinus 
with menthol-iodin-chloroform vapor. Should this maneuver 
succeed, Politzer's bag should be used at sufficiently frequent 
intervals to prevent a return of the frontal headache. The 
patient should spray his nose every two hours with a i : 10,000 
solution of adrenalin as a home treatment, and every effort 
should be made to maintain the ostium in a patulous condition 
until the inflammation of the frontal sinus subsides. Some- 
times the patient can aspirate fluid from the frontal sinus by 
closing the nostrils with the thumb and finger and attempting 
forced inspiration through the nose. The infundibiilum is a 
narrow groove in the outer wall of the nose. Its crescent- 
shaped opening into the middle meatus is the hiatus semilunaris. 
The frontonasal canal or duct, as the upper anterior portion 
of the infundibulum is called when it becomes a closed canal by 
becoming covered at its median side by the anterior attach- 
ment of the middle turbinate, generally extends upward from 
the infundibulum to the frontal sinus, where its opening is 
called the ostium frontale. However, in 50 per cent, of cases 
the upper portion of the infundibulum is not inclosed and 
hence there is no nasofrontal duct and the ostium opens 
directly into the middle meatus beneath the anterior extremity 172 
DISEASES OF THE NOSE, THROAT, AND EAR 
of the middle turbinate. The distance from the floor of the 
frontal sinus through the nasofrontal duct if it exists is rarely 
more than f inch. The distance from the nasal end of the 
duct to the lower border of the bulla ethmoidalis, the lowest 
possible region of obstruction to frontal drainage, is about | 
inch (Fig. 78). When using adrenalin the patient should be 
Fig. 78.-1, 2, 3, 4, 5, Laminae or partitions of the uncinate process, bulla, middle 
superior and supreme turtenates. a, Posterior ethmoid cells, opening together with 
the sphenoid antrum c into the superior meatus; b, anterior ethmoid cells, opening 
together with the frontal sinus and maxillary antrum into the middle meatus; e, in- 
fundibulum leading upward to the osteum of the frontal sinus, d, when covered by 
the anterior attachment of the middle turbinate, the upper portion of the infun- 
dibulum is.converted into the naso-frontal duct; f, hiatus maxillaris; g, anterior 
portion of inferior turbinate removed to show lacrimal duct which is laid open. 
told to direct the spray from an atomizer so that it will reach 
the middle turbinate region. Not infrequently a small 
polypus is found beneath the middle turbinate anteriorly, 
and its removal is followed by a cessation of recurrent attacks 
of frontal sinus inflammation. However, the obstruction 
generally is due to hyperemia and swelling of either the lateral DISEASES OF THE NOSE 
173 
wall of the middle turbinated body or the mucous membrane 
of the infundibulum, the uncinate process, and the bulla 
ethmoidalis. Suitably treated, at least 95 per cent, of acute 
Fig. 79.-Sinus probe. This probe or sound is perfectly flexible and may 
be bent in any desired shape for sounding the frontal, maxillary or sphe- 
noidal sinuses. It is supplied with three markings showing the distance to the end of 
the sound (7 centimeters, 9 centimeters and 11 centimeters). These markings are 
invaluable when sounding the sphenoidal sinus as one can determine at a glance the 
depth to which the sound has penetrated. The instrument is also of use in determin- 
ing the consistency of tissues lying deep in the nose (.hypertrophies, polyps, etc.). 
cases recover without operation, but where relapses are fre- 
quent it is advisable to remove the anterior ethmoid cells. 
Fig. 8o.-Sullivan's frontal sinus rasps. Six sizes-'fitting into one handle. 
In a large proportion of cases the removal of the cells 
exposes the ostium and permits the introduction of a small 
curette or rasp by (Fig. 80) which the ostium if necessary 
may be still further enlarged at the expense of its anterior and 
lateral border. 174 
DISEASES OF THE NOSE, THROAT, AND EAR 
Chronic Purulent Disease of the Frontal Sinus.-Symptoms. 
-'The headache is usually persistent, but may assume an inter- 
mittent type. There may be deep-seated pain on pressure on 
the floor of the sinus at the inner canthus. Upon inspection 
the parts about the infundibulum are red, swollen, and covered 
by a small amount of pus, sometimes offensive in character. 
If the discharge is greatly obstructed, the roof of the orbit 
may be so far crowded downward as to produce displacement 
of the eyeball with diplopia or even amaurosis. Should the 
posterior wall be necrosed, dulness, apathy, increased headache 
and other symptoms referable to the brain will probably mani- 
fest themselves. Meningitis or brain-abscess may occur. 
Treatment.-Chronic cases require irrigation with a mild 
alkaline solution. This may be accomplished by means of 
Hartmann's cannula (Fig. 81). This cannula should be made 
Fig. 81. Hartmann's frontal sinus cannula. The instrument should be made 
of pure, soft silver, so that its curve can readily be slightly changed. However* 
all of the accessory sinuses can be reached by a pure silver Eustachian catheter* 
which can, of course, be attached to a syringe. 
of virgin silver, so that its curve can be slightly changed to 
suit varying conditions. The parts are first cocainized and 
an effort made to probe the sinus with a small virgin silver 
probe (Fig. 77). As the distance from the vestibule of the nose 
to the ostium frontale is about 7 centimeters, the probe should 
be marked with rings at distances of 7, 9 and 11 centimeters 
from its tip. About 1 inch from its tip, the probe is curved 
somewhat abruptly at an angle of about 70 or 8o°. The 
region of the bula ethmoidalis is located and the tip of the 
probe inserted beneath the middle turbinate immediately 
in front of the bula so that the tip will rest upon the upper 
edge of the uncinate process. With this as a guide the tip 
of the probe is moved forward and upward until it is felt to 
enter a cavity which may be either the sinus or an anterior DISEASES OE THE NOSE 
175 
ethmoid cell. If the tip of the probe is in the sinus it will 
enter within the nose from 7 to n centimeters according to 
the size of the sinus. The tip of the probe will be also some- 
what freely movable within the sinus. If the operator is in 
doubt, he may withdraw the probe and place it alongside the 
patient's nose with its tip on the forehead in such a manner 
as to compare its curve with the contour of the patient's face 
and if necessary slightly change the curve of the probe before 
attempting to probe the sinus again. In many cases the 
nasofrontal duct is not a direct continuation of the infun- 
dibulum which ends either as a blind pouch or in an anterior 
ethmoid cell. The ostium frontale with or without a short 
duct opens under the anterior end of the middle turbinate 
in a line with the unciform groove and a little above it. Hence 
when the probe enters the blind pouch in which the infun- 
dibulum sometimes ends or enters an anterior ethmoid cell, 
it should be withdrawn and an effort made to locate the ostium 
frontale further back. Generally the probing is facilitated 
by bending the very tip of the probe laterally at an angle of 
5 or 6°. As force is absolutely unnecessary, great gentleness 
should be used in probing the sinus; for the cribriform plate 
is not far distant from the field of operation. When the probe 
has entered the sinus, it is withdrawn; the shape of the cannula 
is bent to correspond with that of the probe, and inserted into 
the sinus. The solution used for syringing should be of a 
temperature of about 1200 F., and great gentleness should be 
employed in syringing to avoid giving pain. 
If necessary to improve drainage and facilitate cleansing 
and medication of the sinus, the ostium may be enlarged with 
Good's rasp or Suliran's files (Fig. 84). The use of these instru- 
ments usually destroy the naso-frontal duct and one or more 
of the anterior ethmoid cells. Should there be difficulty in 
probing the frontal sinus and the circumstances require it, the 
anterior ethmoid cells should be removed with a curette, after 
which the sinus is usually readily probed and its ostium 
enlarged with Suliran's files. As in the external operation for 176 
DISEASES OF THE NOSE, THROAT, AND EAR 
exenteration of the ethmoid labyrinth (page 185) the lacrimal 
bone is the guide to the position of the anterior cells. This is 
readily located by pressing the forefinger tip into the tissues at 
the inner canthus, a medium sized mastoid curette, Fig. 201, 
is passed above the anterior attachment of the middle turbinate 
and its concave surface pressed firmly into the cells which are 
opened by rotating the curette backward and downward. 
The septa between the cells are then removed with alligator 
forceps. With the forefinger of the disengaged hand pressing 
on the lacrimal bone there is little danger of injuring either 
this structure or the os planum but should the orbit be pene- 
trated no harm results beside swelling and discoloration of 
of the eye lids which subsides within a few days (Mosher). 
After the sinus has been thoroughly cleansed, any retained 
fluid should be removed by blowing air through the cannula 
with the syringe. After the sinus has been cleansed and dried, 
I dram of a 10 per cent, solution of argyrol or alcohol 50 per 
cent, to 95 per cent., should be injected through the cannula 
by means of syringe a, Fig. 29, and allowed to remain. 
In many cases the discharge loses its fetid odor and becomes 
mucoid but never entirely ceases. However there is no head- 
ache except during acute exacerbations of the disease. Some 
of these cases are improved for the time being at least by the 
use of autogenous vaccines or injecting into the sinus of pure 
cultures of the Bulgarian lactic acid bacillus; but these meas- 
ures are sometimes inadequate to bring about a cure and an 
external operation for obliteration of the sinus is necessary. 
Killian states that the following conditions indicate an 
external operation. 
" 1. When other operations have failed. 
'*2. When there are indications of necrosis as a fistula or 
abscess. 
"3. When there are symptoms of intracranial complications. 
"4. When in a case of chronic purulent frontal sinusitis 
pain and fever appear with a foul smelling discharge. 
"5. When there is headache, particularly when associated DISEASES OF THE NOSE 
177 
with discomfort in the region of the eye, which is not relieved 
by intranasal treatment. 
"6. When in spite of oft repeated irrigations of the sinus, 
the discharge remains foul. 
" 7. When the inflammation of the frontal sinus and anterior 
ethmoid cells produces recurring groups of polypi. 
"8. When a simple purulent discharge is not relieved by 
careful intranasal treatment, and the patient desires perma- 
nent relief by a radical procedure." 
Bryan, Hajek, Killian, Agston, Luc, and Kuhnt have 
devised operations for exposing the frontal sinus by removing 
a portion of its external wall. Kiister, Lathrop, Beck, and 
others have devised osteoplastic operations in which a flap of 
periosteum and bone is replaced after the sinus has been 
curetted. 
Killian's Operation.-The field of operation is sterilized 
in the usual manner; the nostril is filled with a strip of selv- 
edged iodoform gauze which is removed and replaced from 
time to time as required during the operation. A mouth gag, 
tongue depressor and sponge holders should be at hand to 
remove blood that finds its way into the pharynx. A semicir- 
cular incision is made along the eyebrow from near its temporal 
end to the side of the nose and thence downward along the side 
of the nose to below the inferior border of the orbit whence, 
if necessary, it extends for a short distance outward. A some' 
what sharp hemorrhage from arteries near the root of the nose 
will necessitate the application of several hemostats. The 
periosteum is incised just beneath the inferior border of the 
temporal ridge and along the side of the nose, and the perios- 
teum and tissues of the orbit separated from the bone and held 
out of the way with an "eye protector. " For this purpose an 
ordinary tongue depressor may be employed, but care should 
be exercised during the entire operation that injurious pressure 
is not made upon the eyeball either by the "protector" or 
hemostats beneath it. 
A second incision through the periosteum is now made 178 
DISEASES OF THE NOSE, THROAT, AND EAR 
about | inch above the superciliary ridge and parallel to its 
inferior border and the bone of the forehead, above this line 
denuded of its periosteum to the upper limits of the frontal 
sinus as determined by a. skiagraph before the operation. 
Should the frontal sinus be large and extend high up upon the 
forehead, it will be necessary to make a second incision 
through the skin and periosteum vertically from the first at the 
root of the nose, thus producing a triangular flap of skin and 
periosteum which is lifted up from the bone. The periosteum 
and bone of the superciliary ridge are left intact as a bridge, 
that as little deformity as possible shall result from the opera- 
tion. The width of the bridge should be about that of the 
base of the nasal bone of the side operated upon. As a con- 
tinuation of the base of the nasal bone at the completion of 
the operation it arches upward and outward to the lateral 
limit of the sinus. Extreme care is necessary at certain stages 
of the operation to avoid fracturing it. 
The periosteum is incised somewhat above the line of this 
bridge so that it can be turned over the superior surface of 
this bridge and form a covering for the upper surface of the 
bridge. The boundary of the upper border of the bridge is 
marked out by a groove made with Killian's triangular chisel 
(Fig. 76.) This groove is deepened by successive chiselings 
until the mucous membrane of the antrum is reached. The 
mucous membrane is pushed out of the way with a probe, and 
enough of the bone removed with a gouge to permit the probe 
being inserted in every direction between the mucous membrane 
and the bone and the boundaries of the antrum shown by the 
skiagraph verified. With chisel and rongeur forceps the entire 
outer wall of the frontal is removed. The swollen mucous 
membrane is now lifted up from the bone with a separator, 
and removed entire with a pair of forceps. As the mucous 
membrane when thickened and inflamed is attached very 
loosely to the bone its removal is usually a matter of little 
difficulty, a small gouge answering well as a separator. All 
overhanging ridges of bone are chiseled away, all angles of DISEASES OF THE NOSE 
179 
softened bone are smoothed down with a curette, so that no 
dead spaces remain when the wound is completed. The 
operator now proceeds to remove the floor of the autrum, 
and thus form a large opening into the nose. 
The periosteum of the orbit above and at the side of the nose 
is carefully separated from the bone until the lacrimal sac is 
reached which is lifted from its groove exposing the lacrimal 
bone which is punctured with a chisel and removed with 
alligator forceps (Figs. 44 and 82), exposing the anterior 
ethmoidal cells. 
Fig. 82.-Alligator forceps. 
The articulation of the nasal process, of the superior maxil- 
lary, the nasal bone and the frontal form a T-shaped suture 
which is readily perceived when the bones are bared of their 
periosteum. The floor of the frontal sinus lies immediately 
above where the vertical portion joins the horizontal portion 
of the T-shaped suture and the floor of the sinus should be 
removed with a gouge and also a sufficient portion of the 
nasal process of the maxilla to secure sufficient room for the 
use of alligator forceps (Figs. 44 and 82). At least the anterior 
ethmoidal cells are torn away with this instrument including 
the outer wall of the orbit (lamina papyraciae). When the 
entire ethmoid is suppurating the cells are bitten away with 
the forceps until the outer wall of the sphenoid is reached; 
which is also removed. The bony floor of the antrum, which 
is also the roof of the orbit, is entirely removed with the for- 
ceps and all angles smoothed down with a curette. 
A strip of selvedge-edged iodoform gauze is inserted from the 
antrum into the nose. Above this another strip of gauze is 180 
DISEASES OF THE NOSE, THROAT, AND EAR 
inserted at the inner angle of the wound and another protruded 
from the outer angle. The skin wound is then brought together 
with sutures so arranged that the pulley of the superior oblique 
is brought as nearly as possible back into its original position. 
Because of the large opening into the nose the skin over the 
wound moves inward and outward with each breath of the 
patient. If this were allowed to continue, it would prevent 
the parts adhering by first intention and a pad of suitable size 
is adjusted over this region and held firmly in place with a 
Fig. 83.-Grooves made with the V-shaped chisels to form the upper surface 
of the bridge and to outline the portion of the frontal process of the maxillary 
bone to be removed. 
Fig. 84.-Extent of bone removed in Killian operation. 
bandage. If the temperature remains normal and the patient 
does not complain of pain the dressings are not disturbed for 
48 hours when that part of the packing extending into the nose 
is seized with forceps and at least a part removed. The strips 
of gauze at the inner and outer angles of the wound are re- 
moved wholly or partly the next day. The patient is cau- 
tioned against blowing his nose after the operation but re- 
moves all secretions by sniffing them backward into the 
pharynx. After the removal of the nasal packing the nose is 
syringed gently once a day until healing is complete. DISEASES OF THE NOSE 
181 
One of the dangers of the operation is that the diploe of the 
frontal bone become infected with a slowly advancing osteo- 
myelitis usually fatal. 
Mucocele of the frontal sinus is a retention cyst containing 
a serous exudate from the mucous membrane. The contents 
of the cyst are prevented from escaping by partial or complete 
occlusion of the osteum frontale. 
Symptoms.-Pain, neuralgic in character, due to pressure 
caused by the accumulation. The pressure may be so great 
as to cause the tumor to bulge into the nose. The bone over 
the frontal sinus, especially the orbital portion, is painful on 
pressure. 
Treatment.-If the cystocele bulges into the nose, it should 
be incised and its contents allowed to escape. When there is 
no bulging into the nose and an x-ray photograph discloses the 
probable presence of a fluid within the frontal sinus, one of the 
endonasal or even an external operation must be done. 
Diseases of the Ethmoid Cells.-The most common are 
acute catarrh and suppuration; chronic hyperplasia, gener- 
ally with polypi and chronic suppuration generally without 
polypi. Hyperplasia is generally without purulent secretion and 
results from long-continued irritation. Pus indicates infec- 
tion and hyperplasia with pus signifies both irritation and 
infection. Chronic suppuration usually runs its course with- 
out polypi and is generally associated with necrosis of the 
intercellular bony walls. It may infect the orbit causing 
orbital abscess with exophthalms; or, especially in the young, 
may cause meningitis, often rapidly fatal. 
Pathology.-The mucous membrane of this portion of the 
nose extends inward to line the cells of the ethmoid. It is 
inseparable as a membrane from the periosteum beneath. 
The inflamed mucous membrane and cellular tissue, proliferat- 
ing after its kind, frequently forms masses of granulation 
tissue and polypi. 
When the deeper cells of the ethmoid are involved the pus, 
instead of finding its way into the nose, sometimes breaks 182 
DISEASES OF THE NOSE, THROAT, AND EAR 
through into the orbit. Occasionally the anterior cranial 
cavity becomes infected and an epidural abscess may exist 
in this location for a long time without other symptoms 
then slight headache and irritability of temper. A trifling 
cause, such as a slight intranasal operation, especially in the 
middle turbinate region may spread the infection and change 
a latent localized meningitis into diffuse septic meningitis. 
Thrombosis of the longitudinal or cavernous sinus sometimes 
complicates ethmoidal suppuration. 
Symptoms.-In chronic hyperplasia a red and swollen 
middle turbinate may press upon the septum. Should both 
turbinates be diseased, the septum is nipped between the 
hypertrophied bodies, and reflex skin rashes upon the face, 
tinnitus and asthenopia, or other forms of eye disease may be 
present. In chronic suppuration there exudes a creamy, 
tenacious mucus, which the patient removes from his nose 
with great difficulty. At this stage of the disease nasal 
asthma and cough or unilateral paresis of the soft palate are 
reflex symptoms sometimes present. There is a sensation of 
pressure at the root of the nose, tenderness at the inner can- 
thus when pressure is made backward and inward toward 
the ethmoid. Acute ethmoiditis is occasionally an exacerba- 
tion of the chronic condition. All symptoms are exaggerated. 
There is pain at the root of the nose increased by pressure at 
the inner canthus. The middle turbinate and ethmoid is 
greatly swollen and covered with pus. There may be delir- 
ium at night and a sudden rise in temperature. Should 
symptoms of sinus thrombosis, meningitis or orbital abscess 
develop, an operation should not be long delayed. Bilateral 
exophthalmos indicates that the infection has probably ex- 
tended through the cavernous and circular sinuses and that 
an operation will probably not prevent pyemia or a fatal 
intracranial lesion. 
Treatment.-'The secret of success is the securing of ventila- 
tion and good drainage of the diseased area. Acute catarrhal 
cases recover almost spontaneously by the patient's use of an DISEASES OF THE NOSE 
183 
adrenalin spray at sufficiently frequent intervals. After 
cocainization, daily applications should be made by the phy- 
sician of a 10 per cent, solution of argyrol; a few drops of 
which are deposited in the infundibulum and also high up 
above the middle turbinate by means of a hypodermic 
syringe whose nozzle is a fine silver canula 8 or 9 centi- 
meters long. The fluid is often retained for an hour or 
more apparently by the capillary attraction of the nasal walls. 
In chronic suppurative cases, drainage from the ethmoid cells 
can be greatly improved by the removal of the middle tur- 
binate, either wholly or partly. The anterior attachment 
of the bone, which is nearly vertical, is severed with Beck- 
mann's scissors (Fig. 45), and the cutting continued somewhat 
as far back as necessary, and the loosened portion removed 
with a snare. In severe cases the ethmoid cells will require 
Fig. 85.-Ballenger's ethmoid knife. 
removal to secure efficient drainage. 
Ballenger removes the middle turbinate with a special probe- 
pointed curved turbinate bistoury. The probe point is in- 
serted beneath the turbinate posteriorly and the body severed 
from the attachment by drawing the knife forward. He has 
modified this knife by adding a right-angled blade to its tip, 
which necessitates that the instrument should be made in 
pairs, one for the right nostril and the other for the left (Fig. 
85). The knife is passed through the nose with the right- 
angled portion of the blade hanging downward until the 
pharynx is reached. When the knife is rotated until the right- 
angled part becomes horizontal. The edge of the right- 
angled blade is inserted posterior to the middle turbinate and, 
by cutting first upward and then forward, a large portion of 
the ethmoid, including the middle and superior turbinates, is 
shaved off from its attachment to the sphenoid and. orbital 184 
DISEASES OE THE NOSE, THROAT, AND EAR 
plate. The knife is removed by rotating the right-angled 
part of the blade up into a nearly vertical position and is with- 
drawn with the severed portion of the ethmoid adhering to it. 
Any remains of the partitions between the cells should be 
removed with alligator forceps. The cell walls are thinner and 
more fragile than the ethmoidal wall of the orbit and when 
operating it is ordinarily not difficult to differentiate between 
them. The lateral capsules of the ethmoid because of the 
conical shape of the orbits is wider behind than in front which 
should be borne in mind when drawing the knife forward. 
However, should a portion of the orbital wall or "lamina 
papyracea" be removed, the exposure of the orbital fat 
does not delay the healing. The after treatment consists in 
packing the ethmoidal region with iodoform gauze, should 
persistent hemorrhage require it. This gauze should be re- 
moved and renewed if necessary in 24 hours. However all 
nasal wounds heal more rapidly if the nose is not packed. 
The wounds should be cleansed with a syringe as often as 
necessary, care being taken during the first few days not to 
use sufficient force to cause hemorrhage. 
Fig. 86.-Hajek's ethmoid hook. 
When it is necessary to remove only the posterior ethmoid 
cells the method of Hajek is probably best. An incision as 
nearly vertical as possible is made with scissors through the 
middle turbinate in the region of the bulla, and the turbinate 
posterior to the cut is removed with a snare or alligator forceps 
the small Hajek's hook (Fig. 86) is inserted flatwise between 
the septum and the middle turbinate as high as possible 
without using force and its point turned outward and inserted 
into the most posterior ethmoid cell, and the nasal wall torn 
through by a strong pull on the hook. The pieces that remain 
hanging are now easily removed with alligator forceps. It 
should be borne in mind that the posterior wall of the ethmoidal DISEASES OF THE NOSE 
185 
capsule is the anterior wall of the pars ethmoidalis of the 
sphenoid antrum. This partition is as thin as those between 
the ethmoid cells and hence in cleaning up with alligator forceps 
after the operation of Ballenger or Hajek this thin partition 
not unfrequently comes away and exposes the cavity of the 
sphenoid antrum. 
When an orbital abscess has formed, it may be sufficient to 
open it through the eyelid and use a curette until a sufficiently 
wide opening has been made into the nose. The pus is usually 
under the periosteum of the orbit posterior to the lacrimal 
bone, and hence in searching for pus the knife should be thrust 
in this direction. However in most cases of orbital abscess, 
it is generally better to first establish by means of x-ray nega- 
tives the condition of all the accessory nasal cavities of the af- 
fected side. Not unfrequently the frontal or sphenoid sinuses, 
as well as the ethmoid, are involved in the suppurative process. 
In some cases a radical external operation is required. 
The patient is etherized and the Killian incision previously 
described is made through the inner half of the eyebrow down- 
ward along the side of the nose. The periosteum is separated 
from the bone into the orbit and the lacrimal sack, with the 
periosteum beneath, lifted from the groove in which it lies. 
As the periosteum is being elevated still further into the 
orbit, generally a gush of pus indicates that the abscess has 
been opened and the probe readily detects necrosed bone. 
With a curette the lacrimal bone is removed and the anterior 
surface of the ethmoidal labyrinth exposed to view. When 
the entire lateral half of its capsule is a mass of suppurating 
cells, as is often the case, it should be removed, including the 
middle turbinate and a sufficient surface of the lamina papy- 
racea to give room for the procedure. This is readily ac- 
complished by tearing away the bone piecemeal with alligator 
forceps. 
As the region of the sphenoid is approached, due care should 
be taken and its antrum opened or not at the discretion of 
the operator by removing the posterior wall of the ethmoidal 186 
DISEASES OE THE NOSE, THROAT, AND EAR 
labyrinth. Because of the position of the optic nerve, cavern- 
ous sinus and internal carotid artery, it is unadvisable to 
curette the sinus or upper posterior ethmoid, but the last 
vestige of the cell structure should be broken down and 
removed with alligator forceps. 
The hemorrhage resulting from the exenteration of the 
lateral capsule of the ethmoid is readily controlled by sponging 
or packing the operation cavity from time to time with 
strips of iodoform gauze. It is probably better in most in- 
stances at the beginning of the operation to pack the naris 
with a strip of iodoform gauze to prevent blood trickling into 
the throat; and before its removal, the wound should be 
cleansed by syringing with warm normal salt solution. The 
wound is packed loosely with a strip of iodoform gauze, 
the end of which is brought out through the nostril and cut 
short. The skin wound is completely closed by sutures. 
At the end of from 24 to 48 hours the gauze packing is removed 
from the nose. The after treatment consists in gently cleans- 
ing the wound through the nose with normal salt solution 
once a day until the parts have completely healed. In this 
operation and the intranasal method for the removal of the 
ethmoid cells (page 176) the lacrimal bone is the landmark 
for the position of the anterior cells. After these have been 
opened the septa between the others including that between 
the posterior ethmoid cell and the sphenoid are readily broken 
down with a curette and alligator forceps. 
Empyema of the Sphenoidal Cells.-It is probable that 
catarrhal disease of the sphenoidal cells is of not infrequent 
occurrence. Generally it subsides spontaneously and the same 
is true of acute suppurations if the offending bacteria are of 
slight virulence and the ostium remains open. 
Symptoms.-Purulent discharge, seen by posterior rhinos- 
copy, or the nasopharyngoscope, flowing from above the middle 
turbinate into the pharynx. Pain, said by the patient to be 
located in the center of the head and radiating into the ears, and 
probably due to the pressure of retained secretions. Ocular DISEASES OE THE NOSE 
187 
symptoms vary from impairment of the field of vision to com- 
plete blindness. Because of the proximity of the cavernous 
sinus to the lateral wall of the sphenoid, septic thrombosis or 
fatal hemorrhage from this vessel may occur. 
The treatment should consist in the use of alkaline sprays and 
the application of alterative solutions to the mucous mem- 
brane of the upper part of the nose and vault of the pharynx 
by means of a syringe whose nozzle is a small silver canula 
(p. 183.) This treatment will suffice for the milder cases of 
catarrhal inflammation which tend to recover spontaneously. 
However, the opening into the sinus is as readily entered by 
the canula as by the probe as described below. The sinus 
is then cleansed with normal salt solution, 10 per cent, argyrol 
injected and allowed to remain. 
The ostium of the sphenoid is usually located in the upper 
third, practically always in the upper half of its nasal wall; 
except when an ethmoid cell lies directly over the antrum. 
From a surgical standpoint such a conformation may be re- 
garded as an antrum divided horizontally into two apart- 
ments, each with its ostium. That of the antrum proper 
will be much lower than normal while above anteriorly is 
that of the ethmoid cell. 
The ostium usually lies deep in the sulcus between the 
sphenoid and the ethmoid cells and is completely hidden from 
view by the posterior border of the middle turbinate. After 
thorough cocainizations, it can sometimes be exposed by in- 
serting Killian's speculum (Fig. 14) between the septum and 
the middle turbinate. When the antrum is suppurating, a 
pulsating drop of pus will sometimes be seen protruding from 
the ostium. 
If a straight probe (Fig. 83) is passed over the exact center 
of the middle turbinate it will strike the anterior wall of the 
sphenoid (Zuckerkandl's line) generally sufficiently near the 
ostium for it to be found by gently manipulating the probe 
in various directions but more especially laterally. It may be 
necessary to slightly bend the very end of the probe so that it 188 
DISEASES OF THE NOSE, THROAT, AND EAR 
will penetrate more deeply into the spheno-ethmoid sulcus 
before the ostium is located. 
The distance from the anterior, inferior nasal process to the 
sphenoid ostium is rarely over 7I mm. even in large heads: 
so that if a probe passes along Zuckerkandl's line for a dis- 
tance of from 8 to 10 cm. it may be assumed to have entered 
the antrum. Generally the probe enters the antrum with 
a little jerk as if a slight resistance had been overcome, 
because the bone about the ostium is very thin and its im- 
mediate edge consists only of mucous membrane. In sup- 
purative cases when the probe is withdrawn from the antrum 
its end will have a fetid odor. 
Should this method of probing the sinus prove a failure, 
the posterior ethmoid cells can be removed and the anterior 
wall of the sinus destroyed by the method of Hajek: 
" After complete anesthesia (local or general), I introduce my 
ethmoid hook into the posterior part of the rima olfactoria 
against the anterior wall of the sphenoid sinus as high as pos- 
sible without using the slightest possible force. Since the point 
of the hook is always directed inferiorly an injury to the lamina 
cribrosais absolutely excluded. I then turn the hook so that 
the point penetrates the internal wall of the ethmoid labyrinth. 
When I now press the handle of the hook against the septum I 
am sure that the hook has penetrated deeply into the ethmoidal 
labyrinth. The internal (nasal) wall of the labyrinth with 
that portion of the middle turbinate which lies beneath is 
torn through by means of a strong pull on the hook. The 
pieces which remain hanging can easily be removed with a 
pair of good nasal forceps or the conchotomes of Grunwald or 
Hartmann. The advantage of the hook in this procedure is 
not to be underestimated. It is so slender that its point can 
be easily seen and followed during every phase of the opera- 
tion, while the curette hinders the light and requires too much 
room. . . . The bleeding is usually trivial and is almost always 
controlled by wiping with sterile gauze. ... I now proceed 
to resect the anterior wall of the sphenoid sinus. To this end DISEASES OF THE NOSE 
189 
I use my bone forceps, but the ostium sphenoidale must have a 
definite width before we can introduce them into the sphenoid 
sinus. This I accomplish by means of my hook, tearing the 
inferior edge of the ostium piece by piece until the opening 
is sufficiently large to permit the passage of the bone forceps." 
Skillern has modified the hook and punch forceps of Hajek. 
Because of the difficulty of introducing the hook, he devised a 
double hook or "evulsor" (Fig. 88). This is readily inserted 
through the ostium but is so constructed that it is prevented 
Fig. 87.-Skillern-Hajek's sphenoid punch. 
from penetrating too deeply and wounding the posterior or 
upper wall. When the instrument has entered the antrum, its 
hooked blades are widely separated and withdrawn tearing 
outward the thin antral wall. The evulsor is then reinserted, 
turned horizontally and withdrawn from the antrum. In this 
manner a large portion of the anterior wall is removed so that 
the punch forceps are readily introduced. Skillern has had the 
distal extremity of Hajek's punch forceps slightly curved, so 
that it more readily grasps the lower part of the anterior wall 
of the antrum, where the bone is thicker than above. With 
the punch the whole anterior wall of the antrum is removed and 190 
DISEASES OF THE NOSE, THROAT, AND EAR 
so large an opening established that it will be many months 
in closing. However, should exuberant granulations tend to 
close the opening prematurely, they are removed with a curette 
and the parts touched with a 12 per cent, solution of nitrate 
of silver. 
In operating care should be taken not to injure the upper 
wall because on it lies the optic nerve; nor the lateral wall 
Fig. 88.-Skillern's evulsor. 
because of the proximity of the cavernous sinus with the in- 
ternal carotid passing through it. Because of dihiscences in 
the bone either the nerve or the sinus may be covered only by 
mucous membrane. Should the cavernous sinus be wounded 
the hemorrhage will be profuse. The operator should at 
once introduce the forefinger of the left hand behind the 
palate and endeavor to insert its tip into the antrum or at 
least temporarily close the instrumental opening in its anterior 
wall with his finger-tip. A strip of iodoform gauze is then 
carried through the nostril by means of a pair of forceps and 
packed into the antrum. This will control the hemorrhage. 
Douglass who recommends this method, states that the gauze 
should not be interfered with before the third day and then 
removed, slowly and with great gentleness and caution. 
The after-treatment consists in simply cleansing the parts 
with normal salt solution and preventing the premature closing DISEASES OF THE FJOSE 
191 
of the opening into the antrum. In most cases the mucous 
membrane of the antrum quickly assumes a normal appear- 
ance if there are no retained secretions. 
Accidents and Dangers of Operations on the Accessory 
Cavities.-The region of the supra- and infraorbital foramina 
should be respected as far as the exigencies of an operation 
will permit; although cutting the nerve in either locality 
produces no greater disaster than a feeling of numbness 
and slight discomfort which may persist for years. The 
lifting of the lacrimal sack from its groove should be done 
with sufficient care to avoid tearing the sack and the nasal 
orifice of the duct should be avoided if possible. However 
it is difficult to understand why simple resection of the duct 
at its inferior portion during a Caldwell-Luc operation should 
lead to infection of the duct and stricture but this sometimes 
occurs, and necessitates probing and medication or the wearing 
of a style. Injuries of the orbit through the nose are some- 
times attended by disastrous results. In such cases, a punc- 
ture, because of the lack of proper drainage if the orbit becomes 
infected, is more dangerous than the removal of a considerable 
portion of its bony wall as in a Killian operation. Fig. 74 
shows how readily the orbit might be punctured when the 
needle is thrust through the middle meatus, when the antrum 
is small. Douglass observed a case where the antrum was 
greatly narrowed by a curious guttering of the orbital floor 
to the extent that the orbit might readily be punctured by a 
needle thrust beneath the inferior turbinate in the usual 
position. In a case reported by Seaman, washing the an- 
trum through the alveolus with 1-2000 bichloride solution 
resulted in infection of the contents of the orbit including the 
optic nerve. Vision in both eyes was ultimately lost. The 
same author relates an instance where an operation in the 
ethmoid region was followed by haematoma of the orbit, 
exophthalmos and ultimate blindness with divergent squint. 
However the prognosis as far as permanent injury to the eye 
in orbital hemorrhage is good when prompt measures are 192 
DISEASES OF THE NOSE, THROAT, AND EAR 
taken to relieve injurious pressure. The same remark applies 
to the accidental injection of a moderate amount of sterile 
normal salt solution into the orbit. In cases where emphysema 
of the orbital tissues result from fracture of the orbital plate 
of the ethmoid, the prognosis is also good. The only treat- 
ment necessary being a light pressure bandage and the avoid- 
ance of sneezing and blowing the nose. 
The danger of osteomyelitis after the Killian operation 
has been alluded to. If in an operation upon the accessory 
sinuses, the dura is exposed, the same rules apply as in mastoid 
operations. The exposure should be made sufficiently large 
to afford ample drainage. If the dura is accidentally punctured 
it should be incised through the puncture to the extent of half 
an inch as such wounds are less likely to cause meningitis, 
than punctures. 
Reference has been made to danger of curetting the 
sphenoid antrum because of the proximity of the optic nerve 
and great blood vessels. However, curetting the upper por- 
tion of the lateral wall of the most posterior ethmoid cells 
is also dangerous, and even unnecessary probing of this 
region should be avoided. THE PHARYNX 
ANATOMY OF THE PHARYNX 
The pharynx is a conic, musculomembranous bag suspended 
base up from the basilar process of the occipital bone. It 
extends downward to the lower border of the cricoid cartilage 
and fifth cervical vertebra, where it merges into the esophagus. 
It is composed of three layers-an inner, mucous; a middle, 
fibrous, sometimes called the pharyngeal aponeurosis; and an 
outer, muscular layer. 
At birth the nasopharynx is nearly as long anteroposteriorly 
as in the adult, but is relatively very low, being merely a 
narrow passage, running backward and downward from the 
constricted posterior nares. Consequently, the soft palate 
is more horizontal than in the adult. The height of the naso- 
pharynx increases with the development of the posterior 
nares. At birth their height is from 6 to 7 mm. and the breadth 
between the pterygoid process about 9 mm. 
For the first six months the height of the nasal passages 
increases rapidly to double the size at birth, after which the 
increase is relatively slow. The nasopharynx is very vascular, 
with an abundant supply of lymph-glands, so that its lymphoid 
ring is well developed at birth. 
Relations of the Pharynx.-Posteriorly the pharynx is con- 
nected by loose cellular tissue with the first five cervical 
vertebrae (Fig. 71). The first, or Atlas, forming a promontory 
extending forward into the pharynx on a level with the palate. 
On each side posteriorly are the longus colli and recti capiti 
antici muscles. Laterally are the styloid processes with their 
muscles, the internal carotid arteries, the internal jugular 
vein, the eighth, ninth, and sympathetic nerves. Near its 
193 194 
DISEASES OF THE NOSE, THROAT, AND EAR 
apex are the lobes of the thyroid gland, the common carotid 
and lingual arteries, the lingual nerves, and the sternohyoid 
muscle. 
Divisions.-The pharynx is divided into the nasopharynx, 
sometimes called the posterior nasal space, the oropharynx, 
and laryngopharynx. The nasopharynx extends downward to 
the edge of the soft palate, the oropharynx from this to a line 
drawn through the cornua of the hyoid bone, and the laryngo- 
pharynx the rest of the distance to the commencement of the 
esophagus at the fifth cervical vertebra. 
Attachments.-The pharynx is attached to the internal 
pterygoid plate, pterygomaxillary ligament, inferior maxillary 
bone, base of the tongue, cornua of hyoid bone, stylohyoid 
ligament, and the thyroid and cricoid cartilages. 
Muscles.-There are seven muscles-the superior, middle, 
and inferior constrictors, two stylopharyngei, and two palato- 
pharyngei muscles. The latter, covered by mucous membrane, 
form the anterior pillars of the fauces, the stylopharyngei, the 
posterior pillars. A not very uncommon anatomic peculiarity 
is that one or both the palatopharyngei are completely sur- 
rounded by mucous membrane, so that a probe can be passed 
betweem them and the rest of the outer wall of the pharynx. 
Arteries.-There are four arteries supplying the pharynx- 
two branches of the external carotid and two branches of the 
internal maxillary. These are the ascending pharyngeal and 
branches from the superior thyroid; descending pharyngeal 
and pterygopalatine. Occasionally arteries as large as the radial 
are seen pulsating on either side beneath the mucous membrane 
of the pharynx. These are supposed to be displaced occipital 
arteries. 
Nerves.-The pharynx is supplied by a plexus composed of 
branches from the pneumogastric, glossopharyngeal, superior 
laryngeal, and the superior cervical ganglion of the sympathetic. 
The mucous membrane of the nasopharynx is covered with 
stratified, ciliated, columnar epithelium, the oropharynx with 
squamous epithelium, and the laryngopharynx with squamous ANATOMY OF THE PHARYNX 
195 
posteriorly, and ciliated epithelium anteriorly. There are 
simple follicular glands, compound follicular, and racemose 
glands. 
Tonsils and Lymphatics of the Pharynx.-The laryngo- 
pharynx has few or no lymphatics. Above the supply is pro- 
fuse, being located mainly in the mucous membrane of the 
superior and posterior wall. 
The tonsils are a part of an irregular ring of adenoid tissue 
surrounding the pharynx and continuous with the general 
lymphatic system. There are seven tonsils: 2 faucial, 2 tubal, 
2 lingual, and the pharyngeal. The faucial tonsils are situ- 
ated one on each side of the fauces between the anterior and 
posterior pillars of the fauces. The lingual tonsils are situated 
at the base of the tongue, the tubal tonsils at the pharyngeal 
Eustachian orifices, and the pharyngeal tonsil in the vault 
of the pharynx posterior to the nasal orifices. Any of these 
tonsils when hypertrophied may cause annoying symptoms, 
but the lingual tonsil is more apt to prove troublesome after 
middle life if at all, while hypertrophy of the faucial and 
pharyngeal tonsils are generally diseases of childhood. 
The faucial tonsils are oblong in shape with their long axis 
vertical. At birth they are i to f inch long and to A inch 
wide. The tonsils develop in size up to the sixth or eighth 
year, when they are 1 to i| inches long, f to 1 inch wide, and 
from 4 to 1 inch in thickness. They are frequently swollen 
without infection during the eruption of teeth at the 2d, 6th, 
12th, and 17 th years and carious teeth probably are frequent 
causes of tonsillar infection. The tonsils consist of lymphoid 
masses held together by a trabecula of connective tissue 
containing the vessels and nerves, and are surrounded, except 
on the free surface, by a capsule or sheath. The faucial sur- 
face is covered by an extension of the adjacent mucous mem- 
brane, with its stratified epithelium extending inward'to line 
the crypts. 
Above the tonsils and between the anterior and posterior 
pillars is situated the triangular fossa supratonsill arts. Here 196 
DISEASES OF THE NOSE, THROAT, AND EAR 
a number of crypts extend vertically into the tonsil, the reten- 
tion of whose excretions plays an important role in the pro- 
duction of peritonsillar abscess. The number of crypts, both 
vertical and horizontal, rarely exceeds fifteen for each tonsil. 
They vary in length from | to | inch or even more in 
tonsillar hypertrophy (Fig. 94). The tonsils are frequently 
attached to the anterior pillars in such a manner as to form 
pouches, which are effective culture-tubes for the propagation 
of pathogenic organisms, and the anterior lower third of the 
tonsil is often covered by the hyperculum plicatriangularis, 
a triangular fold of mucous membrane extending from the 
anterior to the posterior pillars downward and backward 
across the tonsil. This fold may interfere with the drainage 
of the crypts it covers or form a pocket of retained secretions. 
It should be removed with the tonsil in tonsillectomies. 
Its anterior, inferior border is firmly attached to the tonsil and 
anterior pillar where it forms a sort of ligament which when cut 
permits the tonsil to be drawn toward the median line of the 
pharynx away from the pillar and opens the cellular space 
external to the capsule for the introduction of an enucleation 
instrument. 
When diseased, the crypts sometimes branch and communi- 
cate with each other in such a manner as to retain lymph and 
epithelium cells; so that cholesteatomatous masses collect 
whose decomposition imparts a fetid odor to the breath. The 
faucial tonsils drain into the deep lymphatics of the neck, so 
that systemic infection may occur by way of the thoracic 
glands and duct, or the apex of the lung may be, it is said, 
infectd with tubercle bacilli from the tonsil by way of these 
glands. 
The tonsils themselves lie too deep to be felt through the skin 
of the neck and according to Wood the deep lymphatic or 
"tonsillar gland," into which the tonsil empties, lies external 
and slightly anterior to the internal jugular vein. Hypertro- 
phy of this gland means its dislocation outward and forward, 
but generally it can be pushed back beneath the sternomastoid ANATOMY OF THE PHARYNX 
197 
muscle, which is not the case with hypertrophied superficial 
lymphatics. 
According to Deaver, the tonsils are supplied with blood from 
the ascending pharyngeal branch of the external carotid, the 
tonsillar and ascending palatine branches of the facial artery, 
the dorsalis lingua branch of the lingual artery, and the 
descending palatine branch of the internal maxillary artery. 
Externally, the tonsil is separated from the internal carotid 
and the ascending pharyngeal artery by the superior constrictor 
muscle and the pharyngeal aponeurosis. Of these vessels the 
ascending pharyngeal is the more apt to be injured by opera- 
tions for the removal of the tonsil, because it lies directly oppo- 
site the tonsil on the external surface of the superior con- 
strictor. Malignant growths of the tonsil are best removed 
through an incision made parallel to the anterior border of the 
sternomastoid, because the involved lymphatics cannot satis- 
factorily be removed through the mouth. The line of incision 
for ligation of the external carotid is parallel to the anterior 
border of the sterno cleidomastoid muscle, from the angle of 
the jaw to the cricothyroid membrane. Working from below 
upward by dry dissection the superior thyroid artery is soon 
encountered, which serves as a guide to the external carotid, 
which should be tied below the origin of the ascending pharyn- 
geal, which means as close to the junction of the external and 
internal carotids as possible. However in operations upon 
the tonsils it is usually the veins and not the arteries that 
cause troublesome hemorrhage. There are two large veins, 
one close to the anterior lateral border of the tonsil behind the 
anterior pillar and the other close to the posterior lateral border 
behind the posterior pillar. Both are in the cellular tissue 
external to the capsule and are usually avoided in tonsil- 
lectomies but when either is torn or cut the hemorrhage is 
profuse but usually readily controlled by digital pressure 
through a gauze sponge. 
The functions of the tonsils are similar to those of other 
lymphatic glands. As a part of the hemopoietic system they 198 
DISEASES OF THE NOSE, THROAT, AND EAR 
form young lymphocytes most of which pass into the circula- 
tion, but some escape to the free mucous surface, and carry off 
with them effete products. 
The tonsils are most active during youth, while the thymus, 
a large blood-forming gland, is atrophying. There is consid- 
erable difference of opinion as to the phagocytic action of the 
tonsils, some authorities claiming that the tonsils constitute a 
weak part of the throat and expose the system to the inroads 
of diphtheria, tuberculosis, syphilis, acute articular rheuma- 
tism, and other diseases. 
In evidence of the difference in the behavior of tonsillar 
epithelium toward dust and bacteriae, Jonathan Wright dusted 
carmin over the tonsil. Fifteen minutes later all the particles 
of carmin had passed through the epithelium into deeper 
layers and could be detected in sections under the microscope; 
while bacteria, situated at the exact point where the carmin 
entered, remained quiescent and unabsorbed. 
Good has endeavored to prove that the chief function of the 
tonsils is to establish immunity to infection especially early 
in life. Secretions from the nose are carried toward the tonsillar 
crypts as demonstrated by Jonathan Wright. Secretions from 
the lungs are coughed or carried toward the tonsils and in vomit- 
ing, the contents of the stomach are brought directly in 
contact with the tonsils. Hence bacteria that have entered 
the mouth or nose are directed toward the tonsillar crypts, 
which are lined with stratified epithelium and the mucus 
within them serves as a culture medium for the development 
of vaccines which enter the lymph current of the tonsil and 
are carried into the entire system, where they come into contact 
with the fixed cells and excite them to produce antibodies 
such as opsonins, agglutinins, etc., and thus produce immunity. 
Until immunity is established, the lymphocytes of the tonsil- 
lar secretions have no great affinity for bacteria which conse- 
quently flourish; but when immunity is established for the 
variety of bacteria within the crypts, their secretions contain 
opsonins and hence the lymphosites attack the bacteria and DISEASES OF THE NASOPHARYNX 
199 
destroy them by phagocytosis. In the act of deglutation the 
tonsils are squeezed by the superior constrictor and their 
contents emptied into the pharynx. Agglutination and bac- 
teriolysis can also take place in the tonsils, their interfolli- 
cular connective tissue is composed of interlacing fibers whose 
interspaces are filled with lymphocytes and polyneuclear 
leucocytes which offer every protection to the general system 
from bacteria that pass through the epithelium of the crypts: 
so long as the tonsillar functions are not so altered by disease 
as to render the tonsils a possible portal for systemic infection, 
and not a protection. 
According to the experiments of Ott and Scott, injection of 
an extract of powdered tonsil into an animal produced at first 
a great fall in blood pressure followed by a rise, above normal 
and a slower and stronger heart beat. The amount of urine 
was also increased many times the normal amount. 
DISEASES OF THE NASOPHARYNX OR POSTNASAL 
SPACE 
Postnasal catarrh may be either secondary, as when a nasal 
accessory sinus discharges into the postnasal space, or the 
disease may be primary, and extend to either the nose or 
Eustachian tubes. The nasopharynx may be blocked by pos- 
terior hypertrophies of the turbinated bodies or by polypi, 
cysts, fibroid tumors, or malignant growths springing from the 
posterior nares or from the vault of the pharynx. A somewhat 
common affection beginning generally in childhood is hyper- 
trophy of the pharyngeal or Luschka's tonsil. 
Adenoid vegetations or hypertrophy of the pharyngeal 
tonsil is an overgrowth of the normal adenoid tissue of the 
pharyngeal vault. The affection is often associated with 
hypertrophy of the faucial tonsils, and generally commences 
in childhood, but may be met with in patients of any age. 
Symptoms.-If the adenoid vegetations are at all large they 
block up the posterior nares and compel mouth-breathing, 200 
DISEASES OF THE NOSE, THROAT, AND EAR 
the pinched nostrils and half-open mouth giving the face 
a vacant and well-nigh idiotic expression (Fig. 89), which 
ordinarilly disappears as soon as nasal respiration is rees- 
tablished. However, if mouth-breathing be continued into 
adult life permanent deformity of the bones of the face and 
even of the chest results. Breathing is audible sometimes 
Fig. 89.-Typic appearance in adenoid vegetations: boy ten years old (Friihwald). 
during the day and there is always loud snoring during sleep. 
The voice is toneless, articulation is indistinct, and the hearing 
is often impaired. 
Treatment.-Adenoid vegetations tend to no longer obstruct 
nasal respiration as the individual passes into adult age and the 
nose and nasopharynx grows larger, but may, in the meantime, 
have produced irreparable injury to the ears and altered the 
shape of the bones of the face. Application of Formula 112 
to the postnasal space will sometimes bring about a slow ab- 
sorption of the hypertrophied tissue. In children, when the DISEASES OF THE NASOPHARYNX 
201 
growth is not large, such applications should be made by the 
surgeon two or three times a week, the parents in the mean- 
time cleansing the nose night and morning with the spray from 
an atomizer containing an alkaline wash and afterward placing 
in each of the child's nostrils a mass the size of a pea of gallic 
acid ointment 5 to 10 grains to the ounce of vaselin. The child 
should then lie on its back for a few moments until the ointment 
melts and runs into the nasopharynx. However, the only 
treatment adequate in the majority of cases is a thorough 
removal of the mass by surgical procedures. In adults post- 
Fig. 90.-Juracz's adenoid forceps. 
nasal cutting forceps (Fig. 90) may be used; the operator 
being careful to begin operating in the median line, and work- 
ing from it in each direction until the entire mass is cut and 
torn away from its attachment, at the same time being 
exceedingly careful not to wound the orifices of the Eustachian 
tubes. 
In children or in adults, when the pharyngeal tonsil is still 
comparatively soft, a curette (Fig. 91) is a most efficient instru- 
ment. Young children should be seated in the lap of a nurse 
upon a piano stool opposite the operator, in the same manner 
as for an ordinary examination of the nose and pharynx. The 
murse passes her arms beneath those of the child and places 
her hands, one on each side of the child's forehead, in such a 
manner as to control the movements of the head. The nurse 
then elevates her elbows so as to bring the child's arms into 
such a position that it is impossible for the child to reach its 
mouth with its hands. The curette is now passed behind the 
palate, and the handle of the instrument depressed until the 202 
DISEASES OF THE NOSE, THROAT, AND EAR 
outer edge of the ring is felt to rest 
against the septum. By sweeping 
the ring upward, backward, and 
downward against the pharyngeal 
wall the growth is brought within 
the curet.e and is cut from its at- 
tachment. Without removing the 
instrument from the mouth the 
maneuver is quickly repeated at 
each side of the median line, in 
order to be certain that the major 
portion of the growth has been 
removed. The operation should 
be performed quickly, but with 
gentleness, little force being re- 
quired to sever the growth from 
its attachment. 
The nurse then releases the 
child's head, and the operator 
passes his left arm around the 
child's head and thrusts his fore- 
finger hard against the child's 
cheek, in such a manner that the 
cheek protrudes between the 
child's open jaws, so as to form an 
efficient mouth-gag. The oper- 
ator then quickly passes the fore- 
finger of his right hand behind the 
child's palate until the posterior 
edge of the septum is felt. The 
posterior nares, Rosenmuller's 
fossae, and the vault of the pharynx 
are inspected, as it were, by the 
sense of touch. If any shreds of 
the growth remain they are 
removed with the finger-nail, 
Fig. pi.-Adenoid curettes. The 
original Gottstein curette was de- 
signed for scraping rather than cut- 
ting. The improved form is shown 
at D, whose cutting edge should be 
kept sharp in order to easily sever 
the growth. Fetterolf's modifica- 
tion, A. B, C, consists in the attach- 
ment of a spring clamp, serrated in 
such a manner as to firmly grasp all 
adenoid tissue cut from the pharynx. 
The set consists of three, with vary- 
ing angles to the blade and different 
lengths of crura, in order that no 
matter what the shape of the 
pharynx or the situation of the 
growth it can be reached and re- 
moved by one of the instruments. DISEASES OF THE NASOPHARYNX 
203 
scraping them from below, upward, and forward. Before 
removing his finger the operator should spare no pains to assure 
himself by the sense of touch not only that nothing remains to 
obstruct nasal respiration, but that Rosenmuller's fossae are 
freed from any mass likely to interfere with the blood-supply 
of the Eustachian tubes. The hemorrhage following the 
operation is generally trifling and the after-treatment consists 
in simply keeping the parts clean with an alkaline wash. 
When a general anesthetic is employed it should be ether 
and not chloroform, because in this condition, the so-called 
"habitus lymphaticus" of Kalisco, chloroform is especially 
dangerous, somewhat numerous deaths having been reported. 
Ether is not necessary to secure an adequate removal of the 
hypertrophy. However, the major portion of successful 
operators prefer to operate under ether, stating that the 
operation then can be done more deliberately, and there is less 
danger of failure to remove all portions of the hypertrophy. 
The patient's mouth is opened widely with a mouth-gag in 
the hands of an assistant, and the operator carefully explores 
the nasopharynx with his forefinger to ascertain its shape and 
the size and attachment of adenoid tissue. The finger is then 
removed from the mouth, the tongue held down with a tongue 
depressor, and a suitably shaped guarded curette (Fig. 91) 
inserted in such a manner that its blade glides along the 
posterior border of the septum and encircles the adenoid mass, 
which is cut away and held by the serrated spring as the blade 
sweeps upward, backward, and downward in close contact with 
the nasopharyngeal wall. The operator's forefinger is re- 
introduced behind the soft palate and shreds of adenoid tissue 
are either rubbed away with the finger-tip, covered by gauze, 
or, if large, grasped with the forceps (Fig. 90) and cut away. 
The finger-tip should be inserted into each posterior naris 
and every pains taken to detect little shreds of adenoid tissue 
that have escaped the curette because of their anterior position, 
and, which if allowed to remain, will greatly impair the success 
of the operation. In aural cases the surroundings of the 204 
DISEASES OF THE NOSE, THROAT, AND EAR 
Eustachian prominences should receive especial attention, and 
masses of adenoid tissue still remaining in Rosenmuller's fossae 
should be carefully rubbed away with the finger-tip or re- 
moved with the forceps. 
Some operators prefer to remove the entire adenoid mass 
with forceps, which are introduced closed behind the soft 
palate. The biting tips are then opened and forced upward 
against the vault of the pharynx, the handles brought into 
contact with the patient's upper teeth, the blades pushed 
backward against the posterior wall of the pharynx and 
closed about the growth, which is removed with a downward 
and outward pull. The forceps can be reintroduced as often as 
necessary to remove the entire mass, but it is important that 
the handles should be kept in contact with the patient's upper 
teeth, for the curve of the forceps is such that otherwise the 
posterior edge of the septum will be grasped. 
When operating under ether the foot of the operating table 
should be elevated about 3 inches and the patient should lie 
upon his left side with the arm and the shoulder of that side 
drawn behind and under him, so that the head readily can be 
rotated downward in order that the blood may flow from the 
mouth and not enter the larynx. Ordinarily pools of blood 
and clots collect in the hollow of the left cheek, which requires 
mopping out, especially if the tonsils have been excised pre- 
liminary to the removal of the adenoids. From the third 
tonsil most of the hemorrhage escapes from the nasal passages, 
and for a moment is abundant, but quickly subsides. Should 
this not be the case, a small gauze sponge in the grasp of a 
curved hemostat should be passed up behind the palate and 
pressure maintained upon the bleeding spot until the hemor- 
rhage ceases. 
Under ether cutting forceps are much safer than an operation 
with the ordinary curette, because the portions of tissue severed 
by the forceps are removed in the grasp of the instrument, so 
that they cannot be inspired into the larynx. However, good 
operators, in their desire to do a "thorough" operation, have DISEASES OF THE NASOPHARYNX 
205 
bitten off with the forceps portions of the posterior edge of 
the vomer or even of the soft palate, and it is safer, unless the 
operator has great experience, not to introduce the forceps 
unless guided by the forefinger of the left hand, inserted behind 
the palate, so that he may be certain that neither the posterior 
edge of the vomer, the soft palate, nor one of the Eustachian 
tube mouths enter between the cutting blades of the forceps, 
and the operation should not be so "thorough" as to expose 
the fibrous tissue overlying the vertebra or tear loose a portion 
of the upper border of the superior constrictor of the pharynx. 
It is a good plan to insert the left forefinger into each 
choanae and strip the adenoid mass downward and back- 
ward from the pharynx so as not to leave a fringe of its 
upper border when the operation is complete. 
The improvement in nasal respiration and in pronunciation 
following the operation is immediate and pronounced; and if 
hearing was impaired as the result of interference with the 
function of the Eustachian tubes, the acuteness of hearing 
rapidly improves after the operation. In adults the reaction 
from the operation is but trifling. However, children some- 
times complain for a few days that the throat is sore and that 
it hurts them to swallow. 
Sometimes a considerable time elapses after the operation 
before a young child can be taught to breathe entirely through 
his nose. Of course, in cases where mouth breathing is the 
result of other causes than adenoids, removal of the third 
tonsil does not secure nasal respiration, and before resorting 
to an operation, which may be unnecessary, the surgeon should 
bring about a cure of any nasal catarrh that is present. In 
cases where, as a result of a faulty position of the teeth or 
malformation of the jaws, the lips do not come together when 
the child's face is at rest, it will be necessary to correct the 
dental deformity as well as remove adenoids to secure nasal 
respiration and a symmetric development of the bones of the 
face. In individuals between five and twenty-five years of 
age, if there is a fair amount of nasal respiration, the faulty 206 
DISEASES OE THE NOSE, THROAT, AND EAR 
position of the teeth should be corrected before any nasal 
operation is undertaken, but if nasal respiration is greatly 
impaired, operations on the air-passages sufficient to secure 
nasal breathing should be done before regulating the teeth. 
Thomwaldt's Disease or Chronic Bursitis.-The bursa of 
the pharyngeal tonsil was described by Luschka, and chronic 
inflammation of this structure was later elucidated by Thorn- 
waldt, after whom the disease has been named. 
Symptoms.-When chronically inflamed the bursa of the 
third tonsil secretes a considerable amount of thick, tenacious 
mucus, globular masses of which may be hawked out by the 
patient from the pharynx several times a day. There are no 
other subjective symptoms in uncomplicated cases. The 
bursa is discernible and may be explored to a variable depth 
by means of a probe suitably bent. 
Treatment.-The concensus of opinion seems to be that a per- 
manent cure can only by effected by the radical destruction of 
the bursa by means of the galvanocautery or some other 
method, a difficult matter to accomplish because of the 
anatomic situation of the bursa. However, almost complete 
cessation of the discharge, for the time being at least, can be 
brought about by thorough cleansing of the parts and applica- 
tions to the interior of the bursa, by means of a cotton-tipped 
probe, of a 12 per cent, solution of nitrate of silver at suffi- 
ciently frequent intervals. 
DISEASES OF THE OROPHARYNX 
Acute tonsillitis is an inflammation of the tonsils and adjacent 
structures. There are two common varieties-the croupous 
and the phlegmonous. 
Acute follicular tonsillitis or croupous tonsillitis is an in- 
flammation of the tonsil, originating in the crypts and accom- 
panied by the formation of a pseudomembrane which, at 
first confined to the neighborhood of the crypts, often ex- 
tends over the entire tonsil or tonsils. Occasionally the DISEASES OF THE OROPHARYNX 
207 
pharyngeal or lingual tonsils are involved or the disease may 
occur in these structures independently. 
Etiology.-The disease is the result of infection, but is conta- 
gious only to a very limited degree. It is an inoculation of the 
tonsils with bacteria capable of producing a croupous pseudo- 
membrane, the most common of such bacteria being the strep- 
tococcus and staphylococcus. Probably exposure to cold and 
an excess of uric acid in the blood are predisposing causes. 
Occasionally cases of croupous tonsillitis are followed within a 
month by acute articular rheumatism, and it is mantaind that 
the tonsils are the points at which the bacteria causing the 
rheumatism find entrance into the system. 
Fig. 93.-Crypts in cases of 
tonsillitis: A, Acute, lacunar; B, 
hronctc hypertrophic; a, surface 
epithelium; b, accumulated con- 
tents of crypt; c, lymphoid fol- 
licles surrounding crypt. (Kauf- 
mann.) 
Fig. 92.-Follicular tonsillitis. 
Pathology.-The brunt of the inflammation is borne by the 
crypts of the tonsils, which pour out an abundant fibrinous 
secretion, which, adhering to the surface of the tonsil, presents 
somewhat the appearance of a diphtheritic membrane (Figs. 
92 and 93). The membrane consists largely of necrotic epi- 
thelial cells, and does not involve the deeper tissues. The 
tonsils are somewhat swollen and the entire pharynx is 
inflamed. 
Diagnosis.-In typic cases occurring in adults there is usually 
no difficulty in distinguishing by the unaided eye the differ- 
ence between such a membrane and the more yellow, thicker, 
and sometimes seminecrotic membrane of diphtheria. The 208 
DISEASES OF THE NOSE, THROAT, AND EAR 
croupous membrane is thin, white, perhaps opalescent, and 
can somewhat readily be wiped away, a small piece at a time, 
by means of a cotton-tipped probe. Ordinarily it does not 
extend beyond the tonsils. 
However, in the case of young children, diagnosis by the 
unaided eye between the two affections is by no means easy. 
The struggles of the child allow only a momentary glance at 
the parts, and for the same reason some bleeding may occur 
in the effort to remove a part of the membrane. Occasionally 
a thin opalescent patch occurs upon the anterior pillars or 
elsewhere in the neighborhood of the tonsil, whose appearance 
is very deceptive. 
In no case can an absolutely positive diagnosis between croup- 
ous tonsillitis and diphtheria be made without the aid of a 
competent bacteriologist, whose investigations shall not only 
consist of the examination of smears and culture tests, but also 
inoculation experiments, to exclude Hoffman's bacillus, which 
closely resembles in all respects, except virulence, the Klebs- 
Loffler bacillus. 
Mucous patches upon the tonsils and the superficial ulcer of 
tertiary syphilis have sometimes been mistaken for croupous 
tonsillitis, but ordinarily the diagnosis is easy. 
Symptoms.-There is often a chill, then dryness and stiffness 
in the throat, soon followed by dysphagia. There is tender- 
ness on pressure over the lymphatics of the neck, which may 
be somewhat swollen, but never to the extent seen in diphtheria. 
Ordinarily the temperature is higher in croupous or fol- 
licular tonsillitis than in diphtheria, but some cases, after a 
temperature of 103° F. or thereabouts for the first twenty- 
four hours, assume the characteristic lower temperature of 
mild diphtheria. 
Rare in the adult, at least a croupy cough is to be expected 
in young children with follicular tonsillitis, and sufficient 
laryngeal stenosis to require intubation is not impossible. 
Typical cases run a course of about five days and end in 
recovery. DISEASES OF THE OROPHARYNX 
209 
Treatment.-In the case of adults the writer has aborted 
follicular tonsillitis by the following method: Each affected 
crypt was in turn washed out with hydrogen peroxid, by 
means of a Blake's middle-ear cannula screwed on to a hypo- 
dermic syringe. The curved tip of the cannula employed is 
about | inch in length and capable of reaching to the bottom 
of the follicle. Only a drop or two of the peroxid is injected 
at one time, but the process is repeated until all of the exudate 
has disappeared. A fine Allen's probe with a few fibers of 
cotton wrapped about its end is then bent to an appropriate 
angle, and, after being dipped into a 12 per cent, solution of 
nitrate of silver, is carried to the bottom of a follicle, and the 
process repeated until each of the affected crypts has received 
the silver solution. The surface of the tonsil is then painted 
with the same solution. The treatment is followed imme- 
diately by a sense of relief and comfort, and the difficulty in 
swallowing is in a great measure alleviated. The process 
may be repeated two or three times a day, and in successful 
cases brings about a cure at the end of the second or third 
day. 
In cases of children or in adults, when as the result of ti- 
midity or excessive irritability of the fauces this method is not 
applicable, spraying the parts with hydrogen peroxid and the 
application of a 12 per cent, solution of nitrate of silver suffices 
for the local treatment. A 12 per cent, solution of silver care- 
fully applied to the tonsils occasions little or no discomfort 
in health, and when the mucous membrane of this region is 
inflamed the solution acts as a sedative and its application is 
followed by a sense of relief and comfort. This, however, is 
by no means true of the mucous membrane covering the pos- 
terior wall of the pharynx, and care should be exercised not 
to irritate it by the application of the silver solution. 
The patients if seen early in the attack should be purged, 
preferably with calomel; and if the temperature is high and the 
discomfort great, relief follows drop doses of tincture of aconite 
every hour for six or eight hours. A simple astringent gargle 210 
DISEASES OF THE NOSE, THROAT, AND EAR 
or a lozenge of guaiac and tannin may be prescribed (Formula 
64), or the patient may spray his throat every hour with a 
solution of alumnol. Keefer treated 60 cases in the military 
hospital at Fort Russell, Wyoming, by spraying the throat 
with a saturated solution of sodium bicarbonate three times a 
day, immediately followed by the liberal application of finely 
powdered acetyl salicylic acid (aspirin). The results were 
that the tonsils became blanched and the patients entirely 
comfortable within twenty hours, with an average duration 
for the disease of three days. No case so treated was followed 
by articular rheumatism. In another series of 6c cases treated 
by the usual methods the average duration of the disease was 
Fig. 94.-Posterior view of the extirpated tonsil from a case of chronic follicular 
tonsillitis. Bristles have been introduced into the follicles (Fruhwald.) 
six days, and 9 cases (15 per cent.) developed subsequently 
acute articular rheumatism. No cases were apparently 
benefited by aspirin internally. 
Chronic follicular tonsillitis is characterized by a feeling of 
fulness and discomfort in the region of the tonsils. Upon 
inspection the tonsils, although not hypertrophied, are perhaps 
redder than normal, and many of the crypts are filled with a 
cheesy exudate (Figs. 92 and 94). The neighboring lym- 
phatics are generally enlarged and tender to the touch. 
Treatment.-The cheesy exudate should be carefully removed 
from the crypts, and a solution of iodin (Formula 112) applied 
to the interior of each crypt by means of a few shreds of 
absorbent cotton wrapped about the end of a fine probe which DISEASES OF THE OROPHARYNX 
211 
is bent to a right angle. Should biweekly applications of 
iodin in this manner to the interior of the crypts not prove 
successful, a fine galvanocautery-knife should be inserted while 
cold into such of the crypts as resist treatment, and while in 
situ sufficiently heated to destroy the secreting surfaces and 
burn through the tissues to the surface. In cases where the 
crypts are very deep, cutting through to the surface of the 
tonsil is a somewhat painful procedure, and a tonsil crypt 
knife had better be used for the purpose, after which the wound 
Fig. 95.-Hurd's separator and pillar retractor. 
should be seared with the galvanocautery to prevent its re- 
uniting during the healing process. The cheesy secretions 
are readily removed by means of a syringe (Fig. 29, fitted 
with nozzles 6 and 7). After the crypts have been thoroughly 
cleansed, iodin solution or 10 per cent, nitrate of silver may 
be applied, as described above. This treatment is frequently 
sufficient to prevent the formation of tonsillar concretions or 
Fig. 96.-Myles' tonsil knife. 
cholesteatoma and the recurrent attack of peritonsillar abscess. 
However, treatment is tedious and the result somewhat un- 
certain, so that the trend of opinion at the present time is 
toward the complete removal (see Tonsillectomy) of tonsils 
with diseased crypts. 
Peritonsillar abscess is sometimes apparently the result 
of exposure to cold and wet. Recurrent attacks of periton- 
sillitis often occur in chronic inflammation of the tonsils, 212 
DISEASES OF THE NOSE, THROAT, AND EAR 
with or without hypertrophy. The cheesy secretion that is 
retained within the crypts becomes from time to time a 
source of infection, and inoculates either the tonsillar structure 
itself or, more frequently, the surrounding cellular tissue. 
For these reasons, tonsillotomy or partial excision of hyper- 
trophied tonsils is not always followed by a cessation of re- 
current attacks of quinsy, unless, after excision, care is taken 
to destroy with the galvanocautery-knife all crypts that may 
remain in the stump of the tonsil, in order to destroy all re- 
ceptacles capable of retaining putrid secretions. 
Symptoms.-There is a chill or chilly sensations, and pain 
in the legs and back, headache, and fever which may reach 
1040 F. As the disease progresses the sufferings of the patient 
become severe. The dryness of the throat causes frequent 
attempts at swallowing saliva, which are exceedingly painful. 
The mouth can be opened only with pain and difficulty and 
speech becomes almost unintelligible. The tongue is heavily 
coated and the breath intolerably fetid. The hearing is 
frequently blunted from extension of the disease to the Eus- 
tachian tubes, and abscess of the ear sometimes results, while 
nasal breathing is usually entirely abolished. The fever, 
pain, and difficulty of swallowing become greater if an abscess 
is forming, and the relief is proportionate after it has opened. 
As the patient expectorates the pus he feels almost well, so 
great is the sense of relief, the fever and pain subsiding 
together. 
Treatment.-A thorough application of a 12 per cent, solu- 
tion of nitrate of silver frequently aborts the attack if applied 
early and the inflammation is superficial. The silver solution 
should be freely painted upon the tonsils and adjacent inflamed 
mucous membrane by means of a swab of cotton. The relief 
experienced by the patient as the result of the application is 
almost instantaneous, and the application should be repeated 
once or twice a day until all inflammatory symptoms have 
subsided. If the inflammation is not too severe the crypts 
may be syringed with an alkaline solution in the expectation of DISEASES OF THE OROPHARYNX 
213 
removing putrid retained secretions which may have caused the 
attack. The nares and pharynx should be washed by means of 
a spray from an atomizer containing a detergent solution 
(Formulas i to 5) before making these applications. It is 
best to open the patient's bowels thoroughly at the com- 
mencement of an attack by means of a saline cathartic. 
When these measures do not succeed in aborting the attack, 
but the fever and the suffering of the patient are constantly 
increasing, aconite in drop doses of the tincture every hour or 
two until eight to ten doses have been taken will give most 
excellent results. When pus has 
formed the abscess should be 
opened. 
The surgeon should carefully 
search for fluctuation by means of 
his forefinger introduced into the 
patient's mouth. As the abscess 
isj almost always peritonsillar, a 
fluctuating area is most commonly 
felt through the anterior pillar above 
the tonsil. Into this place, the 
so-called point of election (Fig. 97), 
a small bistoury should be care- 
fully thrust with the blade ver- 
tical, in order to avoid cutting any 
large vessel that may occupy an 
anomalous position in this region. If a sudden secession 
of resistance indicates that an abscess-cavity has been 
penetrated, the blades of a pair of angular scissors or for- 
ceps should be introduced and the puncture stretched open 
until the pus has escaped. If necessary the opening may be 
enlarged by cutting downward with a probe-pointed knife. 
The cavity may then be washed out with sterile water. The 
escape of pus is followed by immediate and great relief and all 
symptoms usually quickly subside. Even when no pus escapes 
Fig. 97.-Phlegmonous tonsil- 
litis. The black line represents 
the so-called point of election 
for puncturing a peritonsillar ab- 
scess, but it is not high enough, 
as the incision is made through 
the palate and not into the tonsil. 214 
DISEASES OF THE NOSE, THROAT, AND EAR 
from the incision, the bleeding affords a certain amount of re- 
lief and may bring about resolution of the inflammation. 
Frequently a peritonsillar abscess may be opened with a 
strabismus hook or a stout steel probe of similar shape. 
The tip of the instrument is inserted into the supratonsillar 
fossa as deeply as possible, and an effort made to enter one of 
the vertical crypts or insert the probe between the tonsil and 
the anterior pillar. When this is accomplished pus will 
sometimes well out alongside the instrument. Generally the 
escape of pus is sufficient to bring about a cure, but in some 
cases it is necessary to maintain the opening by the daily 
passage of a probe. Newcomb has collected from medical 
literature 51 well authenticated cases of severe hemorrhage, 
with 28 deaths following the spontaneous or operative opening 
of peritonsillar abscesses, apparently the result of the sudden 
removal of pressure from an artery involved by the suppura- 
tion. While in post tonsillectomy hemorrhages it is usually 
sufficient to ligate the external carotid below the origin of the 
ascending pharyngeal and as close to the bifurcation as 
possible, severe hemorrhage following a suppurative process 
generally requires ligation of the common carotid. 
Cyst of the Tonsil.-Occasionally the tonsil becomes the seat 
of cystic disease. Usually the cyst is small in size, but some- 
times it may be of sufficient capacity to contain | dram of 
milky fluid, or the contents of the cyst may be of cheesy 
consistency. 
Treatment.-'The anterior wall of the cyst should be excised 
and its interior painted with saturated tincture of iodin or 
Battey's solution (Formula 29). 
Hypertrophy of the Tonsils.-'There are four varieties of 
chronic hypertrophy of the tonsils: First, the ordinary soft 
hypertrophy of the tonsils found in children and young 
adults; second, the so-called ragged tonsil; third, the scirrhous 
or hard tonsil, characterized by an enormous increase of the 
connective tissue of the gland and a canalicularization of its 
blood-vessels; fourth, the submerged or buried tonsil, where DISEASES OF THE OROPHARYNX 
215 
the hypertrophied tonsil does not project beyond the faucial 
pillars. 
Symptoms.-There is generally more or less obstruction to 
breathing, the patient snoring during sleep. The articulation 
is thick and there may be some difficulty in swallowing, 
especially in the cases of young children. The crypts of the 
tonsil may become filled with cheesy masses, which, under- 
going putrefaction, imparts to the breath an offensive odor. 
Hypertrophied tonsils also sometimes interfere with the proper 
performance of the functions of the Eus- 
tachian tubes and thus are the cause of 
aural catarrh and deafness. 
Treatment. - Tonsillectomy, tonsillot- 
omy, or the treatment of diseased crypts 
with the galvanocautery. 
Galvanopuncture is performed in the 
following manner: A small galvanocau- 
tery-knife is introduced (cold) into one 
of the crypts of the tonsils and, being 
heated while in situ, is made to burn its 
way out. Two or three such burns may be made at a sit- 
ting, and will be followed by considerable shrinking of the hy- 
pertrophied gland. But one of the tonsils should be operated 
upon with the galvanocautery at any one time, and from 
five to fifteen such operations are required to reduce the gland 
to satisfactory dimensions. 
Galvanopuncture is useful to destroy any diseased crypts 
that may remain after tonsillotomy. Sometimes in the case 
of bleeders and others it is desirable to remove a small tonsil 
piecemeal. For this purpose the tonsil punch (Fig. 98) may be 
used. Such instruments are useful also in removing shreds 
of tissue that may remain after an operation with the tonsillo- 
tome or snare. 
Tonsillotomy with the tonsillotome is performed as follows: 
The patient, if a child, should be seated in the lap of an assist- 
ant, who holds the child's legs between his own to prevent 
Fig. 98.-Myles' tonsil 
punches. 2l6 
DISEASES OE THE NOSE, THROAT, AND EAR 
struggling. The assistant then passes his arms under the 
child's arms and grasps the child's forehead with his two hands 
so as to control the movements of the child's head. When 
the assistant elevates his elbows the child's arms are extended 
in such a manner as to prevent the child reaching his face with 
his hands and interfering with the operation. 
The tonsillotome is introduced into the child's mouth flat- 
wise, like a tongue-depressor, and serves to hold down the root 
of the tongue and afford a good view of the lower border of 
the tonsil. The ring of the tonsillotome is now passed around 
the tonsil from below in order to be sure that the lower border 
of the tonsil is encircled by the ring, which is pressed firmly 
Fig. 99.-Ermold's tonsillotome. 
against the wall of the pharynx. The blades of the instrument 
are now closed and tonsillotome and tonsil removed together 
from the mouth. If the operator is provided with two tonsil- 
lotomes it is generally feasible to remove the second tonsil 
before releasing the child, unless bleeding is so great as to 
interfere with a view of the fauces. 
The operator should be provided with a set of at least three 
sizes of tonsillotomes, in order that he may select one with a 
ring of just sufficient size to snugly fit around the tonsil to be 
removed. After encircling the tonsil the instrument should be 
closed somewhat deliberately, and the operator should be 
careful to make no effort to remove the tonsillotome from the 
mouth until the tonsil has been completely severed. The 
operation is not especially painful, and probably causes less 
discomfort to the patient than the administration of ether. 
However, there is no objection to administering ether for ton- DISEASES OF THE OROPHARYNX 
217 
sillotomy. Under such circumstances the tonsils are removed 
with the child lying on its side and its head turned to one side, 
with the foot of the operating table elevated about 3 inches, 
as previously described for the removal of adenoids (p. 204). 
Tonsillectomy, or the complete removal of the tonsil, in con- 
tradistinction to tonsillotomy, or the removal of that portion 
of the tonsil projecting beyond the pillars of the fauces, is 
advocated by the larger proportion of laryngologists. Tonsil- 
lectomy is always advisable in submerged tonsils and in small 
tonsils with diseased crypts. Tonsillectomy can be done on 
docile adults after the injection of local anesthetics into the 
tissues about the tonsils (Formula 11), but it is better under- 
taken under etherization. The position of the patient on his 
side and the elevation of the operating table is the same as 
for the removal of adenoids. 
A mouth gag in inserted, the tongue is held down and forward 
with a depressor; mucus and saliva are removed from the 
pharynx with a gauze sponge; the tonsil is grasped with stout 
volsellum forceps provided with a catch to render them self- 
retaining. The upper blade of the instrument should be in the 
supratonsillar fossa and the lower inserted into the lower 
border of the tonsil in such a manner that a part of the capsule 
and so considerable a portion of the tonsil is included within the 
grasp of the forceps that they will not readily tear out. The 
tonsil is now pulled strongly toward the median line of the 
pharynx, so that its extent beneath the anterior pillars is readily 
seen. While traction toward the median line is maintained, 
the anterior and posterior pillars are dissected loose from the 
tonsil by means of the tonsil knife (Fig. 96), the tonsil being 
rotated downward and inward out of its bed or pushed or pulled 
away from the pillars to facilitate the procedure. Especial 
attention is directed to the attachment of the tonsil to the 
anterior pillar at the point where the plica triangularis leaves 
the anterior pillar to extend backward over the lower third of 
the tonsils. The capsule of the tonsil extends forward and 
medianly to attach itself to the edge of the anterior pillar at 2l8 
DISEASES OF THE NOSE, THROAT, AND EAR 
this point, and hence, severing this attachment, opens up the 
space behind the capsule and permits the tonsil to sag outward 
from its fossa toward the median line of the pharynx. The 
tonsil is attached now only by its lateral portion to its bed, 
from which it can be still further enucleated by the use of the 
finger-tip inserted into the supratonsillar fossa, better with 
Hurd's enucleator, a stout steel curette, slightly curved at the 
tip, which is about the size but much thicker than the fore- 
finger-nail (Fig. 95). The loop of a snare (Fig. 100) is now 
slipped over the forceps and made to surround the base of the 
tonsil, which by the use of the enucleator and finger-tip has 
become pedunculated and adherent only at its inferior portion. 
Fig. ioo.-Martin's tonsil snare. This is one of the best of the tonsil snares 
that can be used readily with one hand. Tyding's snare, although larger and 
more clumsy, removes the tonsil as quickly as a tonsillotome, and hence is cer- 
tainly the preferable instrument when operating without general anesthesia. 
As soon as the tonsil is enucleated its fossa should be filled 
with a small gauze sponge, either held in long curved tonsillar 
hemostats or placed in position and firm pressure maintained 
with the fingers. After a few moments the wound should be 
inspected. Frequently it will be nearly dry or oozing at only 
a few points, which can be clamped with tonsillar hemostats 
or disregarded until the other tonsil has been removed, by which 
time the wound may have become entirely dry. When the 
patient is lying on the left side 'the left or lower tonsil is re- 
moved first, then the right or upper tonsil, and finally adenoids 
if present. 
In some cases it is difficult to at once grasp a sufficiently 
large portion of the tonsil to prevent the forceps tearing out 
when firm traction is made, especially when some of the tough 
fibers of the capsule are not within the grasp of the forceps. 
Under such circumstances, it may be desirable to draw the 
tonsil out of its bed toward the middle line of the pharynx DISEASES OF THE OROPHARYNX 
219 
before applying the forceps. Tenaculum forceps of many 
patterns have been devised by operators: some with four 
prongs, some with six and some with even eight. The author's 
preference is for a small four-pronged instrument bent laterally 
near the tip; in fact the familiar double tenaculum forceps 
used by surgeons during the past half century or more, 
whether or not it is provided with a catch is a matter of com- 
plete indifference, but its small size is a decided advantage 
over the larger six- or eight-pronged instruments. It is con- 
venient for the operator to be provided with several tenaculum 
forceps, so that if one shows a tendency to tear loose another 
can be applied further back through the capsule of the tonsil. 
The entire operation can be done with forceps and Hurd's 
enucleator or some similar instrument or even with forceps 
and the finger-tips. The objection to this procedure is the 
unnecessary traumatism and shock occasioned by the rough 
handling of the parts. It is far preferable to cut the small 
amount of cellular tissue binding the anterior and posterior 
pillars to the sides of the tonsils with a shark-knife thus making 
a smooth cut through the mucous membrane and preserving 
as much of it as possible. The hemorrhage is so trifling that 
the parts are easily in view until the base of the tonsils is 
reached. Then when Hurd's enucleator is pushed underneath 
the tonsil it serves to lift the tonsil and prevent the necessity 
of very hard traction with the forceps. It is sufficiently blunt 
to prevent much hemorrhage; not more than enough blood 
to stain a few sponges being usually lost unless the foot of the 
operating table is raised sufficiently to cause congestion of the 
pharynx. 
The attachment of the lower pole of the tonsil is often 
thick and tough and while it can be torn through with the 
finger or an enucleator, it is better to cut it with scissors or a 
snare. For this purpose any snare large enough to carry No. 
9 piano wire will answer and the more quickly the loop can be 
closed the better. Before tightening the loop the parts 
should be inspected to see that the uvula is not included, 220 
DISEASES OF THE NOSE, THROAT, AND EAR 
which might occur if there is considerable oozing of blood. 
If there is any difficulty in keeping it out of the way it should 
be grasped by its tip with a small hemostat, which will effectu- 
ally prevent its being included in the loop. 
Open wounds of the pharynx heal more quickly if let alone; 
especially when retching, gagging and increased irritation 
result from medication of the wound. Frequently a superficial 
slough presents somewhat the appearance of a pseudomem- 
brane; but is without significance as far as healing is concerned. 
However cases of sepsis severe enough to endanger life, and 
thrombosis of the internal jugular extending upward into the 
cavernous sinus have been reported. The patient should 
remain in bed for a day or so, or until the temperature is 
normal, and subsist on a soft diet until the soreness of the 
parts subsides sufficiently to permit the swallowing of more 
solid food. If the wound is not doing well, it may be touched 
with a 12 per cent, solution of silver nitrate or dusted by means 
of a powder-blower with a powder of iodoform, tannic acid, 
and bismuth (Formula 119), which will closely adhere to the 
wound and remain in contact with it for a long time. 
Occasionally operations on the tonsil are followed by danger- 
ous hemorrhage. This generally occurs at the time of the 
operation or some hours after the patient is thoroughly 
recovered from the ether. Before operating the pharynx 
should be carefully inspected for anomalous arteries and the 
region of the tonsil palpated to detect any unusual pulsations. 
Resident physicians in hospitals should be trained in the 
methods of controlling hemorrhage after tonsil operations 
and nurses should be instructed to inspect a child from time 
to time after a tonsillectomy to be assured that the child is 
not swallowing blood; for when hemorrhage occurs some 
hours after the operation in young children, the blood is 
usually swallowed; so that the first symptom of danger may be 
the vomiting of a large quantity of blood, rapidly followed 
by collapse. Under such circumstances, a tonsil clamp may 
be useful in controlling the hemorrhage until more effective DISEASES OF THE OROPHARYNX 
221 
measures can be instituted. The clamp can be applied 
either alone or over a gauze sponge inserted into the tonsillar 
fossa. However no clamp is as effective in controlling hemor- 
rhage as digital pressure through a gauze sponge on the bleeding 
tissues. The pressure should be continued for a few moments, 
the sponge then gently removed and the parts inspected. 
It is possible that all parts of the wound will be found apparently 
oozing blood. Under such circumstances, the sponge should 
be moistened with peroxide of hydrogen, inserted into the 
tonsillar fossa and pressure again applied upon the removal 
of this second sponge, the hemorrhage will be manifestly less 
and probably will be controlled by painting the parts with 
dilute Monsell's solution. Possibly one or more points will 
still continue to bleed and to these the undiluted Monsell's 
solution should be applied by means of a cotton-tipped appli- 
cator held firmly upon the bleeding point. Monsell's solution 
is an irritant and the undiluted solution should be used with 
care that no excess of the solution trickles down the pharynx 
into the larynx. After the oozing of blood from one tonsil 
is controlled, the other should be treated in the same manner 
and if blood is seen flowing from the adenoid wound behind the 
palate, dilute Monsell's solution should be painted upon this 
wound also by means of a bent cotton-tipped applicator. 
If the removal of a tonsil is followed by profuse hemorrhage, 
it should be controlled by inserting one or more sponges into 
the tonsillar fossa and making firm digital pressure. After 
a few moments, the sponges are cautiously withdrawn in such 
a manner that one part after another of the wound is exposed 
so that any spurting artery can be seized by long Kocher 
hemostats and tied. If at the first attempt the vessel is 
not seized, a slight twist upon the instrument will probably 
control the hemorrhage sufficiently to enable the operator to 
see the bleeding spot more distinctly and clamp it with a second 
pair of hemostats. Small spurting arteries give no especial 
trouble except that it is a little more awkward to tie them than 
in a superficial wound. Occasionally a vessel upon the inner 222 
DISEASES OF THE NOSE, THROAT, AND EAR 
surface of the anterior pillar will bleed in such a manner as 
to momentarily confuse the operator; because when the pillar 
is drawn forward the pressure will be sufficient to control the 
hemorrhage, which recurs immediately the pillar is released. 
However, if the anterior edge of the pillar is seized with forceps 
in such a manner that its cut posterior surface can be inspected, 
the bleeding vessel is easily found and tied. 
Hemorrhage after the removal of adenoids may be so severe 
as to require a postnasal plug of iodoform gauze in order to 
control it, which is inserted in the manner already described, 
for the control of nasal hemorrhage. 
Occasionally after the removal of adenoids and tonsils 
patients recover from their ether very unsatisfactorily and for 
a long time remain nearly pulseless with shallow respiration. 
The extremities are cold and the little patient although 
conscious is aroused with difficulty to answer questions. 
Such symptoms occur sometimes in children who are fairly 
robust and who have not received an inordinate amount of 
ether nor lost a large amount of blood at the operation. 
Fatal cases of this character have been attributed to the 
presence of a thymus gland that has not undergone spontaneous 
metamorphosis and partial absorption, the so-called 1 'habitus 
lymphaticus." It is probable that in some of the fatal cases 
reported, the element of surgical shock must have played an 
important role; and that it is always safest to subject the tissues 
of the pharynx to as little rough handling as possible during 
tonsillectomies and as little blunt dissection as is compatible 
with safety from hemorrhage. If during the operation the 
use of the tongue depressor caused the patient's respiration to 
cease, pressure should be relaxed until the respirations become 
normal. If necessary, the tongue should be drawn out of the 
mouth with volsellum forceps and pressure applied to only that 
portion of its base necessary to display the tonsil. In some 
cases embarrassed respiration becomes very much improved 
after the removal of the first tonsil. No more ether should 
be used than is necessary to produce relaxation of the pharyn- DISEASES OF THE OROPHARYNX 
223 
geal muscles and it should be remembered that the pharyn- 
geal reflex is one of the last to disappear under ether. There 
should be no more hemorrhage than is unavoidable and the 
surgeon or his assistant should take the time and pains to stop 
practically all bleeding after one tonsil is removed before 
removing the other. Lowering the head more than is just 
sufficient to prevent blood gravitating into the larynx or lower- 
ing the head by bending the head backward so greatly in- 
creased the congestion of the pharynx that what is gained 
by decreased probability of blood reaching the larynx is lost 
by increased congestion. Consequently there is commonly less 
hemorrhage with the patient lying on one side, as already 
described, so that blood gravitates into the hollow of the cheek 
that when the patient is prone because there is less necessity 
for greatly lowering the head. 
If in spite of precautions, the little patient is profoundly 
shocked by the operation, the foot of the bed should be raised 
and oxygen administered. The heart's action should be main- 
tained by heat over the heart and strychnine, and blood pres- 
sure increased by the use of 8 ounces of normal salt solution 
by hypodermoclysis and the institution of enteroclysis by the 
drop method. 
Sepsis, severe enough to threaten life, deep cervical cellulitis, 
resulting in abscess, and thrombosis of the internal jugular 
extending through the lateral sinus into the cavernous with 
resulting loss of vision in one or both eyes have been reported. 
Considering the fact that the mouths of children on whom 
tonsillotomies are done, often contain carious teeth, it is 
astonishing that such wounds do not oftener become infected. 
However it is noticeable that infection most often occurs at 
the hands of those who are most careful of the after treatment 
of tonsillectomy wounds and it is possible that the gagging and 
retching and consequent irritation of the wound may invite 
infection rather than tend to prevent it. The author's routine 
treatment of tonsillectomy wounds consists of inspection for 
the first three days. His only case of infection occurred in a 224 
DISEASES OF THE NOSE, THROAT, AND EAR 
young woman with a tubercular history who developed a 
severe cervical adenitis followed by abscess. A slight hemor- 
rhage occurred the night following the operation which was 
controlled by digital pressure and some hours later painting 
the wound with Monsells' solution. She left the hospital on 
about the fourth day after the operation, remained for a day 
or two in a house where there was diphtheria and returned to 
the hospital with the glands at the angle of the jaw greatly 
swollen. As there was no pseudomembrane and the diphtheria 
bacillus was not found and the tonsillectomy wound on the 
other side of the pharynx healed without incident, it was 
thought that the handling of the wound necessary to control 
hemorrhage was probably the main cause of the infection. 
The lingual tonsil is subject to the same diseases that affect 
other adenoid structures of the pharynx. Occasionally a 
Fig. ioi.-Reflex spasms of the glottis, caused by a large hypertrophy of the lingual 
tonsil (Rice). 
venous varix occurs at the base of the tongue on and about the 
lingual tonsil. If its size is a source of irritation the principal 
veins should be destroyed with the galvanocautery, which, 
for this purpose, should not be above a dull-red heat or the 
vein will be opened and hemorrhage occur. The lingual tonsil 
(Fig. ioi) becomes sufficiently hypertrophied sometimes to 
cause irritation and reflex cough. Under such circumstances 
the redundant tissue should be cut away by suitably curved DISEASES OF THE OROPHARYNX 
225 
scissors with serrated edges to prevent the flabby tissue slip- 
ping from the blades. Occasionally the so-called lingual goiter 
is found at the base of the tongue and should not be mis- 
taken for hypertrophied lingual tonsils. 
Acute pharyngitis is an acute inflammation of the mucous 
membrane and underlying structures of the pharynx. 
Etiology.-Acute pharyngitis is generally the result of ex- 
posure to wet and cold, especially of persons of the rheumatic 
diathesis or of debilitated constitutions. It may also result 
from traumatism or the presence of a foreign body in the 
pharynx. Slight unilateral pharyngitis is not uncommon 
after an intranasal operation, and is probably due to a mild 
infection. It lasts for a day or two and then passes away. 
Pathology.-The inflammation is usually by no means evenly 
distributed, the glandular elements being always most affected. 
Their secretion is at first increased, but becomes after a time 
decreased, starchy, and glue-like in character. The tonsils 
are always involved to a greater or less extent. 
Symptoms.-The constitutional symptoms are usually tri- 
fling, a feeling of lassitude with slight fever. The throat feels 
sore, dry, and stiff. The local symptoms may increase until 
pain, especially when deglutition is attempted, becomes quite 
severe. The cervical glands are often swollen and painful to 
the touch. The voice is usually husky and a sensation as of 
a foreign body in the throat keeps the patient hawking and 
spitting. When the tonsils or larynx are seriously involved in 
the inflammation, symptoms are present referable to these 
organs. 
Treatment.-A saline cathartic should be administered in 
sufficient quantities to secure one or more free movements of 
the bowels. A io per cent, solution of nitrate of silver should 
be freely painted over the inflamed lateral walls once or twice 
a day. It is immediately followed by a sensation of relief 
and comfort, and tends to materially shorten the course of the 
disease. Applied to the posterior pharyngeal wall solutions 
of silver nitrate of over i or 2 per cent, produce a sensation 226 
DISEASES OF THE NOSE, THROAT, AND EAR 
of dryness, stiffness, and discomfort, and stronger solutions 
should not be used. In this region a io per cent, solution of 
argyrol sprayed upon the parts is preferable to the use of the 
nitrate. When acute pharyngitis is the result of the presence 
of a foreign body, it should, of course, be at once removed and 
the inflamed pharynx treated as ordinary acute pharyngitis. 
When the rheumatic diathesis exists, the administration of 
guaiac (Formulas 62 and 63) will be found to yield most ex- 
cellent results, while in gouty sore throat colchicum should be 
prescribed. A spray of adrenalin chlorid (1 :10,000) used 
every hour by the patient quickly relieves the congestion in 
most cases; but other astringent sprays are sometimes equally 
efficient, the best probably is alumnol (1 dram to 4 ounces of 
water). If it is inconvenient for the patient to use an at- 
omizer, lozenges may be prescribed. The camphomenthol 
lozenge (Formula 66) is sedative and relieves the feeling of 
dryness and stiffness by increasing the secretions, and the 
same may be said of a lozenge of guaiac and potassium iodid. 
However, one of the most popular lozenges in this condition 
is that of guaiac and tannic acid (Formula 64). 
Simple chronic pharyngitis is a chronic inflammation of the 
mucous membrane of the pharynx, generally the result of 
chronic rhinitis and accessory sinus disease. The disease is 
often complicated by inflammation of the follicles of the mucous 
membrane, and is then called follicular pharyngitis. 
Treatment.-It is all important to bring about cure of the 
nasal disease, to the presence of which the pharyngeal malady 
is due. After a cure of the primary nasal affection has been 
brought about, simple chronic pharyngitis will get well almost 
without treatment. During the treatment of the nasal affec- 
tion, however, applications should be made to the vault of the 
pharynx of Formulas 112, 113, or 114 in the following manner: 
A tongue-depressor (Fig. 8) should be used to hold down the 
tongue and the patient requested to try to breathe through his 
nose or say "One" in order to relax the palatine muscles, when 
the application may be made without difficulty by means of DISEASES OF THE OROPHARYNX 
227 
an applicator, the end of which has been wrapped with cotton 
and bent to a suitable curve. Should, however, the palate 
lie closely in contact with the pharyngeal wall, considerable 
force will be required to carry the end of the applicator into 
the postnasal space, while most of the solution with which the 
cotton on the end of the applicator has been saturated will be 
squeezed out and remain in the fauces. Applications made 
in such a manner tend rather to increase the existing inflam- 
mation than to subdue it, and it is always best to desist from 
making an application to the pharyngeal vault rather than em- 
ploy force. When the uvula has become elongated or the 
mucous membrane of the fauces relaxed as the result of con- 
stant hawking, the daily application of the spray from an 
atomizer containing a solution of sulphate of copper (2 gr. to 
an ounce of water) will render material assistance in restoring 
the "relaxed throat" to a condition of health. In some in- 
stances it is necessary to amputate redundant mucous mem- 
brane at the tip of the uvula. 
Chronic follicular pharyngitis, or clergyman's sore throat, 
is a chronic pharyngitis characterized by inflamed and hyper- 
trophied lymph-follicles. 
The pathology is similar to simple chronic pharyngitis, except 
that the lymph-follicles are involved in large numbers and to a 
greater degree. The subdivision of pharyngitis and follicular 
pharyngitis is a matter of convenience rather than fact, as in all 
simple inflammations of the pharynx, the mucosa, the lymph- 
follicles, the submucosa, and often the muscles are usually in- 
volved in varying degrees. The watery portions of the secre- 
tions are decreased and hence the expectorations are thick 
and glue-like from an increased proportion of mucin, epithelium 
debris, and mineral salts. 
Etiology.-The disease is generally the result of or part of a 
nasopharyngeal catarrh, nostrils too wide to efficiently warm 
and moisten the inspired air, excessive or faulty use of the voice, 
excessive use of tobacco and distilled liquors, the rheumatic 
or gouty diathesis, indigestion, and, in women, pelvic diseases. 228 
DISEASES OF THE NOSE, THROAT, AND EAR 
Symptoms.-The secretions are usually somewhat scanty and 
viscid, but voided with considerable difficulty. There is a 
short, frequent cough, distressing alike to patient and friends; 
the so-called "useless cough," because it accomplishes nothing, 
either in ridding the throat of secretions or the constant phar- 
yngeal irritation, of which many of these patients complain. 
The appearance of the pharynx varies somewhat; usually 
there is a venous hyperemia over the entire surface, but greatest 
in the neighborhood of patches of hyperplastic follicles. In 
other cases the pharynx is less congested, the hypertrophied 
follicles projecting above the surrounding surface and sur- 
rounded by varicosities. Sometimes a number of inflamed 
follicles coalesce in such a manner as to form a red, sore, and 
swollen area of considerable size. If such patches be situated 
close to the posterior pillars, so that they are rubbed and irri- 
tated by these folds of mucous membrane with every motion 
of the pharyngeal muscles, the sufferings of the patient amount 
to actual pain. 
Treatment.-The irritability of the mucous membrane cover- 
ing areas of hypertrophied follicles can be decreased by lightly 
painting with a 12 per cent, solution of nitrate of silver. 
However, care should be exercised to prevent the silver solu- 
tion spreading over the surrounding mucous surface, because 
strong solutions of silver nitrate are irritating when applied 
to the posterior wall of the oropharynx. 
A certain amount of relief is experienced by the use of de- 
mulcent lozenges, either slippery elm, red gum, camphomenthol 
(Formula 66), or, better still in many instances, a lozenge of 
orothoform. 
Where the so-called useless cough is a prominent symptom, 
it should be controlled by appropriate doses of sodium bromid. 
For this purpose as much as 10 to 15 gr. after meals and at 
bedtime will be required. The matter is of considerable im- 
portance, as the constant coughing greatly irritates the pharynx 
and increases the existing inflammation. 
The condition of the tonsils should be carefully examined. DISEASES OF THE OROPHARYNX 
229 
Often they are slightly hypertrophied and the crypts contain 
cholesteatomatous masses. The removal of any concomitant 
disease of the nasal cavities also will have much to do with the 
success of the treatment. 
The hypertrophied follicles can be destroyed by touching 
one at a time with Battey's solution (Formula 29). 
With many practitioners the radical destruction of the dis- 
eased glands by means of the galvanocautery is a favorite 
method of treatment. A very small cautery-knife should be 
selected, and great care should be exercised not to burn too 
deeply, or the resulting scar will cause more trouble than the 
original disease. It is unwise to apply the galvanocautery- 
knife to more than two or three hypertrophied follicles at one 
time, or the treatment may be followed by a somewhat sharp 
attack of acute pharyngitis. 
Emil Mayer removes the offending follicles by means of a 
special curette. By this method of treatment, which is much 
less painful than the use of the galvanocautery, all the hyper- 
trophied follicles are removed at a single sitting. 
Atrophic pharyngitis is an atrophic condition of the mucous 
membrane and submucous tissue of the pharynx. 
Etiology.-.Atrophic pharyngitis generally results from the 
inadequate warming and moistening of inspired air and long 
contact with the irritating discharges of nasal catarrhs. It 
frequently exists when atrophic rhinitis is present. A dry 
condition of the faucial mucous membrane, amounting almost 
to pharyngitis sicca, is found in all mouth-breathers, but 
disappears spontaneously as soon as the nose has been rendered 
sufficiently patulous. 
Symptoms.-The patient complains of his throat feeling dry 
and stiff. Upon inspection the mucous membrane of the 
throat appears light colored, thin, and as if varnished. Fre- 
quently the mucous membrane is so thin that the outline of 
each cervical vertebra can be distinguished. Sometimes 
masses of inspissated mucus, perhaps dark colored from the 
dust inhaled, and swept into ridges by the motions of the 230 
DISEASES OF THE NOSE, THROAT, AND EAR 
soft palate, are seen adhering to the atrophied mucous 
membrane. 
Treatment.-Attention should be mainly directed to the 
condition of the interior of the nose, because when a cure of 
the nasal affection has been brought about, the concomitant 
throat disease will get well almost without treatment. The 
general health should receive attention and if necessary, 
tonics should be prescribed, while a sluggish condition of the 
bowels may indicate the use of saline laxatives. If atrophic 
rhinitis has caused the affection, plugs of cotton, previously 
mentioned as useful in atrophic rhinitis, should be made long 
enough to project somewhat from the posterior nares into the 
pharynx, while a weak solution of nitrate of silver (gr. v-vx to 
fgj) should be applied to the atrophied mucous membrane, 
both above and below the soft palate, to stimulate the atro- 
phied glands to increased secretion and bring about renewed 
growth of the atrophied structures. In certain cases it may 
be advisable to give for a short time some drug like iodid of 
potassium, phosphorus, or muriate of ammonia to stimulate 
the pharyngeal secretions. A pill containing gr. of phos- 
phorus may be given after meals or the lozenge of guaiac and 
iodid of potassium, one every three or four hours, may be 
ordered. It should be borne in mind that the stomach does 
not tolerate well any lengthy administration of these remedies, 
and in most cases their use is best avoided. 
Hyperkeratosis or mycosis of the pharynx is a disease in- 
volving in most cases the faucial, pharyngeal, and lingual 
tonsils, although other parts of the upper respiratory tract do 
not always escape. It is characterized by little white, conic 
elevations, sometimes as large as a grain of rice, due to accu- 
mulations of horny epithelium extending outward from crypts 
and follicles, with an admixture of bacteria and sometimes fungi 
of the mycosis class, most frequently the leptothrix buccalis. 
Etiology.-Leptothrix is so frequently found in the secretions 
of the mouth that it might almost be termed a normal constitu- 
ent. It is especially prevalent in the mouths of individuals DISEASES OF THE OROPHARYNX 
231 
with carious teeth, accumulations of tartar, etc. Why it 
should in some individuals cause the horny, chalk-white 
growths characteristic of mycosis is not well understood, and 
it is probable that bacteria play an unimportant role in the 
causation of the disease. 
Symptoms.-A few cones of keratosis may be present in the 
pharynx without causing any symptoms whatever. Under 
such circumstances the masses may be discovered incidentally 
upon the tonsils while examining the throat. Usually, how- 
ever, patients with mycosis complain of a tickling sensation 
in the pharynx and spasmodic cough. 
Treatment.-On the tonsils and other easily accessible por- 
tions of the pharynx the little masses should be grasped one by 
one and pulled off with the smallest size of Farnham's alligator- 
forceps or, better, Hartmann's ear forceps. After the removal 
of the little masses the mucous membrane where they grew 
should be brushed with io per cent, nitrate of silver. In in- 
accessible localities, like the base of the tongue and beneath 
the epiglottis, leptothrix is better attacked with a small 
galvanocautery-knife than the forceps. 
Some of the cones re-form after their removal. Applications 
of io per cent, silver nitrate prevents this to a considerable 
extent, and occasionally when applied to the surface where 
leptothrix is growing will cause the cones to disappear after 
frequent applications. Ultimately the growths disappear 
spontaneously if untreated, the disease running its course in 
one or two years. 
Erysipelas of the Pharynx.-Erysipelas of the face some- 
times extends to the pharynx, or the disease may originate in 
the pharynx. 
Etiology.-Like erysipelas elsewhere, the disease is the re- 
sult of the presence of Fehleisen's erysipelas streptococcus. 
Pathology.-The fauces are dusky red and swollen. Vesicles 
form on the surface filled with seropus. The disease is evi- 
dently contagious under certain circumstances, as epidemics 
have been described, notably that in America in 1842. Erys- 232 
DISEASES OF THE NOSE, THROAT, AND EAR 
ipelas may extend to the middle ear through the Eustachian 
tube or to the lungs through the larynx. 
Prognosis.-In the milder cases the prognosis is good. The 
phlegmonous variety of the disease is almost invariably fatal. 
The treatment is that of erysipelas elsewhere. Large doses 
of the tincture of chlorid of iron (20 to 30 drops in water) 
should be given every three hours, with strychnin, & gr., if 
necessary. The nose and pharynx should be sprayed with an 
alkaline wash every three hours, followed by adrenalin solution 
(1:1000). The spray of adrenalin should be repeated at in- 
tervals of a few moments until the parts have somewhat 
blanched, after which they should be covered with a 20 per 
cent, solution of argyrol by means of the spray from an 
atomizer. 
Phlegmonous pharyngitis is an acute infection of the pharynx 
phlegmonous in character, extending to the deeper structures 
and usually terminating fatally in from five to ten days. 
Etiology.-The disease usually attacks those of broken-down 
constitutions or the aged. There is usually a history of slight 
traumatism, followed by virulent infection. 
Pathology.-There is an enormous swelling of the fauces at 
an early stage of the disease, followed by a speedy formation of 
pus, which infiltrates the surrounding tissues and produces 
pyemia. The organism present in the pus is usually strep- 
tococci, or there may be a mixed infection. 
Symptoms.-The onset of the disease is sudden. The tem- 
perature rises to 1030 or 1040 F. The throat is sore and, as in 
a case observed by the author at the Philadelphia Hospital, the 
swelling may be so rapid as to necessitate tracheotomy within 
twenty-four hours to prevent suffocation. There are. symp- 
toms of general infection; a clammy perspiration, great 
weakness and debility, often followed by collapse and death. 
Treatment.-Local treatment is of little avail. If asphyxia 
is imminent, tracheotomy should be resorted to; suspected ab- 
scesses should be opened either externally through the skin 
by a free incision or in the pharynx if fluctuation is detected. DISEASES OF THE OROPHARYNX 
233 
Hourly hypodermic injections of antistreptococcus serum 
should be given, with normal salt solution by the rectum. 
Nutritive enemas also will be necessary if the patient is unable 
to swallow, with hypodermics of strychnin gr.) every three 
or four hours to prevent collapse. 
Ludwig's angina was first described by Ludwig in 1836 as a 
severe infection, beginning in the submaxillary region, where it 
soon assumes a character which he termed "gangrenous in- 
flammation of the neck." 
Etiology is so similar to that of phlegmonous pharyngitis 
that Semon and others have maintained that the diseases were 
practically identical. There is usually a mixed infection of 
streptococcus with staphylococci or diplococci. 
Pathology.-The disease is essentially a rapidly spreading 
cellulitis, beginning in the region of the submaxillary gland 
from a point of infection, usually a carious tooth, tonsillitis, 
or an ulcer in the mouth. Fatal results occur from invasion 
of the larynx, trachea, and the lungs with general systemic in- 
fection. It should be borne in mind that any rapidly spread- 
ing cellulitus of the floor of the mouth is a menace to life be- 
cause the anatomic conditions favor the early involvement of 
the larynx; and because of the compression of the inflammatory 
material between the inner sides of the jaw and under the 
tongue. 
Symptoms.-The disease begins as a hard painful swelling 
in the submaxillary region, which may run a mild course for 
days and then suddenly assume an alarming character, be- 
cause the swelling of the parts interferes with respiration and 
the swallowing of nourishment. Temperature and pulse are 
often comparatively low, but dyspnea may require trache- 
otomy within twenty-four hours of the onset of the disease. 
In most cases septic intoxication is of less moment as a cause 
of death than the involvement of the respiratory tract, and 
death may occur even after tracheotomy in syncope and 
dyspnea in spite of artificial respiration and oxygen. 
Treatment.-Early incision parallel to the lower border of 234 
DISEASES OF THE NOSE, THROAT, AND EAR 
the jaw over the submaxillary triangle should be done in the 
expectation of laying bare the focus of infection, which is 
reached with more certainty in most cases than by the safer 
median incision beneath the chin above the hyoid bone. In- 
cisions on the floor of the mouth are rarely successful in liberat- 
ing pus. When pus is not found in the submaxillary incision 
the mylohyoid muscle should be divided and the sublingual 
cellular tissue exposed. Early incision will probably prevent 
the irregular septic temperature; profuse sweating and delir- 
ium recorded in some cases. However, after the sublingual 
tissue has been exposed, should the symptoms indicate, hourly 
injections of antistreptococcus serum with normal salt solu- 
tion by the rectum and stimulants should be given, as in the 
treatment of phlegmonous pharyngitis. 
Vincent's angina is an infection of the pharyngeal mucous 
membrane with fusiform bacilli and Spirochaetae which are 
different forms of the same micro-organism. 
The disease may be associated with diphtheria, syphilis, or 
streptococcus or staphylococcus infection. 
Diagnosis.-The disease differs from an ordinary acute 
pharyngitis due to streptococcus or staphylococcus infection 
in the usually less severe constitutional symptoms, the great 
tendency to ulcerations, and the presence of characteristic 
organisms. However, Vincent states that in the diphtheroid 
form of the disease there is simply a membranous inflammation 
without ulceration and that only fusiform bacilli can be isolated. 
The symptoms are usually those of subacute pharyngitis, 
unless mixed infection is present. Headache, general malaise, 
with a temperature up to 102.50 F., may be present. The 
breath is foul, the throat painful when swallowing, and there 
is generally some swelling of the submaxillary glands. 
The prognosis, where no mixed infection is present, is good, 
the symptoms abating in three or four days, although some 
redness of the pharyngeal mucous membrane may persist for 
many days. In cases of mixed infection the severity of the 
symptoms depend upon the character of the mixed infection. DISEASES OF THE OROPHARYNX 
235 
Treatment.-In uncomplicated cases local treatment con- 
sists in the application of a solution of nitrate of silver (2 to 
4 per cent.). The patient should apply to his throat, as a 
home treatment, the spray from an atomizer containing | to 
1 per cent, sulphate of copper. A mild quarantine had per- 
haps better be observed until the throat clears up. In the 
more severe forms of mixed infection the internal treatment 
is similar to that of the phlegmonous pharyngitis. When 
pseudomembrane or ulcerations are present, the parts should 
be cleansed and Lbffler's solution applied once or twice a day 
by means of a cotton-tipped applicator. Neosalvarsan is said 
to be useful in all diseases in which spirilla play a part. The 
remedy may be injected as in the treatment of syphilis or a 3 
per cent, solution applied to the ulcers and pseudomembrane. 
Simple Ulcer of the Pharynx.-Most ulcers of the pharynx 
are either syphilis, epithelioma, or tuberculosis. However, 
there is an ulceration of the pharynx or fauces, generally the 
result of mixed infection, that is occasionally observed. Some 
cases are the result of traumatism followed by infection. 
The symptoms vary according to the size and location of the 
ulceration. The pain will be severe, especially during swallow- 
ing, if the ulceration is so localized as to be irritated by the 
action of the faucial muscles. Under such circumstances there 
may be regurgitation of food through the nose. If the in- 
flammation extends to the larynx there will be hoarseness or 
loss of voice, and if the tissues about the Eustachian tubes are 
involved by the inflammation, earache. If the ulceration is 
long continued there will be a progressive loss of flesh. 
Upon inspection the ulcer is seen upon the pharynx either 
medianly or laterally. It may be round or oblong. The edges 
are usually well defined and the ulcer may be filled with 
sloughing tissue, or the floor of the ulcer may be comparatively 
clean and. so deep that when situated medianly the bone 
of the vertebra is bared. 
The diagnosis in ulceration of the pharynx rests between 
syphilitic, tuberculous, epitheliomatous, simple ulceration, and 236 
DISEASES OF THE NOSE, THROAT, AND EAR 
Vincent's angina. The Wassermann reaction test or the 
administration for a week or ten days of io to 20 gr. of iodid 
of potassium after meals and at bedtime will clear up the 
diagnosis as far as syphilis is concerned. 
Cancer of the pharynx is differentiated by examining micro- 
scopically a small section removed from the edge of the ulcer, 
and tuberculosis by the tuberculin-test, the condition of the 
patient, or by microscopic examination of the sputum. 
The treatment of syphilitic, epitheliomatous, and tubercular 
ulcerations has been described elsewhere. In simple ulcera- 
tion tonics and 10 to 15 gr. of pepsin after meals should be 
given. The ulcer should be cleansed each day with Dobell's 
solution or peroxid, and an application made of nitrate of 
silver (15 per cent.), after which the floor of the ulcer should be 
dusted either with orthoform or a mixture of iodoform, tannic 
acid, and bismuth (Formula 120). Both orthoform and the 
above powder are analgesic and relieve pain. They are also 
antiseptic and adhere to the ulcerated surface sometimes for 
hours. Of the two, the iodoform and tannic acid powder gives 
the better results. 
Syphilitic pharyngitis is an inflammation of the pharynx 
due to the presence in the system of the syphilitic poison. 
The primary sore is not infrequently seen. Mucous patches 
are by no means rare, while gummata or their characteristic 
cicatrices are very often met with in the pharynx, especially 
in dispensary practice. 
Symptoms.-In primary syphilis, examination shows a 
whitish abrasion, soon followed by swelling of the glands about 
the angle of the jaw. Secondary lesions may present either 
the form of mucous patches or erythema, characterized by a 
diffuse redness of the entire fauces or, more commonly, in milder 
attacks, by a broad red line extending upward upon each of the 
anterior pillars, and ending abruptly and symmetrically at 
the root of the uvula. Mucous patches and erythematous 
patches in the throat are almost always symmetric; that is, 
both sides of the throat are attacked in corresponding localities DISEASES OF THE OROPHARYNX 
237 
by similar lesions, while tertiary lesions do not as frequently 
present this symmetry. Gummata more frequently involve 
the tonsils or soft palate than other parts of the throat. A 
gumma may be absorbed under treatment or, breaking down, 
result in a rapidly spreading ulceration. When an ulcerating 
gumma is situated upon the posterior wall of the pharynx, the 
cervical vertebrae or even the cervical cord itself may finally 
become involved, and a fatal issue result. In such cases also 
the utmost care is required to prevent union of the soft palate 
and uvula to the pharyngeal wall when the ulceration involves 
the posterior surface of the palate. Where union has taken 
place, it is difficult at any subsequent period to permanently 
restore satisfactory communication between the oropharynx 
and nasopharynx by any operation because of cicatricial con- 
traction after the operation. 
Treatment.-In pharyngeal syphilis, as in syphilis elsewhere, 
constitutional treatment is of primary importance, and the 
same remedies may be employed internally as already recom- 
mended in the treatment of nasal syphilis. If the symptoms 
are urgent, salvarsan injections should be given. Local treat- 
ment consists in maintaining perfect cleanliness of the diseased 
parts and stimulating mucous patches and ulcerations to heal 
by daily applications of the acid nitrate of mercury diluted 
with 5 parts of water, and the application, by means of the 
powder-blower, of a small quantity of Formula 119 or 120. 
Leprous Pharyngitis.-According to Hoffmann, leprosy of 
the pharynx begins by the formation of small tubercles, which 
break down, forming ulcerations which finally penetrate the 
soft palate, so that in some instances the perforations are so 
numerous that the palate resembles a sieve. Similar ulcera- 
tions occur on the pharyngeal wall and the tonsils. In some 
cases a small ulcer may assume a gangrenous character, 
associated .with marked systemic toxemia. Under these 
circumstances, treatment consists in the injection here and 
there into the gangrenous ulceration of a few drops of a 5 per 238 
DISEASES OF THE NOSE, THROAT, AND EAR 
cent, solution of zinc chlorid, which in a day or two causes a 
slough which, when separated, exposes clean healthy tissue. 
The tonsils frequently are the seat of leprous tubercles and 
become greatly hypertrophied, with subsequent fibroid 
changes. 
Tuberculosis.-The presence of the tubercle bacilli is some- 
times demonstrable by means of the microscope in the secre- 
tions of a mild chronic pharyngitis of nurses and attendants 
in the tuberculous wards of hospitals. Primary tuberculous 
pharyngitis with marked lesions is rare. Secondary tuber- 
culous pharyngitis in phthisic patients is somewhat common, 
and is usually observed as ulcerations resembling those of 
tertiary syphilis. 
Infection probably reaches the pharynx through some 
localized solution of continuity from the secretion of the 
tuberculous lungs. Tubercles form in the submucosa, which 
finally break down and ulcerate. 
Treatment.-In cases where there are no marked lung lesions 
and the diagnosis is obscure, the Wassermann reaction test or 
antisyphilitic remedies should be administered until the 
surgeon has satisfied himself that the disease is not syphilis. 
When ulceration has occurred the ulcers should be cleansed 
with hydrogen peroxid, cocainized, and touched with lactic 
acid once in two or three days. As these applications are 
somewhat painful, even after cocainization, it is well not to 
employ a stronger solution than 25 per cent, until the amount 
of pain and reaction caused by the application has been 
ascertained, after which the concentrated syrupy acid may be 
employed if deemed advisable. Rarely is it necessary to 
employ the curette, and the prognosis as regards healing is 
favorable. 
Lupus vulgaris is a form of inflammation involving the 
mucous membrane and submucous tissues of the pharynx, 
generally ending in ulceration due to the presence of the 
tubercle bacilli. 
Etiology.-The disease is said to be more common on the con- DISEASES OF THE OROPHARYNX 
239 
tinent of Europe than in America. It occurs in tuberculous 
families and in those frequently brought in contact with 
tuberculous patients. 
Symptoms.-'The general condition of the patient may be 
that of good health. The disease is insidious and causes little 
annoyance until the ulcers are sufficiently large to interfere 
with the functions of the parts. Early in the disease soft 
reddish nodules about the size of sago grains appear on one or 
both sides of the pharynx. These finally break down, pro- 
ducing ulcers which may spread to the pillars of the fauces, the 
palate, or the larynx, one portion of the ulceration healing 
while another is extending. 
Pathology.-Portions of the diseased tissue curetted away 
show, under the microscope, typic giant cells. However, 
tubercle bacilli are found only in small numbers and with 
difficulty. 
Diagnosis.-'The ulcerative stage may be mistaken for 
herpes, syphilis, or epithelioma. The short duration of 
herpes and the more rapid progress of epithelioma should 
serve to differentiate the disease from lupus. . In suspected 
syphilis the Wassermann reaction or the "therapeutic test"- 
serves to clear up the diagnosis. The tuberculin-test gives a 
positive reaction, causing local hyperemia and some rise of 
temperature, which subsides in twenty-four hours. The micro- 
scope shows typic tubercle giant cells. 
Treatment.-The parts should be thoroughly curetted and 
the solid stick of nitrate of silver applied. Cures have been 
reported by the use of the rr-ray. 
Glanders, farcy, or equinia is a contagious, specific disease 
with both local and constitutional symptoms, usually con- 
tracted from infected horses. It is due to the presence of the 
bacillus mallei. 
Symptoms and Course.-'Pemphigus-like vesicles appear at 
the point of infection, usually the face. The vesicles ulcerate 
and the parts sometimes become gangrenous. Metastatic ab- 
scesses occur on the face, trunk, and extremities. In milder 240 
DISEASES OF THE NOSE, THROAT, AND EAR 
cases vesicles and abscesses heal in a short time and the patient 
recovers. In severer cases there is marked prostration, with 
rapid rise in the temperature, headache, pain on swallowing, 
dryness of the throat, and enlargement of the suxmaxillary and 
cervical glands. Foul-smelling pus flows from the nose and 
pharynx and a purulent bronchitis is usually present. The 
severe form of the disease is usually fatal. 
Treatment.-Local treatment consists in cleansing the nasal 
and pharyngeal mucous membranes with diluted hydrogen 
peroxid and detergent washes and then spraying the nose and 
pharynx with carbolated albolene. The systemic treatment 
should be supportive. There is no known specific remedy for 
the disease. 
Actinomycosis is a parasitic, infectious, inoculable disease, 
first observed in cattle and later in man. It is due to the 
presence of the leptothrix streptothrix, or ray fungus. The 
most frequent and curable form of the disease is when abscesses 
form about the jaws or fauces. When the parasite has found 
a nidus in the lungs or digestive tract the disease is fatal. 
Etiology.--Actinomycosis is the result of inoculation with the 
ray fungus, which gains entrance to the mouth, pharynx, or 
nose from ingesta or inspired air. The disease may originate 
primarily in either of these cavities and, more rarely, in the 
larynx or ear. 
Pathology.-A slow swelling occurs, usually first at the angle 
of the jaw, which renders swallowing difficult. Upon inspec- 
tion, if suppuration has not already occurred, the mass will be 
found to be firm to the touch and involve one or more of the 
cervical glands or the tonsils. At the seat of infection a nodule 
occurs which breaks down and discharges pus containing typic 
granular masses, which, upon compression, form star-like 
bodies, yellowish in color, with a center which stains blue with 
Mallory's stain. 
Symptoms.-The symptoms and pathology of the disease, as 
affecting the human tonsils, was first described by Jonathan 
Wright (1904). The symptoms are those of granulating, pain- DISEASES OF THE OROPHARYNX 
241 
less abscess with general systemic infection. The laryngolo- 
gist is usually first consulted by the patient for catarrh and 
hypertrophied tonsils. One or more crypts of the tonsils may 
be suppurating and lined with granulations. 
Treatment.-The affected tonsil or tonsils should be ampu- 
tated. Where this cannot be done, the application of the 
galvanocautery is the best form of treatment. Each nodule or 
suppurating crypt should be thoroughly destroyed. Abscesses 
occurring in localities other than the tonsils should be opened, 
curetted, and cauterized with the solid stick of nitrate of silver, 
lodid of potassium in large doses is stated to inhibit the growth 
of the ray fungus, and Sawyer reports favorably results from 
the injection into tumors of from 15 to 30 minims of a 1 per cent, 
solution of the iodid. 
Retropharyngeal abscess is an abscess of the posterior 
pharyngeal wall. It may be hidden above and behind the soft 
palate and require the rhinoscope to ascertain its outline; it may 
be situated opposite the larynx, and only be seen in its entirety 
with the laryngoscope, or it may be situated in such a manner 
as to be hidden by one of the posterior pillars of the pharynx. 
However, the most common seat of abscess is the posterior 
wall of the pharynx opposite the oral cavity on one side or the 
other of the median line. 
Etiology.-'Abscess may occur as the result of phlegmonous 
inflammation of the cellular tissue of the pharynx, scroula and 
syphilis being predisposing causes. Traumatism and necrosis 
of the vertebrae are sometimes causes of the affection. 
Symptoms.-'There is usually but slight systemic disturbance. 
Chilly sensations may perhaps be complained of, but local 
symptoms are usually the first to attract attention. When the 
abscess is situated high up upon the pharyngeal wall, a sensa- 
tion as of a foreign body causes almost constant hawking and 
spitting, while there may be present obstructed nasal respira- 
tion with more or less pain and tinnitus. When the abscess 
is opposite the larynx, dyspnea is a marked symptom, appear- 
ing in "spasms" which may endanger the patient's life, while 242 
DISEASES OF THE NOSE, THROAT, AND EAR 
swallowing of liquids or solids in dangerous, owing to their 
frequent passage into the larynx. In the case of an eighteen- 
months-old child seen in consultation by the writer, the mere 
attempt to introduce a tongue-depressor into the mouth was 
followed by collapse and apparent death. The child's life was 
saved only by a rapid tracheotomy with the only available 
instrument, a penknife. The next day after the operation 
the cause of the obstructed respiration was discovered to be 
a retropharyngeal abscess situated low down in the pharynx 
opposite the larynx. The abscess was opened and the child 
made a good recovery. 
An abscess in the pharyngeal wall opposite the oral cavity 
presents none of these symptoms unless very large. 
Treatment.-Left to itself, a retropharyngeal abscess will 
discharge either into the throat or at some more remote point, 
but as soon as the diagnosis is established an incision should 
be made into the abscess at its lowest part, and if required the 
opening maintained patulous by the daily passage of a probe 
as long as necessary to bring about a cure of the affection. 
The author has several times opened a retropharyngeal 
abscess without general anesthesia with the child in an up- 
right position. However, it is probably better to place the 
patient on his side, with the foot of the operating table ele- 
vated as for a tonsillectomy. The abscess is then located with 
the forefinger-tip, which serves as a guide for a long-handled 
knife, and the abscess incised, washed out with boric acid 
solution, and iodoform emulsion in glycerin injected. When 
the abscess is complicated by caries of the vertebra it is better 
opened through the skin by the external route. An incision 
two or three inches long, is made on a plane with the abscess 
parallel to the anterior border of the sternocleido-mastoid 
muscle. The deep cervical fascia is opened and the anterior 
border of the sternocleido-mastoid muscle exposed and drawn 
forward. By blunt dissection the carotid sheath with its ves- 
sels and nerves is separated from the vertebra and drawn for- 
ward and the dissection carried in front of the vertebra to DISEASES OF THE OROPHARYNX 
243 
the abscess wall, which is punctured and a closed hemostat 
inserted and withdrawn opened. The cavity is then explored 
by the finger for necrosed bone and a drainage-tube inserted. 
Aneurysm has been mistaken for retropharyngeal abscess with 
fatal results following incision, so that it is important to 
arrive at a correct diagnosis before operating. 
Prognosis is favorable except in those cases where the spinal 
vertebrae are involved. In all operations upon the posterior 
wall of the pharynx it should be borne in mind that a large 
artery is occasionally found in this position, probably the verte- 
bral, which sometimes enters its osseofibrous canal as high 
up as the fourth or even second vertebra. It has been seen to 
leave its canal at the third vertebra, to re-enter it at the atlas. 
Tumors.-Any of the varieties of tumor found in other parts 
of the body may occur in the pharynx. They are most fre- 
quently located in the lateral walls and may involve the sur- 
rounding structures. In the following order of frequency there 
is found in the pharynx gumma, sarcoma, carcinoma, lupus, 
papilloma, cyst, fibroma, osteoma, enchondroma, adenoma, 
and aneurysm. 
Symptoms.-When the growth is large it may become an 
obstruction to deglutition or even respiration. In carcinoma 
and ulcerating lupus pain is present, which in many instances 
radiates into the ear. 
Treatment.-Except in the case of gumma, the treatment of 
which has been already described, early extirpation with the 
knife, galvanocautery, or snare should be practised. 
NEUROSES OF THE PHARYNX 
The more common neuroses of the pharynx are anesthesia, 
hyperesthesia, paresthesia, neuralgia, and paralysis, either uni- 
lateral or complete. 
Anesthesia is most often the result of hysteria. The pharyn- 
geal reflexes are abolished; there is a more or less complete loss 
of pharyngeal sensation when the parts are touched with a 244 
DISEASES OF THE NOSE, THROAT, AND EAR 
cotton-tipped probe. The condition is observed in cases of 
progressive bulbar paralysis and in the general paralysis of 
the insane. 
The treatment depends on the cause of the condition: in 
hysteria the strong galvanic or induced current with strychnin 
internally, possibly in increasing doses. 
Hyperesthesia is generally the result of some disease of the 
nose and nasopharynx that has rendered the secretions viscid 
and sticky, so that frequent hawking is necessary to dislodge 
them. The excessive use of tobacco, especially chewing- 
tobacco, will produce the condition. In some cases of hyper- 
esthesia of the pharynx the reflexes are increased to such an 
extent that barely touching the pharynx is sufficient to produce 
emesis. There is, of course, hyperesthesia of the pharynx in 
practically every case of pharyngitis. 
Treatment.-'Cessation of the excessive use of tobacco or 
cure of the nasopharyngeal catarrh that has produced the con- 
dition is ordinarily sufficient to reduce the hyperesthesia to 
normal and diminish the reflexes. Temporary relief is afforded 
by the administration of sodium bromid in doses of io or 15 
gr. three times a day. When the reflexes are not increased 
to an extent to produce vomiting whenever the pharynx is 
sprayed, the patient should spray his pharynx three or four 
times a day with an atomizer containing a | to 1 per cent, 
solution of sulphate of copper. 
Paresthesia is most frequently manifested as a sensation 
as of a small foreign body in the pharynx. This sensation 
and burning, itching, or tickling, as well as spasm of the 
pharyngeal muscles, the well-known "globus hysteriae," are 
not uncommon in hysteric females. However, in the larger 
proportion of these so-called hysteric cases some lesion will 
be found to account for the symptoms if the pharynx be care- 
fully inspected. The most common lesions are inflamed fol- 
licles or an erosion on the side of the pharynx, posterior to the 
posterior pillar, or in any other position where two folds of 
mucous membrane rub together in deglutition. DISEASES OF THE OROPHARYNX 
245 
Treatment.-The symptoms are usually quickly relieved by 
io or 15 gr. of bromid of sodium after meals and at bedtime. 
After relief has been secured by the use of the bromid, a general 
tonic treatment should be prescribed for building up the 
nervous system-rest, iron, quinin, phosphorus. Pil. sumbul 
comp., one or two after each meal, frequently yields very 
satisfactory results. When inflamed follicles or any erosion is 
found in a position where it is irritated by each movement of 
the pharyngeal muscles, it should be touched every day or 
two with a 12 per cent, solution of nitrate of silver. 
Paralysis of the Pharynx.-Etiology.-Paralysis of the 
pharynx may result from diphtheria or syphilis, or be the 
result of a cerebral affection involving the nerves that supply 
the pharyngeal muscles. Transient paralysis of the palate, 
either unilateral or bilateral, is common as the result of 
diphtheria; more rarely are the pharyngeal muscles also par- 
alyzed in severe cases. 
Pathology.-One or both sides of the pharynx may be in- 
volved, and one or all three of the pharyngeal constrictors be 
paralyzed, as well as the vellum palati; but paralysis of the 
soft palate, either unilateral or bilateral, occurs independently 
as a "reflex" in ethmoiditis. 
Symptoms.-Difficult deglutition; liquids being more easily 
swallowed than solids, but more frequently passing into the 
larynx; or, when the soft palate is also paralyzed, both solids 
and fluids may be forced into the posterior nares through the 
efforts of the tongue to assist deglutition. 
Treatment.-'The central cause of the affection should be 
carefully sought and treated. In suitable cases strychnin, in 
gradually increasing doses until the limit of toleration has been 
reached, will do good; while arsenic and tonics are especially 
valuable where the paralysis is of diphtheritic origin. 
Foreign bodies of two classes are found in the pharynx: 
First, those whose bulk does not allow them to pass through 
the esophagus, and second, sharp-pointed objects, like pins, 246 
DISEASES OF THE NOSE, THROAT, AND EAR 
needles, fish-bones, etc., that are forced into the pharyngeal 
walls by contraction of the constrictor muscles. 
Symptoms.-Large objects may cause death by holding 
down the epiglottis. Sharp-pointed objects cause a pricking 
sensation, sometimes felt at two places in the pharynx, as 
in the case of a pin or needle. Localized spots of inflammation, 
when situated low down upon the pharyngeal wall, give rise 
to the sensation of a foreign body, and this fact, as well as the 
imaginary foreign body of hysteric women, should be remem- 
bered after an unsuccessful search for a foreign substance in 
the pharynx. 
Treatment.-It is not always possible to use the laryngo- 
scope to advantage when the foreign body is situated low down 
in the pharynx, and in such cases the finger should be intro- 
duced into the pharynx, and if a foreign body be felt an effort 
should be made to scratch it loose with the finger-nail and 
withdraw it. When the offending substance can be seen, a 
pair of forceps, either straight or curved, according to its posi- 
tion, should be used to withdraw it. It should be remembered 
that after the removal of a foreign body sometimes a sensa- 
tion as of its presence remains for some days. 
DISEASES OF THE UVULA 
Inflammation of the uvula may occur primarily or as the 
result of extension of inflammation from the tonsils or palate. 
Occasionally it becomes edematous. The distention may be 
so great as to produce dyspnea. The treatment consists in 
cocainizing the uvula, seizing it with a pair of mouse-tooth 
forceps, and freely incising the mucous membrane in a number 
of places in order to allow the fluid to escape. The same object 
may be accofnplished sometimes more conveniently by snip- 
ping off the mucous membrane at the tip of the uvula. 
Pseudomembranous Uvulitis.-'The extension of a pseudo- 
membrane from the tonsils to the uvula is somewhat character- 
istic of diphtheria. However, this occurs in other forms of 
pseudomembranous pharyngitis. DISEASES OF THE OROPHARYNX 
247 
Treatment of Inflammation of the Uvula.-As inflammation 
of the uvula generally is only part of an inflammation involving 
the rest of the fauces, it is best to begin treatment by spraying 
the fauces with a i : 1000 solution of adrenalin; the uvula 
should then be painted with a xo per cent, solution of nitrate 
of silver. This should be done in the physician's office once 
or twice a day, the patient in the intervals either spraying his 
fauces every two or three hours with a i : 10,000 solution of 
adrenalin or a 3 per cent, solution of alumnol. 
Ulceration of the Uvula.-The uvula sometimes becomes 
ulcerated as the result of traumatism and infection. Syphilis, 
lupus, or tuberculosis may be primarily located in the uvula. 
The uvula is sometimes destroyed by an ulcerating gumma. 
Occasionally these cases are first seen by the laryngologist 
when the ulcer has made considerable progress and the uvula 
hangs, as it were, by a string of mucous membrane. Under 
these circumstances the uvula sometimes can be saved by the 
daily subcutaneous injection of bichlorid of mercury (Formula 
24), which, although painful, probably yields quicker results 
than other methods of treatment. Where an increasing 
gumma involves the posterior wall of the pharynx as well as 
the uvula and soft palate, there is great danger of cicatricial 
adhesions occurring that may entirely shut off communication 
between the posterior naris and oropharynx. 
Deformities of the Uvula.-Bifid Uvula.-The uvula when 
present is always bifid in cleft palate as the result of the same 
cause that produces the palate deformity. Hence, ordinary 
bifid uvula might be considered as an incomplete cleft palate. 
The deformity varies from a little dent at the free extremity 
of the uvula, which is usually club shaped, to a complete 
division separating the uvula into two lateral halves. 
Treatment.-Bifid uvula, when it causes no symptoms, is 
best let alone. However, the parts may be freshened by means 
of a V-shaped incision and sewed together. If the uvula is 
thoroughly cocainized and then sprayed with adrenalin, the 
operation is both painless and bloodless. For anesthetizing 248 
DISEASES OF THE NOSE, THROAT, AND EAR 
the uvula simply painting the parts with a io per cent, solu- 
tion of cocain is not sufficient. The operator should be pro- 
vided with a small cup at the end of a long handle. This is 
partly filled with a 4 per cent, solution of cocain and held 
under the palate in such a manner that the uvula soaks in 
the cocain solution for a few moments before the operation. 
Elongation of the Uvula.-The whole mass of the uvula 
may be hypertrophied. More frequently, however, merely 
the mucous membrane is relaxed and hangs as a conic tip be- 
low the uvula proper. In rare cases a warty growth is at- 
tached to the end of the elongated uvula. 
Etiology.-It is generally the result of chronic pharyngitis, 
the constant hawking to dislodge masses of mucus from the 
pharynx having a tendency to cause the affection. Paralysis 
of the palate is a reflex sometimes observed in ethmoiditis, and 
in such cases paralysis of the azygos uvulae muscles and conse- 
quent elongation of the uvula are concomitant with the 
affection. 
Symptoms.-Patients complain of a "tickling in their 
throats." The elongated uvula hanging in contact with the 
base of the tongue causes an almost constant short cough as an 
effort to dislodge a supposed foreign substance. These efforts 
are sometimes persisted in until nausea and vomiting result. 
Snoring is usually marked and the sleep is disturbed by dreams. 
Treatment.-The redundant portion of the uvula should be 
amputated. This is ordinarily only relaxed and redundant 
mucous membrane at the tip of the uvula. It is rarely or 
never necessary to remove any of the muscular structure of 
the organ, and amputation of the entire uvula close up to the 
soft palate is done only for the removal of malignant disease or 
as the result of the ignorance or awkwardness of the operator. 
The operation is perhaps best done in the following manner: 
The uvula is grasped at a point just below where it is decided to 
amputate with a pair of long hemostats, which are then 
clamped. The position of the hemostat marks the spot on the 
uvula where it has been decided to amputate, so that there is DISEASES OF THE OROPHARYNX 
249 
no danger of cutting off too much or too little. The uvula is 
stretched well forward and cut off close to the forceps by a 
single cut of a pair of somewhat heavy scissors, curved upon the 
flat, and held with their concavity upward in such a manner 
that the uvula is cut somewhat obliquely upward; and the 
wound, being upon the posterior surface, is protected from 
contact with food during the healing process. Generally there 
is but little inflammatory reaction and the wound heals 
promptly, but occasionally a mild acute pharyngitis occurs as 
the result of the operation when the uvula is thick and fleshy. THE LARYNX 
ANATOMY OF THE LARYNX 
The larynx is an expansion of the upper portion of the 
trachea, so that there is formed a musculocartilaginous mem- 
branous box constituting the essential organ of voice. It lies 
in front of the pharynx, of which it, with the base of the 
tongue, forms the lower anterior wall. Its superior aperture 
slopes downward and backward toward the pharynx and is 
partly closed from before backward during deglutition by a 
leaf-shaped lid, the epiglottis. The larynx is connected by 
ligaments and muscles with the surrounding tissues, the muscles 
serving to draw it upward during vocalization and deglutition. 
Cartilages.-The cartilages of the larynx are nine in number, 
three single and three in pairs: The thyroid, cricoid, and 
epiglottic cartilages, the arytenoid cartilages, the cartilages of 
Wrisberg, and those of Santorini. The shapes of these, their 
relative size, and their manner of articulation and relative 
position to the hyoid bone are shown in Figs. 102 and 103. 
The thyroid cartilage, so called from its resemblance in shape 
to a shield, is composed of two plates or wings, united in front 
at an angle in such a manner as to project forward beneath the 
skin of the throat as an elevation-the "Adam's apple." To 
its outer surface are attached the sternothyroid, thyrohyoid, 
and inferior constrictor muscles. To its inner surface are 
attached the epiglottis, the thyro-arytenoid, thyro-epiglot- 
tidean muscles, and the true and false vocal cords. The superior 
border of the cartilage curves backward from a median notch 
to the superior cornua or horns. To this border is attached 
the thyrohyoid membrane or ligament (Figs. 102, 103). The 
lower border gives attachment to the cricothyroid membrane 
250 ANATOMY OF THE LARYNX 
251 
or ligament in the median line, and on each side to the crico- 
thyroid muscles (Fig. 105). The posterior borders and superior 
and inferior horns give attachment to the stylo- and palato- 
pharyngeal muscles. To the apices of the superior cornua is 
attached the thyrohyoid ligament. The inferior cornua 
articulate with the cricoid cartilage. 
Fig. 102.-Articulations and ligaments of the larynx, anterior view: A, Hyoid 
bone, with a its greater, and a' its lesser cornua; 1-5. ligaments; 6, lateral cricoth- 
yroid articulation; 7, junction of cricoid and trachea (Testut). 
Fig. 103.-Articulations and ligaments of the larynx, posterior view: A, Hyoid; 
B, thyroid, with b and b' its cornua; C, cricoid; D, arytenoids; E, cartilages of 
Santorini; F, epiglottis; G, trachea; 1-6, ligaments; 2, opening for superior laryngeal 
artery; 7, junction of trachea and cricoid (Testut). 
Fig. 102 
Fig. 103 
The cricoid cartilage, so called from its seal-ring shape, lies 
below the thyroid with its seal or broad surface posteriorly; 
laterally it articulates with the inferior cornua of the thyroid 
by means of small articular facets, and on the superior border 
posteriorly are two other facets for articulation with the 
arytenoid cartilages. To its lateral surfaces are attached the 
crico-arytenoideus posticus muscles and the longitudinal fibers 252 
DISEASES OF THE NOSE, THROAT, AND EAR 
of the esophagus (Figs. 104, 105). To its upper border are 
attached the cricothyroid membrane and the crico-arytenoidei 
lateralis muscles; to its lower border a fibrous membrane 
connecting it with the upper ring of the trachea. 
Fig. 104.-Larynx with its muscles, posterior view:. I, Epiglottis; 2, cushion, 3, 
aryepiglottic ligament; 4, cartilage of Wrisberg; 5, cartilage of Santorini; 6, oblique 
arytenoid muscles; 7, transverse arytenoid muscle; 8, posterior crico-arytenoid 
muscle; 9, inferior cornu of thyroid cartilage; 10, cricoid cartilage; 11, posterior 
inferior cerato-cricoid ligament; 12, cartilaginous portion; 13, membranous portion 
of trachea (Stoerk). 
Fig. 105.-Larynx and its lateral muscles after removal of the left plate of the 
thyroid cartilage: 1, Thyroid cartilage; 2, thyro-epiglottic muscle; 3, cartilage of 
Wrisberg; 4, aryepiglottic muscle; 5, cartilage of Santorini; 6, oblique arytenoid 
muscles; 7, thyro-arytenoid muscle; 8, transverse arytenoid muscle; 9, processus 
muscularis of arytenoid cartilages; 10, lateral crico-arytenoid muscle; 11, posterior 
crico-arytenoid muscle; 12, cricothyroid membrane; 13, cricoid cartilage; 14, attach- 
ment of cricothyroid muscle; 15, articular surface for the inferior cornua of the 
thyroid cartilage; 16, cricotracheal ligament; 17, cartilages of trachea; 18, mem- 
branous part of trachea (Stoerk). 
Fig. 104 
Fig. 105 
The arytenoid, or "pitcher-shaped" cartilages, articulate 
with the upper posterior border of the cricoid (Figs. 102-105). 
To the anterior surface are attached the false vocal cords and 
thyro-arytenoideus muscles; at the anterior angle or vocal ANATOMY OF THE LARYNX 
253 
process are attached the true vocal cords and the thyro- 
arytenoideus muscles. To the posterior surface is attached 
the arytenoideus muscle. To the posterior angle, or processus 
muscularis (Fig. 107), are attached the crico-arytenoideus 
lateralis and posticus muscles (Figs. 104, 105). The median 
surfaces of the arytenoid cartilages are covered with mucous 
membrane and face each other; their apices articulate with 
the cartilages of Santorini. 
Cartilages of Santorini are two small cartilages at the apices 
of the arytenoid cartilages, to which are attached the aryteno- 
epiglottidean folds. 
Cartilages of Wrisberg are two little masses of cartilage 
contained in the aryteno-epiglottic folds. 
Fig. 106.-Diagram to illustrate the thyro-arytenoid muscles; the figure repre- 
sents a transverse section of the larynx through the bases of the arytenoid carti- 
lages: Ary, Arytenoid cartilage: p.m, processus muscularis; p.v, processus vocalis; 
Th, thyroid cartilage; c.v, vocal cords; Oe is placed in the esophagus; m.thy.ar.i, 
internal thyro-arytenoid muscle; m.thy.ar.e, external thyro-arytenoid muscle; 
m.lhy.ar.ep, part of the thyro-aryepiglottic muscle, cut more or less transversely; 
m.ar.t, transverse arytenoid muscle (Redrawn from Foster). 
Epiglottis.-The cartilage of the epiglottis is leaf shaped 
and attached by its apex to the thyroid's inner surface just 
below the median notch by the thyro-epiglottidean ligament 
(Figs. 102,103). The epiglottic cartilage is covered by mucous 
membrane. Its base is free and points backward from the 
root of the tongue, to which its anterior surface is attached 
by three glosso-epiglottic folds of mucous membrane, and to 
the hyoid bone by the hyo-epiglottic ligament. The lateral 254 
DISEASES OF THE NOSE, THROAT, AND EAR 
margins are connected with the arytenoid cartilages by the 
aryteno-epiglottic folds. Its posterior surface covers the 
superior aperture of the larynx when food passes down the 
pharynx. 
Ligaments.-The larynx has nineteen ligaments-three 
extrinsic, binding the larynx to the hyoid bone, and sixteen 
intrinsic, binding its various cartilages together. 
The extrinsic ligaments are the thyrohyoid membrane and 
two lateral ligaments (Figs. 102, 103). 
The intrinsic ligaments are the cricothyroid membrane, the 
cricothyroid capsular ligaments (two), crico-arytenoid liga- 
ments (two), crico-arytenoid capsular ligaments (two). In 
the false cords or ventricular bands the superior thyro-arytenoid 
ligaments (two). In the true vocal cords the inferior thyro- 
arytenoid ligaments (two), the hyo-epiglottic ligament, the 
thyro-epiglottic ligament, and the three glosso-epiglottic folds. 
Muscles.-There are four pairs of lateral muscles and one 
central muscle, the arytenoideus, which extends from the 
posterior surface and outer border of one arytenoid cartilage 
to the corresponding parts of the other. There are both 
oblique and transverse fibers, and the action of the muscle 
is to draw the arytenoids together and close the posterior 
portion of the chink of the glottis (Fig. 104). It is supplied 
by both the superior and recurrent laryngeal nerves. 
The four pairs of lateral muscles are: 
The crico-arytenoideus lateralis, extending from the pos- 
terior angle of the base of the arytenoid to the upper lateral 
border of the cricoid cartilage. This muscle rotates the ary- 
tenoid inward and, with its fellow of the opposite side, closes 
the glottis except for the posterior portion, closed as described 
above by the action of the arytenoideus, bringing the bases of 
the arytenoid cartilages together. The lateral crico-aryte- 
noideus are supplied by the recurrent laryngeal nerve. 
The cricothyroid, extending from the front and side of the 
cricoid cartilage to the lower and inner border of the thyroid 
(Fig. 106). The action of this muscle is to tilt the thyroid for- ANATOMY OF THE LARYNX 
255 
ward upon the cricoid and thus stretch and render tense the 
vocal cords. It is supplied by the superior laryngeal nerve. 
The crico-arytenoideus posticus extends from the posterior 
angle of the base of the arytenoids to the posterior portion of the 
cricoid (Figs. 104, 105). Its action is to rotate the arytenoids 
Fig. 107.-Vertical transverse section of the larynx: 1, Posterior face of epiglottis, 
with i', its cushion; 2, aryteno-epiglottic fold; 3, ventricular band, or false voca, 
cord; 4, true vocal cord; 5, central fossa of Merkel; 6, ventricle of larynx, with 6' 
its ascending pouch; 7, anterior portion of cricoid; 8, section of cricoid; 9, thyroid 
cut surface; 10, thyrohyoid membrane; 11, thyrohyoid muscle; 12, aryteno-epiglottic 
muscle; 13, thyro-arytenoid muscle, with 13', its inner division, contained in the 
vocal cord; 14, cricothyroid muscle; 15, subglottic portion of larynx; 16, cavity of 
the trachea (after Testut). 
outward and open the glottis while keeping the cords tense. 
It is supplied by the recurrent laryngeal nerve. 
The thyro-arytenoideus extends from the angle of the 
thyroid cartilage and the posterior surface of the cricothyroid 
membrane into the base and anterior surface of the arytenoid 
(Fig. 107). Its action is to shorten and relax the vocal cords 256 
DISEASES OF THE NOSE, THROAT, AND EAR 
bringing the thyroid and arytenoids closer together and to 
compress the sacculus laryngis. It is supplied by the recurrent 
laryngeal nerve. 
The action of the intrinsic muscles may be studied by refer- 
ence in Fig. 98 and the other figures illustrating the anatomy of 
the muscles of the larynx. Briefly, the chink of the glottis is 
closed by the action of the arytenoideus and the crico-aryte- 
noideus lateralis. The cords are tightened and made tense by 
the action of the cricothyroid. The cords are relaxed by the 
action of the crico-arytenoideus and separated by the action 
of the crico-arytenoideus posticus. The study of the action 
of the muscles of the larynx may also be facilitated by inspect- 
ing the figures illustrating laryngeal paralysis (Figs. 121-128). 
The muscles of the epiglottis are three double muscles, all 
supplied by the recurrent laryngeal nerves. Their action is to 
depress the epiglottis and compress the sacculus laryngis. 
The epiglottic muscles are the thyro-epiglottideus, between the 
inner surface of the thyroid and the epiglottis and aryteno- 
epiglottic folds; the aryteno-epiglottideus superior, between 
the apices of the arytenoids to the aryteno-epiglottidean fold; 
and the aryteno-epiglottideus inferior, from the arytenoid 
cartilage just above the ventricular bands to the sacculus 
laryngis. 
The vocal cords, sometimes called the true vocal cords, in 
contradistinction to the/u^e vocal cords or ventricular bands, 
extend anteroposteriorly across the larynx from the angle of 
the thyroid cartilage to the anterior angle of the arytenoids 
(Figs. 103-106). They each consist of a fold of mucous mem- 
brane containing the inferior thyro-arytenoideus ligament 
with the thyro-arytenoideus muscle parallel to it (Fig. 107). 
The ventricular bands are two folds of mucous membrane 
containing the superior thyro-arytenoid ligament extending 
across the larynx above the ventricles of the larynx (Fig. 107). 
The glottis, or rima glottidis, sometimes called the chink 
of the glottis, is the space between the vocal cords. When 
the cords are separated during forced inspiration it is triangular ANATOMY OF THE LARYNX 
257 
in shape, with the apex of the triangle anterior. Its length 
rarely is i inch in the male, and its width posteriorly during 
inspiration does not exceed | inch. 
The ventricles of the larynx are oval depressions between the 
ventricular bands and the cords leading upward toward the 
sacculus laryngis. 
The sacculus laryngis is the upper portion of the ventricle of 
the larynx. It contains sixty or seventy small mucous glands, 
whose secretion lubricates the cords. It is of conic shape and 
is covered by the aryepiglottideus inferior muscle medianly 
and the thyro-epiglottic muscle laterally. Both muscles by 
their action compress it and expel its contents (Fig. 107). 
The mucous membrane of the larynx is somewhat thin. It 
is covered with ciliated columnar epithelium below the level of 
the ventricular bands, extending up in front as high as the 
center of the epiglottis. Over the rest of the mucous mem- 
brane of the larynx is stratified squamous epithelium. 
The abrupt change in the character of the epithelium of the 
larynx probably accounts for the rarity of infection of the 
pharynx extending into the lower air-passages; as it is a well- 
established fact that infections of mucous membranes generally 
respect anatomic boundaries when the character of the 
epithelium covering suddenly changes. 
The arteries of the larynx are the laryngeal branches of the 
superior and inferior thyroid. The most important of these 
from an operative standpoint is the cricothyroid, which extends 
transversely across the cricothyroid membrane to anastomose 
with its fellow of the opposite side. This artery is seldom large 
enough to require ligation in deliberate operating.. However, 
in emergency cases, where it is necessary to open the cricothy- 
roid membrane as quickly as possible, it is better to cut the 
cricothyroid membrane transversely in order to avoid wound- 
ing this vessel. 
The veins empty into the superior, middle, and inferior 
thyroid veins. Ordinarily these are vessels of small size, but 258 
DISEASES OF THE NOSE, THROAT, AND EAR 
in obstructed respiration from stenosis their size is greatly 
increased. 
The nerves of the larynx are the superior and recurrent 
branches of the pneumogas trie joined by branches of the spinal 
accessory and the sympathetic. The superior laryngeal is 
mainly a nerve of sensation. It enters the larynx through an 
opening in the thyrohyoid membrane and supplies the mucous 
membrane, the cricothyroid, and arytenoideus muscles. 
The recurrent laryngeal is a motor nerve. It winds from 
before backward around the subclavian artery on the right side 
and around the arch of the aorta on the left side, and supplies 
all the laryngeal muscles except the cricothyroid. In its course 
it gives off cardiac esophageal, tracheal, and pharyngeal fila- 
ments. It anastomoses with the superior laryngeal. 
Aneurysm of the aorta or subclavian pressing on the recur- 
rent laryngeal nerve produces characteristic paralysis of the 
laryngeal muscles, and the same is true of hypertrophied or 
tubercular lymphatics in the mediastinum or in the neck. 
The size of the larynx varies greatly, being much larger in 
males than in females and children. At the age of puberty in 
boys the voice undergoes a rapid change in character and pitch. 
During this period of change the mucous membrane of the 
larynx is usually at least somewhat congested, and occasionally 
individuals are unable to control the pitch of their voices to 
the extent that they will begin a sentence in a high-pitched 
voice and end it in a bass voice or the reverse. 
Musical notes used in singing have a range of about 3I 
octaves, and voices are classified according to their position in 
the musical scale into soprano, mezzosoprano, contralto, tenor, 
baritone, and bass. Soprano, mezzosoprano, and contralto 
voices are usually found in women, while the male voice is 
usually either tenor, baritone, or bass. Voice production is 
the result of the vibration of the vocal cords amplified by the 
resonant cavities above; that is, the pharynx, the mouth, the 
nose; in the same manner that the sound of a tuning-fork is 
amplified and made many times louder by approaching the ANATOMY OF THE LARYNX 
259 
vibrating fork toward the opening in a wide-mouthed bottle 
of a sufficient depth to contain a column of air capable of 
vibration in unison with the fork. The sound produced by 
the vibrations of the vocal cords is feeble and practically in- 
audible until it is amplified and made loud by the vibration of 
the air in the mouth, pharynx, and nose. The size of this 
cavity can be greatly reduced by the contraction of the palate, 
shutting off the cavity of the nose and nasopharynx from the 
space below, and the size and shape of the cavity of the mouth 
and oropharynx can be changed by the action of the muscles 
of the tongue and pharynx; so that it is possible to produce a 
space containing a volume of air capable of vibrating in unison 
with and amplifying a sound of any pitch produced by the 
vibration of the vocal cords. The larynx possesses the char- 
acteristics of both reed and string musical instruments. The 
pitch of a sound produced by the vibration of the vocal cords 
depends upon their length, thickness, and tension. What 
is called the falsetto voice is the result of the cords vibrating, 
not as a whole, but in two or more segments. The resulting 
sound is high pitched, far above the natural range of the 
individual's voice, and possessing a timbre or character usually 
disagreeable. Voices differ greatly in range, that is, some 
individuals have no more than a few notes of the musical 
scale, while others have 2 and even 2| octaves at their com- 
mand, and above the natural range of their voices a falsetto 
voice, also of considerable range. 
Musical notes have three qualities-loudness, pitch, and 
timbre or character. We have already learned how loudness 
of voice is the result of the amplification of the sound pro- 
duced by the resonant cavities of the mouth, pharynx, and nose. 
The loudness also is dependent on the force and amplitude of 
the vibrations of the vocal cords. 
The timbre or character of the voice is as varied as the dis- 
positions of individuals. It is that quality by which we recog- 
nize the voice of an individual as different from all other 
individuals. In singers the timbre of the voice may be sweet 260 
DISEASES OF THE NOSE, THROAT, AND EAR 
and pleasant or rough, coarse, and unpleasant. It may be 
nasal, from the presence of adenoids or other growths that 
render the use of the nose as a resonant pavity impossible. 
Timbre of the voice is probably the result of the relative size 
and shape of the resonant cavities, the position of the teeth and 
lips, and the thousand and one anatomic peculiarities of an 
individual's vocal organs. In this connection it is well enough 
to insert a word of caution as to the impropriety of suddenly 
greatly altering the size or shape of the upper respiratory tract, 
as, for example, by the ablation of very greatly hypertrophied 
tonsils in the case of professional singers, for fear that the 
character of their voice may be changed for the worse rather 
than the better. 
The singing voice differs from the speaking voice mainly that 
in singing the tone is sustained at the same pitch for an ap- 
preciable length of time, while in speaking the voice is continu- 
ally sliding up and down the musical scale on the vowel sounds. 
(See Acoustics, p. 330.) 
DISEASES OF THE LARYNX 
Anemia--The presence of laryngeal anemia is of especial 
importance: (i) When associated with functional aphonia. (2) 
When, during the course of an attack of chronic laryngitis, the 
mucous membrane covering the aryepiglottic folds, arytenoid 
cartilages, and ventricular bands is abnormally pale while the 
vocal cords are the seat of indolent congestion, the patient 
not being generally anemic. Each of the above conditions is 
premonitory of laryngeal phthisis. 
Hyperemia of the larynx is a congestion of the mucous mem- 
brane of the larynx, most marked where the submucosa is 
loose, fat, and thick, as upon the aryepiglottic folds, ventricu- 
lar bands, and ventricles; the epiglottis, vocal cords, and 
inferior cavity of the larynx being but little altered in color. 
Its presence renders an individual more prone to contract 
acute or chronic laryngitis. DISEASES OF THE LARYNX 
261 
Etiology.-Hyperemia of the larynx is oftenest the result of 
excessive smoking, especially of cigarette smoking. It also re- 
sults from working in dusty rooms and amid irritating chemic 
fumes. 
Acute laryngitis is an acute inflammation of the mucous 
membrane of the larynx, sometimes extending to the sub- 
mucous tissue and muscles. 
Etiology.-Acute laryngitis is generally the result of exposure 
to wet and cold, it being in many instances simply an extension 
of an ordinary coryza downward. Many individuals have an 
hereditary or acquired tendency toward laryngeal inflamma- 
tions. The affection also occurs as a complication in measles, 
variola, scarlatina, typhoid, rbtheln, and chicken-pox, and also 
Fig. 108.-Laryngitis 
involving chiefly the false 
cords as the cause of false 
croup (Friihwald). 
Fig. 109.-Swelling be- 
low the vocal cords from 
laryngitis hypoglottica 
chronica (after Ziemssen). 
as the result of traumatism, such as the inhalation of steam or 
irritating vapors. When acute laryngitis results from trau- 
matism, the inflammation frequently assumes the edematous 
form of the disease, while in children the croupous form is 
frequently met with. 
Symptoms.-The voice in almost all cases, becomes al- 
most aphonic, and its use extremely fatiguing and sometimes 
painful. In adults the respiration is generally unembarrassed, 
embarrassed respiration indicating that the inflammation is 
assuming the character of edema. In children, on the contrary, 
embarrassed respiration is often the first symptom, assuming 
the spasmodic character of croup. The expectoration in 
adults is at first clear, frothy, mucopurulent, but somewhat 
scanty, abundant expectoration indicating that the disease 262 
DISEASES OF THE NOSE, THROAT, AND EAR 
has extended to the bronchi. Expectoration in children being 
always very scanty probably explains why the paroxysms of 
dyspnea are so severe and prolonged, the pain, tickling, and 
sense of tightness in the throat being in them more severe. 
The color of the mucous membrane of the larynx as seen in 
the laryngoscope is always heightened, but varies in different 
parts of the larynx and according to the degree of the in- 
flammation, the cords in slight attacks being quite white, while 
in severe attacks they are so red as to be scarcely distinguished 
from the surrounding parts. The ventricular bands are also 
sometimes so swollen as to entirely cover the vocal cords or 
the cords may be prevented from approximation by swelling 
of the posterior glottic commissure. 
Treatment.-It is well to begin with the administration of a 
saline cathartic. The patient should remain in a warm room, 
avoid using his voice, and draw into the larynx every two 
hours the spray from an atomizer containing a i : 10,000 solu- 
tion of adrenalin. This is readily done by the patient inserting 
the nozzle of an atomizer in his mouth and inhaling deeply 
as he presses the bulb of the atomizer. The patient will feel 
the spray enter his larynx and should continue the use of the 
atomizer until the laryngeal mucous membrane is well covered 
by the spray. An application should be made to the interior 
of the larynx once or twice each day of a sedative and slightly 
astringent powder (Formula 120) by means of a powder- 
blower (Fig. 34). In making such an application to the in- 
terior of the larynx the patient is requested to grasp the tip 
of his tongue with a napkin and hold the tongue well forward. 
The operator, holding the laryngeal mirror in his left hand, 
introduces the mirror into the fauces in such a manner that he 
sees the reflected image of the glottis. The powder-blower 
should be held in the operator's right hand, and its nozzle is 
placed in the pharynx in such a position that it is seen reflected 
in the laryngeal mirror, and moved until it is observed to point 
toward the glottis. The patient is requested to say "a," 
and at the same instant the powder should be blown from the DISEASES OF THE LARYNX 
263 
powder-blower into the larynx. When an individual says 
"a" or, indeed, makes any other sound with his vocal organs, 
the cords are brought together in order to produce it, so that 
any application made at that instant is limited to the part of 
the larynx above the cords. Should it be deemed necessary to 
apply the powder to the larynx below the cords, it may be 
accomplished by using the powder-blower while the patient 
holds his breath, or the powder may be carried deep into the 
bronchi if the powder-blower be used while the patient is 
inspiring. After the more acute stage of the disease has passed, 
Formula 118 or even 117 should be used instead of Formula 120 
as an application to the interior of the larynx. In the more 
severe cases, powders of any kind are not well borne, and under 
such circumstances sprays of cocain, adrenalin, and menthol- 
camphor-albolene should be employed. 
The application of cold or heat to the skin over the larynx 
gives decided relief in the more severe cases. As to the 
selection of heat or cold, the sensations of the patient would 
seem to be the best guide. In the writer's experience heat is 
usually the more grateful. Cold may be applied by means 
of a Leiter coil, a small ice-bag, or a napkin wrung out of ice- 
water and applied to the neck over the larynx. It should be 
changed sufficiently often to maintain the degree of cold 
desired. 
Heat may be utilized by applying a Leiter coil upon the skin 
over the larynx in the usual manner and allowing hot water to 
flow through the coil. A folded napkin should be placed under 
the coil to protect the skin, and the temperature of the water 
should be as high as can be borne comfortably by the patient. 
The more severe forms of acute laryngitis, fortunately rare, 
will require careful watching, and the physician should be 
prepared to prevent suffocation from edema by scarifying the 
epiglottis or, if necessary, by intubation or tracheotomy. 
Subacute laryngitis is an inflammation of the mucous mem- 
brane of the larynx less severe than the acute. 
Etiology.--Subacute laryngitis commonly results from the 264 
DISEASES OF THE NOSE, THROAT, AND EAR 
same causes as the acute form of the disease. It generally 
attacks individuals of feeble constitution or it may result from 
neglecting to treat properly the acute affection. Usually 
slight dyspnea and hoarseness are prominent symptoms. The 
former, generally worse at night, sometimes occasions the 
patient alarm. Feeble individuals, especially children who 
spend most of their lives indoors, are more liable to attacks of 
this disease than the robust and those who are much outdoors. 
A frequent predisposing cause is the admixture of the products 
of combustion with the hot air supplied from furnaces. A care- 
ful supervision of the workman each fall when the furnace is 
put in order for the winter, to make sure that the parts of the 
fire-box are fitted too tightly to allow any escape of carbon- 
dioxide gas into the hot-air chamber, will sometimes prevent 
every member of the household suffering from recurrent 
attacks of sore throat during winter. 
Dusty occupations and the frequent inhalation of irritating 
fumes produce chronic laryngitis and acute exacerbations of the 
inflammation. By far the most common cause is exposure to 
cold. However, it is not usually normal respiration of cold air 
that is responsible for attacks of acute laryngitis, because as 
long as the nose is normal the air inspired through it is moistened 
and its temperature raised sufficiently to render it harmless to 
the larynx. This is not the case in individuals whose noses 
are sufficiently abnormal to necessitate mouth-breathing, and 
it is somewhat curious to note in this connection that during 
the first few years of a chronic nasal catarrh each cold is essen- 
tially nasal; but in the later stages of the disease the brunt of 
such attacks is borne by the larynx and trachea. This is 
probably not due to an extension of the catarrhal disease by 
continuity of surface, but to increasing hypertrophy of the 
turbinated bodies, rendering the individual a mouth-breather 
as soon as he inhales cold air. Many individuals take cold 
through their feet. The ground is a better conductor of heat 
than the atmosphere and, therefore, the soles of the shoes 
should be of heavy material. The shoes should be loose DISEASES OF THE LARYNX 
265 
about the ankles, so as not to impede the circulation, and so 
constructed as not to prevent the evaporation of moisture. A 
dentist friend and patient informed the author that he suffered 
for years with cold feet until he adopted the plan of wearing 
low shoes the entire year. During the winter his woolen 
underdrawers were made long enough to extend over the 
ankles and protect them. He wore cotton or light wool 
stockings. 
Treatment.-The treatment is similar to that of acute laryn- 
gitis. A most important part of the treatment of acute laryn- 
gitis is rest, especially of the inflamed larynx. All unnecessary 
talking should be avoided and no effort made to talk above a 
whisper. In the case of singers, orators, and actors, where it is 
of the utmost importance that a normal voice should be re- 
gained as speedily as possible, absolute rest in bed in a warm 
room will do much to hasten the desired result; | gr. of calomel 
with 5 gr. of bicarbonate of sodium should be given every hour 
until six doses have been taken or the bowels freely moved. 
If the attack is of sufficient severity to cause some elevation 
of temperature and a hot, dry skin, i-drop doses of tincture 
of aconite root should be given every fifteen minutes until 
three or four doses have been taken, and then every hour 
until the skin has become moist. Of the other internal 
remedies, yerba santa usually yields the most speedy and 
satisfactory results, especially in cases accompanied by fever 
and a hot, dry skin. A pill containing i or 2 gr. of the extract 
combined with gr. of strychnin should be given every two 
hours. The patient should inhale the spray from an atomizer 
containing a 1:10,000 solution of adrenalin every one or two 
hours. 
Cocain and antipyrin have sedative and astringent effects 
upon the inflamed mucous membrane of the larynx. The 
application of the former gives relief for only half an hour, and 
is followed by increased congestion. The effect of cocain can 
be maintained by frequent instillation of the drug or by fol- 
lowing its use by a spray of antipyrin, which will maintain the 266 
DISEASES OF THE NOSE, THROAT, AND EAR 
local sedative effects of the cocain in many instances for from 
two to four hours. 
After the more acute stages of the disease have passed, and 
in the milder attacks of hoarseness affecting singers, mineral 
astringents yield better results than adrenalin, and the spray 
from an atomizer containing a 2 to 4 per cent, solution of a 
alumnol may be inhaled by the patient every hour or two with 
decided advantage. In singers and actors with slight laryn- 
gitis the neurotic element plays an important part and voice 
failure when on the stage is largely due to nervousness and fear. 
Under such circumstances a pill containing gr- of strychnin 
or a teaspoonful of the fluidextract of coca in a glass of sherry 
wine, taken immediately before the curtain rises, will do much 
to secure a satisfactory control of the voice during the perfor- 
mance. 
Chronic laryngitis is a chronic inflammation of the mucous 
membrane of the larynx. 
Etiology.-It is generally the result of faulty use of the voice 
by singers or public speakers, and also of excessive smoking, 
especially cigarette smoking. The smoking of cigarettes is 
particularly injurious, not on account of the paper wrappers 
or any peculiarity of tobacco, but from the habit all cigarette 
smokers soon acquire of inhaling the smoke and bringing it 
directly into contact with the sensitive mucous membrane of 
the larynx. It is the very "mildness" of the smoke from 
cigarettes, in comparison with cigar smoke or that of a pipe, 
that makes them more injurious. The convenience and cheap- 
ness of cigarettes also causes the cigarette smoker to light a 
cigarette whenever he has a few moments to spare and under 
circumstances when he would not think of smoking a cigar or 
a pipe, the ill effects of which are generally confined to the 
pharynx. Dusty occupations and the frequent drinking of 
undiluted distilled liquors are also causes of the disease, while 
the affection is sometimes simply the expression of the rheu- 
matic diathesis. The presence of tumors inside the larynx 
usually is the result rather than the cause of chronic laryngitis. DISEASES OF THE LARYNX 
267 
Symptoms.-The voice, as a rule, is chronically hoarse, but 
the degree of hoarseness varies materially from time to time. 
In singers the injury to the voice will be manifested in loss of 
range, diminished endurance, and loss of control. As the dis- 
ease advances, all vocal efforts will be obviously strained and 
labored. Cough is by no means a constant symptom. The 
secretion is at no time very great in amount and diminishes as 
the disease advances. It is thick, starch-like, and tenacious. 
Small amounts of mucus frequently collect in the interary- 
tenoid space and, being suddenly detached by coughing, are 
thrown out through the mouth to a considerable distance, 
while little bridges of mucus are sometimes seen with the laryn- 
goscope extending from cord to cord. There is a constant 
feeling of constriction, as of a foreign body in the air-passages. 
Upon inspection certain portions of the mucous membrane of 
the larynx appear redder than normal; and sometimes the 
entire mucous membrane of the larynx is of a uniform red color, 
with the exception of the cords, which may be somewhat 
lighter in color than the surrounding parts. The mobility of 
the cords is frequently impaired, either from swelling of the mu- 
cous membrane covering the arytenoids or from slight muscular 
pain. Erosion of the interarytenoid space is frequently seen. 
Prognosis.-Recovery from chronic laryngitis is always slow, 
and depends upon the faithfulness with which the treatment is 
carried out. 
Treatment.-'Constitutional remedies, except in rheumatism 
of the larynx, are not of the greatest importance; but, as in 
every other chronic affection, the general health should be im- 
proved as much as possible. Local treatment consists of the 
application by the patient several times a day to the affected 
mucous membrane of a sedative or astringent solution by 
means of the spray of an atomizer, a 4 per cent, solution of 
alumnol being especially useful for this purpose. 
As an office treatment, applications of argyrol (10 per cent.) 
twice a week sometimes yield excellent results, and the occasional 
application of nitrate of silver solution in obstinate cases is 268 
DISEASES OF THE NOSE, THROAT, AND EAR 
very beneficial. The use of the remedy requires some care, 
and a very little of the solution should be used until it is ascer- 
tained that its use is not followed by spasm of the glottis. 
Most larynxes will stand the application of a cotton-tipped 
applicator dripping with a 2 per cent, solution of silver nitrate, 
and 10 per cent, solutions can be employed cautiously. The 
unusually slight irritation produced by the application of 
even the weaker solutions sometimes lasts for several hours, but 
is followed by decided relief of hoarseness and congestion of 
the parts. 
In the more severe cases pain, congestion, and hoarseness 
are sometimes quickly relieved by the insufflation of powdered 
orthoform or antipyrin. A milder astringent powder consists 
of 1 part of alumnol and 2 parts of milk-sugar. It may be used 
with good effect in all cases of chronic laryngeal congestion. 
Sulphate of zinc (from 15 gr. to 1 ounce of milk-sugar up to 
equal parts of sulphate of zinc and milk-sugar) yields good 
results in some cases. 
Laryngitis Sicca.-Is the result of atrophy of the glandular 
elements of the mucous membrane. The disease is generally 
associated with atrophic rhinitis and pharyngitis. 
Pathology.-The appearance of the laryngeal mucous mem- 
brane is similar to that of the nose and pharynx in atrophic rhi- 
nitis and pharyngitis. In some cases the parts are simply dry 
and glazed, looking as if varnished; in other cases there are 
accumulations of inspissated mucus, often greenish in color and 
emitting an offensive odor, similar to that observed in atrophic 
rhinitis. The gross structural alterations that are seen in the 
nose in atrophic rhinitis are not observed in atrophic laryngitis. 
It is a disease characterized by diminished and perverted 
secretions rather than by atrophy of mucous membrane, sub- 
mucous structures, and laryngeal cartilage. The masses of 
inspissated secretions cling to portions of the larynx where 
the glands are most numerous-the subglottic region and the 
upper surface of the ventricular bands. 
Symptoms.-In cases where there are no accumulations the DISEASES OF THE LARYNX 
269 
larynx feels dry and irritated. The voice is slightly hoarse and 
tires upon the slightest exertion. In cases characterized by 
accumulation of fetid secretions the sufferings of the patient are 
mainly due to the irritation produced by the presence of these 
secretions and by the effort to rid himself of them. His 
strength is exhausted by ceaseless and useless coughing, usually 
worse at night. Occasionally a little mass will be ejected from 
the larynx with considerable violence, bringing with it a small 
area of laryngeal epithelium, and producing a slight capillary 
hemorrhage which alarms the patient. In a few cases which 
the writer has seen-for the disease is somewhat rare-the 
patients were fairly Well nourished. 
Treatment.-In cases where the disease is the result of 
atrophic rhinitis, efforts should be directed toward improving 
the condition of the nose, so that the important function of 
warming and moistening the inspired air is restored. The 
wearing of cylinders of absorbent cotten within the nose, as 
directed for the treatment of atrophic rhinitis, is also valuable 
in bringing about an improved condition of the laryngeal 
secretions. 
Patients with atrophic rhinitis do well in a moist climate. In 
one case all laryngeal symptoms had disappeared upon the 
return of the patient to Philadelphia after a year's absence in 
the Philippines. Internally may be given stimulating ex- 
pectorants or drugs, such as iodid of potassium and hydriodic 
acid, that increase the secretions of the upper respiratory tract 
and render them more fluid. 
Inhalations of steam or the use of the bottle-inhaler with hot 
water and tincture of benzoin aid greatly the patient's efforts to 
get rid of the annoying laryngeal accumulations. Great relief 
sometimes follows spraying the larynx with equal parts of 
hydrogen dioxid and Dobell's solution, because the action of 
the dioxid upon the accumulations softens them and increases 
their bulk, and hence aids their explusion horn the larynx. 
The irritation of the larynx is best controlled by spraying the 
parts with a 2 per cent, solution of antipyrin. 270 
DISEASES OF THE NOSE, THROAT, AND EAR 
Inflammation of the Submucous Tissue of the Larynx.- 
Acute edema of the larynx usually is the result of phlegmonous 
inflammation with infiltration of the surrounding submucous 
tissue, frequently endangering life by occlusion of the rima 
glottidis. 
Etiology.-Edema of the glottis may result from traumatism, 
such as the swallowing of corrosive liquids. It occurs rarely as 
a primary affection, resulting from exposure to cold and wet in 
persons of debilitated constitution and also as a neurosis. In 
most instances, however, the disease is secondary, and results 
from syphilitic or tuberculous peri- 
chondritis (Fig. no), retropharyn- 
geal abscess, Bright's disease, gly- 
cosuria, etc. 
Pathology.-The infiltration con- 
sists essentially of a serous or sero- 
purulent fluid, most abundant be- 
neath the mucous membrane of the 
aryepiglottic folds, the ventricular 
bands, and the ventricles. The 
submucous tissue is most abundant in those regions of the 
larynx, but the edema is not always limited to that part of 
the larynx above the vocal cords, but may extend to the sub- 
mucous tissue beneath the vocal cords. Infraglottic edema, 
as the disease is then called, is almost invariably secondary in 
its origin and always serous in character (Fig. 109). 
Symptoms.-In some cases there are no symptoms whatever 
prior to a fatal suffocation or syncope. The voice is usually 
rough and deep or altogether lost, due to thickening and 
heaviness of the cords. In the early stages of an attack the 
chief difficulty in breathing is during inspiration, but, as the 
disease advances respiratory distress increases, with the result 
of producing complete apnea. A short cough is present and 
deglutition is both difficult and painful. When the edema is 
considerable the sense of suffocation is most oppressive. With 
the laryngoscope edema is quickly recognized, the infiltrated 
Fig. no.-Phlegmonous laryn- 
gitis, with phthisic ulcer: a, Epi- 
glottis; b, left aryepiglottic fold; c, 
left pyriform sinus (from v. 
Ziemssen, after Turek). DISEASES OF THE LARYNX 
271 
portion of the larynx being greatly swollen and semitrans- 
parent in appearance. When the edema is subglottic, the 
swollen mucous membrane of that region will almost always 
be seen of a more intense red than the cords above. 
Prognosis.-Recovery from severe primary edema is always 
doubtful, and the prognosis in secondary edema depends upon 
the circumstances of the primary cause of the disease. The 
patient can hardly be said to be out 
of danger under two or three weeks 
from the commencement of an at- 
tack, and may even then become the 
subject of chronic infiltration. When 
death occurs it is almost always the 
result of carbonic-acid poisoning, and 
may be the direct effect of stenosis 
or spasm of the glottis. Another 
danger is the possible occurrence of 
suppuration-abscess of the larynx. 
T reatment.-F ree diaphoresis 
should be produced in suitable cases 
by the hypodermic use of to | gr. 
of pilocarpin or free catharsis with 
croton oil. The temperature of the 
room in which the patient lies should 
be carefully regulated, and cold, dry 
applications kept upon the throat 
over the larynx. As soon as edema 
is seen within the larynx, local scari- 
fication with the laryngeal lancet (Fig. in) should be per- 
formed. If, in spite of scarification and the use of pilocarpin, 
edema continues, with increasing respiratory distress, general 
enfeeblement, and symptoms of carbonic-acid poisoning, in- 
tubation or tracheotomy should be performed at once. Many 
lives probably have been sacrificed by hesitation and delay. 
Laryngitis syphilitica is an inflammation of the larynx due 
to syphilis. 
a 
b 
c 
d 
e 
f 
g 
b 
i 
j 
1 
Fig. hi.-Heryng's laryngeal 
lancets, knives and curettes. 272 
DISEASES OF THE NOSE, THROAT, AND EAR 
Etiology.-'Syphilis of the larynx most frequently occurs as 
a manifestation of the tertiary period, three to many years 
after the primary infection. As a manifestation of secondary 
syphilis laryngeal symptoms may oc- 
cur within a few weeks or may not 
appear until two or three years after 
syphilis has been contracted. 
Pathology.-In secondary syphilis 
the laryngeal symptoms may consist 
of a mere hyperemia, giving rise to 
the symptoms of simple laryngitis. 
Ulcerations may also be present and 
are usually symmetric, that is, if an 
ulcer is present upon one part of the 
larynx, there is usually a similar ulcer 
also upon the corresponding part of 
the opposite side of the larynx. 
Syphilitic warts or condylomata also 
are found in the larynx during the 
secondary stage of syphilis. They 
may undergo ulceration or disappear 
spontaneously. Tertiary manifesta- 
tion consists of gumma, which may 
break down and cause deep ulcera- 
tions, with perichondrosis and necro- 
sis of the cartilages; while stenosis 
may result from cicatricial contrac- 
tion after the healing of syphilitic 
ulcers. 
Symptoms.-The patient usually 
first complains of a slight hacking 
cough, hoarseness, and sometimes 
difficult and painful deglutition. Inspection with the laryn- 
goscope reveals some of the lesions already specified. 
Treatment.-Constitutional remedies already mentioned 
(see Syphilitic Rhinitis) should be employed. Alumnol or 
Fig. i 12.-Browne's hollow 
laryngeal dilator with cutting 
blade (| measurement). DISEASES OF THE LARYNX 
273 
some other astringent should be prescribed for the patient's 
use at home, in the same manner as for simple laryngitis, 
while an application of Formula 119 should be made to the 
interior of the larynx every other day with the powder-blower. 
If shallow ulcers are present they should be touched each day 
with 12 per cent, nitrate of silver solution. After a time, when 
the process of repair is beginning to set in, these applications 
become painful and should be omitted, but insufflations of 
Formula 119 should be continued until the larynx presents 
its normal appearance. Should partial stenosis occur as the 
result of cicatricial contraction, the laryngeal stenosis may be 
Fig. 113.-A, Cicatricial stenosis before treatment; B, the same after use of cutting 
dilator (Lennox Browne). 
overcome by the use of laryngeal bougies or some suitable 
cutting instrument (Fig. 112). 
Tubercular Laryngitis.-'Tubercular laryngitis is a chronic 
laryngitis due to the presence of the tubercle bacilli. 
Etiology.-It is generally secondary to pneumonic phthisis. 
In most all instances the cellular tissue of the larynx is the 
structure first affected. The inoculation in this locality may 
occur through the lymph-channels, the blood-vessels, or by 
means of an abrasion in the mucous membrane exposed to 
tuberculous sputum from the lungs. Inoculation of tuber- 
culosis in syphilitic ulcers in the larynx has been observed, 
and it is stated that the presence of simple catarrhal laryn- 
gitis, either acute or chronic, is a predisposing cause of tuber- 
culous laryngitis when tuberculosis of the lungs is already 
present. Hospital reports, mostly German, vary from 6 to 274 
DISEASES OF THE NOSE, THROAT, AND EAR 
50 per cent, as to the frequency of laryngeal involvement in 
postmortems on individuals dead from pneumonic phthisis. 
Probably about one-third of the cases of lung consumption in 
this country, sooner or later, develop laryngeal lesions. That 
the larynx is not frequently inoculated by the inspiration of 
pulverized dried phthisic sputum is probably due to the fact 
that under ordinary circumstances particles of dust in inspired 
air are arrested within the nose or pharynx and do not reach 
the larynx; and in this connection it is interesting to note that 
those suffering from atrophic rhinitis are proportionately more 
frequently attacked by pneumonic phthisis than those with 
normal noses. More frequently tuberculous lesions of the 
larynx occur on the same side as the lung most affected by the 
disease, although this is not invariably the case. 
Pathology.--The lesions in the larynx are similar to those 
found in tuberculosis elsewhere: Tubercles are formed and the 
bacilli are disseminated into the surrounding tissues, partly 
by their own multiplication and partly by lymph-currents, so 
that the extent of the tissue involvement is always much 
greater than it appears to the eye of the observer. As the 
result of nature's efforts to limit the spread of the affection, 
leukocytes appear about the affected area and a reticulum of 
connective tissue is formed. Degeneration of the tubercle 
then occurs as the result of lack of nutrition, and manifests 
itself as a tissue necrosis, with an ulcer that may involve not 
only the mucous membrane and cellular tissue, but also mus- 
cles and cartilages as well. Bacilli appear in the discharges 
and the tuberculous process extends. 
In tuberculous individuals there is often observable an ashy 
gray appearance, differing from the ordinary paleness of 
anemia of mucous membranes at the junction of the hard 
and soft palate. The same color is also less frequently 
observable in the larynx. There is sometimes slight localized 
congestion of the cords, one of which may be partially paralyzed 
and sluggish in its movements from the pressure of a hyper- 
trophied tuberculous lymphatic upon the recurrent laryngeal DISEASES OF THE LARYNX 
275 
nerve. The voice under such circumstances is somewhat 
aphonic and perhaps slightly hoarse at times. 
Characteristic lesions are submucous infiltrations, generally 
club-like in shape, sometimes involving one or both arytenoids, 
"pyriform arytenoids" (Fig. 114), or producing the "turban- 
shaped" epiglottis. Minute tubercles break down upon the 
cords, producing ulcers that give the cords a "moth-eaten" 
appearance (Fig. 115). Fungus-like thickening of the inter- 
arytenoid mucous membrane is common in laryngeal tuber- 
culosis. Deep ulcerations involving necrosing cartilage is a 
later stage, from which there are few recoveries. Usually the 
Fig. 114.-Laryngeal tubercu- 
losis with characteristic pyriform 
swelling of the arytenoid cartilages 
(Lennox B rowne). 
Fig. i i5.-First stage of tuber- 
culosis of larynx. Ulceration of 
right cord and swelling of jnter- 
arytenoid region with formation of 
folds. May be early ulceration 
here (Sahli). 
concomitant lung lesions have also reached an advanced 
stage, and the fatal end is hastened by the patient's inability 
to swallow or even breathe without pain. 
Differential Diagnosis.-In certain cases the differential 
diagnosis between malignant ulceration and tuberculosis is one 
of extreme difficulty. In malignant ulceration the inflamed 
and reddened appearance of the unaffected mucous mem- 
brane of the larynx contrasts strongly with the pale and 
anemic appearance in tuberculosis. There is the lung involve- 
ment in tuberculosis, the greater involvement of the cervical 
glands in malignant disease. There are two other conditions 
of the larynx that sometimes closely simulate tuberculosis in 
appearance-syphilis and lupus. 276 
DISEASES OF THE NOSE, THROAT, AND EAR 
It should be borne in mind that tuberculosis is sometimes 
engrafted upon a syphilitic ulcer. Syphilitic ulcer of the larynx 
follows the breaking down of a gumma. There is usually a 
history of syphilis or syphilitic lesions may be found upon the 
body elsewhere. The diagnosis will be cleared up by the 
Wassermann reaction test. lodid of potassium must be used 
with considerable care, as tuberculous individuals do badly 
under it. 
Lupus is tuberculosis of the larynx resulting from the in- 
oculation of the larynx with an attenuated tubercle bacilli. 
It is usually secondary to lupus of the mouth or pharynx, and 
is an extremely rare disease. 
Symptoms - In the earlier stages of the disease there are 
practically no symptoms except perhaps occasional transitory 
hoarseness or very slight aphonia. These voice symptoms 
increase as the disease progresses until the voice may be a 
mere whisper and very hoarse. The interference with vocal- 
ization may be due to pressure upon the recurrent laryngeal 
nerve, interarytenoid thickening interfering mechanically with 
the approximation of the cords, tubercular infiltration of the 
muscles or involvement of the arytenoid articulations or ulcera- 
tions upon the cords. 
A hacking, dry cough is often present when there is interary- 
tenoid thickening. When ulceration is present the secretions 
are more abundant and contain the tuberculous bacillus. The 
secretions are sometimes streaked with blood, but abundant 
hemorrhage from tubercular ulcerative laryngitis probably 
never occurs. 
Pain on swallowing occurs where the infiltration of the ary- 
tenoids or epiglottis is great, and there is a sense of obstruc- 
tion in deglutition. Deglutition becomes exquisitely painful 
when ulceration has occurred upon the epiglottis or in the 
aryepiglottic fold. Ulceration within the larynx gives rise 
to little or no dysphagia and liquid gives rise to less pain than 
solid food. So exquisitely painful is the act of swallowing 
in some cases that patients have been known to refuse food or DISEASES OF THE LARYNX 
277 
drink for days rather than endure the torture of swallow- 
ing it. 
Prognosis.-Cures have been reported even in the ulcerative 
stage of the disease, but the progress of the disease in all cases 
is usually slow and tedious. Harland states that the chances 
of improvement in tuberculosis of the larynx are nearly as 
follows: 
"i. Larynx free from disease; prognosis so far good. 2. 
Congestion of cords (vasomotor); prognosis good; examination 
of lungs indicated. 3. Superficial ulcer, localized infiltration 
or tuberculoma; chances of improvement about 60 per cent. 
4. Deep ulceration; chances of improvement about 38 per 
cent. 5. Lesions of vocal cord, ventricular band, or interary- 
tenoidfold; chances of improvement about 89 per cent. 6. 
Lesions of epiglottis or aryepiglottic fold, chances of improve- 
ment about 29 per cent." 
Treatment.-The treatment of the milder forms of the disease 
should be largely systemic. It should be borne in mind that 
the disease only does great harm when it causes pain or 
prevents the taking of food, and that occasionally large ulcers 
have been seen to heal with practically no local treatment. 
Cutting operations, with the expectation of eradicating the local 
disease, are probably, in most cases, worse than useless, as it is 
impossible to know how 'far the bacilli have penetrated the 
apparently sound tissue about a lesion. Of course, if tubercle 
papilloma in the interarytenoid or other regions attain such 
a size as to produce dyspnea, as they rarely do, an effort should 
be made to remove them; otherwise those growths should be 
let alone. They frequently recur after removal. 
Ulcerations should be cleansed with equal parts of Dobell's 
solution and hydrogen peroxid by means of a spray from an 
atomizer. After the parts have been cleansed the ulceration 
should be dusted by means of a powder-blower with Formula 
120. 
Owing to the bulk of the tannic acid contained in this 
powder the amount of morphin in the quantity thrown by the 278 
DISEASES OF THE NOSE, THROAT, AND EAR 
powder-blower into the larynx is very minute, but if for any 
reason the morphin is objectionable, it may be omitted from 
the formula. 
Excessive pain on swallowing may, of course, be relieved by 
cocainizing the larynx, either with an atomizer or a laryngeal 
applicator. A lozenge containing | to | gr. of cocain, dissolved 
in the mouth before meals, yields fairly satisfactory results. 
However, for the relief of painful deglutition, no remedy yields 
such satisfactory results, everything considered, as orthoform. 
This nearly insoluble substance has the property of producing 
analgesia when applied to exposed nerve-endings. It is, there- 
fore, especially valuable as an application to irritable ulcers 
after they have been cleansed with Dobell's solution and 
hydrogen peroxid. Its anesthetic effects are increased by a 
previous application of a solution of cocain and persist for 
four or five hours. When insufflated into a tuberculous larynx 
the powder produces a momentary smarting, followed by 
analgesia more or less complete which persists as long as the 
powder adheres to the abraded surface or an ulcer. The 
powder possesses decided antiseptic qualities and promotes 
the healing of tuberculous ulcerations. It has little effect 
upon the unbroken mucous membrane. 
A nurse or one of the patient's friends can be taught to 
insufflate orthoform into a tuberculous larynx ten minutes 
before each meal, and in many instances thus secure complete 
relief from dysphagia. Orthoform is said to be non-toxic, 
and hence may be used locally in liberal quantities. It may, 
of course, be prescribed in the form of a lozenge, but with 
not nearly as satisfactory results as when the powder is insuf- 
flated into the larynx. 
A i to 2 per cent, spray of menthol in albolene may be used 
by the patient, inhaling each time he compresses the bulb of 
the atomizer. It yields fairly satisfactory results in a few 
cases. However, before using any application to the larynx 
himself the patient should, of course, cleanse it as thoroughly 
as possible under the circumstances by inhaling the spray DISEASES OF THE LARYNX 
279 
from an atomizer containing equal parts of Dobell's solution 
and hydrogen peroxid. 
Fluids, especially if iced, commonly cause much less pain on 
swallowing than solids, and iced milk can sometimes be taken 
through a tube with the patient's head hanging over the bed 
when it would be much more painful to sit up and drink the 
fluid; but in extreme cases the stomach-tube and rectal alimen- 
tation will have to be employed. 
Syrupy lactic acid is a remedy that is said to have the pro- 
perty of destroying tuberculous structures without attacking 
the surrounding sound tissues. Its application to a tubercu- 
lous ulcer is so painful that its use should always be preceded 
by thoroughly cocainizing the larynx with a io per cent, solu- 
tion of cocain. The applications can be made at intervals 
of four or five days and be preceded, if necessary, by curetting 
the cleansed ulcer. It is best to commence by lightly touching 
the parts with a 25 per cent, solution of the syrupy acid and 
gradually increasing the strength from visit to visit as the 
patient becomes accustomed to the pain. The remedy 
undoubtedly hastens cicatrization of ulcers and promotes 
absorption of deposits. It should be used with judgment 
and caution, as the edema is frequently increased for a day 
or two if lactic acid is applied too freely or an attempt is 
made to "rub in" the remedy upon the floor of a tuberculous 
ulceration. 
Leprosy of the Larynx.-According to Hollman, among the 
earlier symptoms are hoarseness and loss of voice. The laryn- 
geal condition is usually an extension of the pharyngeal and 
nasal inflammation. In the great majority of cases there is a 
hypersensitiveness of the larynx instead of anesthesia. Inspec- 
tion shows the hyperemic mucous membrane of the arytenoids 
and the aryepiglottic folds, early becoming studded with small 
yellowish white lepra tubercles and ulcerations. The false 
cords are swollen, obscuring the true cords. In a few cases 
leprous ulceration of the epiglottis occurs. In other cases 
small tubercles in the intraarytenoid space and on both the 280 
DISEASES OF THE NOSE, THROAT, AND EAR 
true and false cords appear, and, like all leprous tuber- 
cles, thicken and indurate the surrounding tissues, then 
ulcerate. 
In some cases the leprous tuberculous growths in the larynx 
become so great as to completely fill its cavity, necessitating 
immediate tracheotomy. 
Treatment consists in the use of eucalyptol spray, with 
insufflation of orthoform, or a 5 per cent, spray of protargol. 
Benign Tumors of the Larynx.-The tumors most commonly 
met with are papilloma, fibroma, angioma, myxoma, and 
cyst. 
Symptoms.-The most notable symptom is mechanical 
obstruction to breathing and 
phonation proportionate to the 
size and location of the growth. 
If the tumor is small and situ- 
ated upon a vocal cord, dys- 
phonia results from interference 
with its vibration, while, if the 
growth is situated in the an- 
terior commissure between the 
cords, aphonia results from the 
tumor preventing their approximation. If, however, the tu- 
mor is small and situated above the vocal bands, but slight, 
if any, subjective symptoms will be noticed. With the growth 
of a laryngeal tumor, dyspnea increases and asphyxia may 
suddenly occur unless prompt relief is at hand. Cough is 
not usually present unless the growth is of such a character 
as to vibrate in the breath-current and titillate, the in- 
terior of the larynx (Fig. 116), when cough and laryngeal 
spasms may occur. Chronic laryngitis is usually present. 
Papillomata found in the larynx of children offer some pecu- 
liarities. They are soft and usually multiple. They are 
usually associated with catarrh of the nasopharynx and 
hypertrophied tonsils, and sometimes disappear under the 
application of astringent powders to the larynx and successful 
Fig. i 16.-Pedunculated fibroma 
upon the under surface of the left vo- 
cal cord; position during inspiration 
(v. Ziemssen). DISEASES OF THE LARYNX 
281 
treatment of the nasal and pharyngeal affection, to the exist- 
ence of which in many instances they seem largely due. 
The papillomata of the adult are harder than those of chil- 
dren, and are usually situated on the vocal cords or ventricular 
bands. 
Etiology.-Any long-continued irritation of the laryngeal 
mucous membrane may result in hyperplasia and the growth 
of warts. When the result of long-continued catarrhal 
inflammation, papillomata usually occupy the interarytenoid 
space and the posterior ex- 
tremities of the vocal cords. 
Papillomatous growths 
are sometimes seen about 
tuberculous ulcerations and 
upon the mucous membrane 
covering gummata and tu- 
mors lying underneath the 
laryngeal mucous membrane. 
In case the papilloma oc- 
cur in connection with laryn- 
geal phthisis, syphilis, or a 
laryngeal tumor, they result from the irritation to the laryn- 
geal mucous membrane caused by the primary disease. „ 
Treatment.-Tumors springing from the epiglottis can 
usually be removed by means of a snare with a curved lip, 
while cysts may be opened with the laryngeal lancet (Fig. in) 
and their contents allowed to escape, after which the end of a 
probe on which nitrate of silver has been fused should be 
passed into the cyst and its interior thoroughly cauterized. 
Papillomata (Fig. 117) and soft or pedunculated tumors should 
be removed by means of the laryngeal forceps, if necessary 
picking off piece after piece until the entire tumor has been 
removed. In every case of tumor of the larynx the emergencies 
of the case govern the operative procedures necessary. If 
the removal of the tumor is very urgent to prevent suffocation 
and the patient's throat is too irritable to permit instrumental 
Fig. ii 7.-Papilloma of larynx (Stoerck). 282 
DISEASES OF THE NOSE, THROAT, AND EAR 
interference without danger of fatal results from induced 
spasm of the glottis, tracheotomy should, of course, be per- 
formed before the removal of the tumor is attempted. 
It is generally useless to attempt the removal of any laryn- 
geal growth with the forceps until the larynx has been so 
thoroughly cocainized that no spasm occurs upon the intro- 
duction of a probe. This can almost always be accomplished 
by painting the interior of the larynx with a io per cent, 
solution of cocain in 1:1000 adrenalin by means of a laryngeal 
applicator until no spasm occurs when the applicator or probe 
is introduced into the larynx. In the larynx cocain anesthesia 
occurs more rapidly than in the nose, but lasts for only 
a short time. 
Laryngeal carcinomata is divided into intrinsic and extrinsic. 
Intrinsic carcinoma attacks the ventricular bands, the ventricle, 
and the vocal cords, or may be subglottic. Extrinsic carcinoma 
has its origin upon the epiglottis, the arytenoid folds, and in 
the pyriform sinus. 
In extrinsic carcinoma the lymphatic glands are affected 
almost from the commencement, the disease rapidly advances 
toward a fatal termination, and is rarely, if ever, cured by 
operation. 
Intrinsic carcinoma is a less grave affection; its advance is 
less rapid, and the neighboring lymphatics often remain for a 
long time uninvolved. Extirpation, either partial or entire, 
should not be undertaken except the disease be intrinsic and 
limited entirely to the larynx. 
Symptoms.-'Continued hoarseness and sharp pain in the 
larynx, pharynx, or ear in a person over forty is sufficiently 
suspicious of carcinoma to render it advisable to keep the 
patient under observation in cases where no growth is visible 
by laryngoscopy, so that the all-important advantage of the 
earliest possible diagnosis is secured. Hoarseness grows worse 
until the voice is aphonic, while the growth progressively 
encroaches upon the lumen of the larynx until dyspnea 
embarrasses the patient. Cough, with the usual scanty DISEASES OE THE LARYNX 
283 
expectoration of chronic laryngitis, is an early symptom, the 
expectoration becoming purulent and bloody only after the 
growth has begun to break down. Dysphagia is an early 
symptom only in extrinsic cases. In intrinsic cases the cervical 
lymphatics are not involved until the tumor begins to break 
down, those in the posterior 
triangle being involved first 
from supraglottic lesions, and 
those at the angle of the jaw 
first when the disease is sub- 
glottic. 
By laryngoscopy a tumor is 
usually visible in the supra- 
glottic cases, involving, at least 
in the early stages, usually only 
one side of the larynx, with 
paralysis of a cord, which, fol- 
lowing Semon's law, involves 
first the abductors and later in 
the disease the adductors. 
Microscopic findings, if nega- 
tive, are unreliable when based 
upon the examination of a small 
piece of the tumor removed by 
cutting forceps through the 
mouth, because the cancerous 
mass maybe superficially papil- 
lomatous in appearance, both 
macroscopically and microscop- 
ically. Growths of this character, operated through the 
natural passages, have given rise to the impression that papil- 
loma are prone to degenerate into cancer. Hence, it is bet- 
ter in all suspicious cases to do a thyrotomy at once even to 
secure a reliable specimen for microscopic examination, more 
especially when it is possible to remove the entire growth by 
this comparatively simple operation. 
Fig. i i 8.-Krause's nasal and laryn- 
geal snares and cuiette forceps 284 
DISEASES OF THE NOSE, THROAT, AND EAR 
Treatment.-'Extirpation of the larynx, either in part or as 
a whole, gives the only hope of cure. The operation should be 
done as soon as a certain diagnosis is established. After all 
laryngeal operations on carci- 
noma and in inoperable cases 
the x-ray should be used as 
a most important part of the 
treatment. A useful voice is 
retained when only one cord is 
removed or even when the en- 
tire half of the larynx is taken 
away. 
Foreign Bodies in the Lar- 
ynx.-'Smooth substances, 
such as small pebbles, shoe- 
buttons, seeds of various- 
kinds, etc., are not apt to 
lodge in the larynx, but are 
either removed by a fit of coughing or drop into the trachea. 
In a case reported by Charles Harper Baker an open safety- 
pin was retained in the bronchus without marked discomfort 
for about a year, when one half of the pin was coughed up 
and a year after the other half. 
Both portions were much cor- 
roded. Substances with sharp 
points, like fish-bones, sand- 
burs, or pins (Fig. 120), are of- 
ten partially imbedded in the 
tissues of the larynx. 
Symptoms.-'Aphonia may be 
the only sign of a foreign body 
in the larynx. Commonly, how- 
ever, there is a sense of irrita- 
tion or even pain, and difficult respiration, resulting either from 
the bulk of the foreign body or the spasm or edema its presence 
has caused. 
Fig. 119.-Carcinoma of the larynx 
(Stoerck). 
Fig. 120.-A pin imbedded in the 
posterior portion of the right vocal 
cord (Seiler). DISEASES OF THE LARYNX 
285 
Treatment.-The foreign body should be removed with laryn- 
geal forceps when possible either by the direct or indirect 
method. In rare cases a wound of the interior of the larynx 
is rapidly followed by edema of the glottis. Therefore, 
in some cases tracheotomy should be performed before 
an attempt is made to remove the offending substance 
through the natural openings or it may be removed by thy- 
rotomy; for it should be borne in mind that such an operation 
is more conservative than prolonged attempts to remove a 
foreign body in timid children and indocile adults, especially 
when the operator is also embarrassed by clumsy instruments, 
imperfect light, or the patient's reflex cough persisting in spite 
of the thorough cocainization already described as necessary 
for the removal of papilloma and other tumors. When a bolus 
of food or a large substance threatens immediate suffocation, 
the finger should be inserted into the patient's mouth and an 
effort made to hook the foreign body out of the larynx. Fail- 
ing in this, a horizontal incision into the larynx through the 
cricothyroid membrane should be quickly made. If nothing 
better is at hand, this may be done with a penknife and the 
blade then turned vertically in such a manner as to hold open 
the wound and permit respiration. Subsequently the foreign 
body may be removed by thyrotomy; or after the insertion of 
a tracheotomy tube, by instrumentation through the mouth. 
Thyrotomy consists in the separation of the two wings of 
the thyroid cartilage by means of an incision through the 
angle of the thyroid cartilage, thus exposing the interior of the 
larynx for the removal of tumors or foreign bodies that cannot 
be removed readily through the mouth. The operation is done 
under chloroform anesthesia and in the trachetomy position. 
An incision is made through the skin from the thyrohyoid 
space to the upper tracheal rings exactly in the median line. 
The underlying structures are divided carefully by means of a 
knife and a grooved director. The thyroid prominence bulges 
out of the wound and can be opened by passing one blade of a 
stout pair of angular scissors through the cricothyroid mem- 286 
DISEASES OF THE NOSE, THROAT, AND EAR 
brane into the larynx. The larynx can also be opened by 
means of a stout bistoury or, when ossified, by means of a Sajous 
saw (Fig. 46). The edges of the wound are now separated with 
retractors in the hands of an assistant, and spasm of the laryn- 
geal muscles, which always occurs when the larynx is opened, 
is controlled by brushing the laryngeal mucous membrane with 
a 4 per cent, solution of cocain. The operation is comparatively 
bloodless and exposes in a very satisfactory manner the in- 
terior of the larynx for the removal of a foreign body or a tumor. 
After the removal of the tumor or foreign body the severed 
edges of the cartilages are united by one or more catgut sutures 
and the skin wound brought together by sutures of worm-gut. 
Union usually occurs by first intention, but the ultimate condi- 
tion of the voice depends upon the amount of damage done to the 
interior of the larynx. The removal of a foreign body or small 
tumor is not followed by appreciable impairment of the voice. 
The after-treatment following removal of a small tumor by 
this method consists in keeping the patient quiet in bed for a 
week or so and forbidding the use of the voice. For the first 
few days the diet should be liquids. 
Neuroses of the larynx are divided into sensory and motor 
neuroses. 
Sensory neuroses are anesthesia, hyperesthesia, and par- 
esthesia. 
Anesthesia of the mucous membrane of the larynx, some- 
times accompanying motor paralyses of the larynx, is occa- 
sionally observed in hysteria and in the insane. 
Hyperesthesia accompanies all forms of laryngeal inflamma- 
tion except some forms of early tuberculosis. It is frequently 
present in neurotics. 
Paresthesia manifests itself chiefly as a sensation of choking 
or as of a foreign body in the larynx of hysteric individuals. 
These sensations are sometimes the result of disease of the 
pharynx or tonsils, and when this condition exists it should 
NEUROSES OF THE LARYNX DISEASES OF THE LARYNX 
287 
receive appropriate treatment. In the meantime considerable 
relief will follow the administration of io to 15 gr. of the bromid 
of sodium three times a day. 
Motor neuroses are spasm incoordination and paralysis of 
the laryngeal muscles. 
Spasm of the laryngeal muscles appears in three forms-• 
spasmodic cough, spasm of the adductors, and spasm of the 
tensors of the cords. 
Spasmodic laryngeal cough or laryngeal chorea is a con- 
dition commonly described under this heading, although other 
respiratory muscles beside those of the larynx are involved in 
the paroxysms of coughing, which is of a peculiar bark-like 
character resembling that of a big dog. The paroxysms of 
coughing occur at frequent intervals during the day, but cease 
during sleep. The disease occurs more frequently in neurotic 
females than in males. It is not associated with chorea in any 
manner whatever, nor is there any evidence of laryngeal 
inflammation on examination with the laryngoscope. 
Treatment should be directed toward improving the individ- 
ual's health. Good results follow the prolonged use of some 
nerve tonic like pil. sumbul comp., one after meals and at 
bedtime, but quicker relief can generally be obtained from 
bromid of sodium, 10 to 15 gr., after meals and at bedtime. 
The use of the induced current, one sponge on the skin on 
each side of the larynx, does good probably from the impression 
it makes on the mind of the patient. To accomplish this the 
electricity should be used as strong as it well can be borne by 
the patient. Aside from the use of electricity, local treatment 
is not indicated. 
Spasm of the Tensors of the Vocal Cords.--This is a rare 
condition affecting singers, actors, and orators, somewhat 
analogous to the spasm of the muscles observed in the muscles 
of the hand in writers' cramp. 
Symptoms.-'The voice is suddenly lost, possibly in the midst 
of a sentence, by a spasm (sometimes painful) of the cords. 
The greater the effort to speak or sing, the tighter and longer 288 
DISEASES OF THE NOSE, THROAT, AND EAR 
the spasm. After a moment the spasm subsides and the voice 
is normal for several minutes, when another spasm may occur. 
Examination with the laryngoscope during a spasm shows the 
cords tightly approximated in the position for vocalization. 
There may or may not be slight hyperemia of the larynx. 
Treatment consists in rest of the voice, preferably in the coun- 
try or at the seashore, tonics, and attention to personal hygiene. 
Spasm of the adductor muscles or laryngismus stridulus, 
false croup, generally involves the crico-arytenoidei externi 
and the arytenoideus. 
Etiology.-'The condition usually occurs in neurotic children 
under three years of age. There is frequently some pathologic 
condition of the nose and nasopharynx that renders the nerve- 
endings of the upper respiratory tract more irritable, and in 
neurotic children is sufficient to induce a reflex spasm of the 
adductor muscles of the vocal cords from trifling causes, such 
as a slight lowering of the temperature during the night after 
the child has gone to bed, kicking off the bedclothing, etc. 
In some adults the entrance of a small particle of food or dust 
into the larynx produces a condition similar to laryngismus 
stridulus. In such individuals applications to the nasopharynx 
of iodin-potassium-iodid-glycerin; solutions of sulphate of 
zinc or any of the other routine applications to the nasopharynx 
may be followed by alarming spasms of the laryngeal adductor 
muscles if a drop of the solution by any mischance happens 
to drip into the larynx. The same thing occurs in such individ- 
uals after the application of an ordinary remedy to the larynx. 
To the experienced laryngologist the symptoms are suffi- 
ciently alarming. After the larnygeal application the patient 
suddenly becomes cyanosed and, with protruding eyeballs, 
clutches at his throat. The patient gasps. The respiration is 
loudly "crowing," like that of a child with laryngismus 
stridulus, and death from suffocation seems imminent. These 
alarming symptoms disappear as suddenly as they occurred 
if the patient makes an effort to pronounce words. The 
practitioner in a loud voice should command the patient to 
say "One, two, three," or in an equally loud and commanding DISEASES OF THE LARYNX 
289 
voice inquire, "What is your name?" When the patient 
makes an effort to answer, the spasm of the glottis vanishes 
and breathing becomes at once normal. 
In the first stage of locomotor ataxia there is occasionally a 
history of spasms of the adductor muscles resembling laryngis- 
mus stridulus, and in an adult such a history in the absence of 
foreign bodies gaining entrance into the larynx should be of 
sufficient warrant to search for other symptoms of this disease. 
In young children enlargement of the thymus gland may be the 
cause of dyspnea and death from pressure on the trachea, 
pneumogastrics, and large venous trunks. The symptoms 
are expiratory as well as inspiratory stridor, which may sud- 
denly assume a dangerous character with labored respirations; 
the patient blue or almost black. Consciousness is lost and 
the patient quickly dies in convulsions. Diagnosis is most 
certainly made by means of the x-ray, and while three infants 
seen by the author recovered under adrenalin spray and expect- 
ant treatment, the removal of a sufficient portion of the sinus 
gland to prevent injurious pressure is the most certain method 
of preventing a fatal termination. 
Symptoms.-Laryngismus stridulus appears suddenly during 
the night in apparently healthy children. The child sits up in 
bed gasping for breath. At the height of the attack it is 
markedly cyanosed, when suddenly there is a deep inspiration 
and the symptoms rapidly disappear. There remains no 
symptoms of laryngeal inflammation except that during the 
day there may be a slight "croupy" cough. 
Prognosis.-The attacks of false croup not infrequently 
recur at intervals for weeks and months. It is said that in 
very young children the attacks sometimes terminate in 
eclampsia or convulsions. 
Treatment is directed to the prompt relief of the laryngeal 
spasm. This can sometimes be accomplished by making the 
child sneeze by tickling the nose with a feather or a pinch of 
snuff. When sneezing occurs the spasms cease. The inhala- 
tion of a few drops of chloroform from a handkerchief is gen- 
erally effective. Extreme heat or cold to the skin over the 290 
DISEASES OF THE NOSE, THROAT, AND EAR 
larynx or 3 drops of adrenalin chlorid solution (1:1000) 
hypodermically will sometimes relieve the spasm. Any or 
all of these measures should be tried while a hot mustard- 
bath is being prepared. Then it should be placed in this and, 
after remaining for a few moments, taken out and carefully 
wrapped in a warm woolen blanket before being replaced in 
bed. For very severe attacks Coakley advised the following 
as a rectal injection: 
3. Chloralis hydratis, gr. vj; 
Potassse bromidi, gr. x; 
Aquae, q. s. ad. fo j.-M. 
Sig.-Use as a rectal injection for a child six months old. 
As a prophylactic between the attacks all sources of irrita- 
tion should be sought for and removed. These may include 
errors of digestion, carious teeth, or nasopharyngeal disease. 
Hearty suppers and lunches at bedtime should be forbidden. 
Sodium bromid in 5-gr. doses should be given every three 
hours during the day for a week or more or until the immediate 
danger of a recurrence of the attack seems to have disappeared. 
The child should then take syrup of iodid of iron after meals, 
1 drop for each year of its age, up to 10 drops, with or without 
cod-liver oil. Syrup of the hypophosphites may be sub- 
stituted for the iron at the physician's discretion. In adults, 
pil. sumbul comp, or some other combination of iron, valerian, 
and asafetida may be given. 
Laryngeal Vertigo or Epilepsy.-This is a rare laryngeal 
neurosis occurring more frequently in males than females. 
Etiology.-The disease occurs in neurotic individuals, and 
the symptoms are probably due to an incoordination of the 
respiratory centers implicating the laryngeal muscles in such 
a manner as to produce closure "of the glottis. 
Symptoms.-The prodromes are a tickling sensation in the 
larynx and a fit of coughing. The patient draws a long breath. 
The glottis closes and the inspired air is confined in the lungs. 
There follows vertigo, cyanosis, and sometimes loss of conscious- 
ness. The "fit" then passes off, to be repeated at intervals. 
The laryngoscope shows no characteristic lesion; a normal DISEASES GF THE LARYNX 
291 
larynx or slight catarrhal inflammation being commonly ob- 
served. Disease of the nose and pharynx, catarrhal in char- 
acter is frequently present in such cases. 
The -prognosis as regards life is favorable. There may, how- 
ever, be a recurrence of the attacks of laryngeal vertigo extend- 
ing over a period of years. 
The treatment, like that of other neuroses, consists in hygienic 
measures calculated to improve the individual's general health, 
and if the attacks are frequent the administration of antispas- 
modics. Galvanic electricity, the positive pole over the 
larynx, may be employed. 
Paralysis may affect but one laryngeal muscle or pair of 
muscles; or it may affect several of them at once, and may be 
either unilateral or bilateral. Paralysis of the larynx may be 
divided clinically into paralysis of the adductors, paralysis of 
the abductors, and paralysis of the tensors of the cords. 
Etiology.-The laryngeal muscles receive their nerve-supply 
by means of two branches of the pneumogastric-the superior 
laryngeal and the recurrent laryngeal. The pneumogastric, at 
its origin, is a sensory nerve, but receives motor fibers from the 
spinal accessory, so that it possesses both sensory and motor 
functions above the point where the superior laryngeal is 
given off. Paralysis of the laryngeal muscles may be due, 
like paralysis of other muscles, to (i) disease or injury of the 
brain involving the cerebral portion of the nerves that supply 
the larynx; (2) injury or pressure of the nerves below their 
cerebral portion; (3) an abnormal condition of the muscles 
themselves, and (4) some systemic dyscrasia, like rheumatism 
or hysteria, because of which the muscles are unable to respond 
to nervous influence. 
Adductor Paralysis.-Adduction of the vocal cords being 
performed by means of the lateral crico-arytenoid muscles and 
the arytenoideus muscle, paralysis of these muscles causes the 
cords to remain in a state of extreme abduction. This condi- 
tion is in most instances due to hysteria, rheumatism involving 
either the muscles or the crico-thyroid joint, or chronic poison- 292 
DISEASES OF THE NOSE, THROAT, AND EAR 
ing by lead or arsenic. If bilateral paralysis exists, the vocal 
cords will be seen in the laryngeal mirror separated to the 
utmost degree (Fig. 12 x), and the voice will be completely lost. 
If paralysis of the arytenoideus muscle alone exists, which, 
however, is rarely the case, the anterior two-thirds of the vo- 
cal bands can be approximated; 
but a triangular space will be left 
behind the vocal processes dur- 
ing phonation, through which the 
breath escapes and renders the 
voice feeble, and its use in singing 
and speaking both fatiguing and 
unsatisfactory. This condition 
of affairs may occur during the 
course of either acute or chronic 
laryngitis from extension of the 
inflammation to the arytenoideus 
In unilateral adductor paralysis only one cord is seen in 
Fig. 121.-Bilateral paralysis of 
the adductors (crico-arytenoidei 
lateralis and arytenoideus). Ap- 
pearance in attempted phonation 
(Lennox Browne). 
muscle (Fig. 122). 
Fig. 122.-Bilateral paralysis of 
the arytenoideus (Lennox Browne). 
Fig. 123.-Unilateral paralysis of 
adductor of left cord.. Appearance 
in attempted phonation (Lennox 
Browne). 
extreme abduction during phonation, and the opposite cord will 
be observed to pass beyond the median line, so as to approach 
as near as possible to its motionless companion (Fig. 123). DISEASES OF THE LARYNX 
293 
Although aphonia exists, the whispered words are usually 
perfectly comprehensible. 
A bductor Paralysis.-Abduction of the vocal cords is accom- 
plished solely by means of the crico-arytenoid muscle, and 
hence the complete paralysis of both of them will prevent 
separation of the cords, and almost completely prevent the 
entrance of air into the lungs; a mere slit posteriorly, which 
represents the action of the arytenoideus, being the extent of 
the available breathing space. 
During expiration, however, the 
vocal cords are forced apart by 
the ascending air-current im- 
pinging upon their under sur- 
faces, which curve upward from 
the sides of the larynx. The 
voice is unimpaired in this affec- 
tion, but where complete paraly- 
sis of the abductors exists it may 
be necessary to perform trache- 
otomy to prevent suffocation oc- 
curring as the result of slight in- 
flammatory swelling of the mu- 
cous membrane of the larynx as 
the result of a cold. Spasmodic 
abductor paralysis, or "laryngeal 
crisis," may occur as a complica- 
tion of locomotor ataxia. Late 
in the disease one cord, generally the left, is often fixed in a hy- 
peradducted position. This is in accordance with Semon's law, 
that in all progressive lesions of the centers or the trunks of 
motor laryngeal nerves the abductors are more frequently 
affected than the adductors. Paralysis of the abductors may 
result from a tumor in the brain involving the origin of both 
pneumogastrics and spinal accessory nerves. In such cases 
the abductors of the larynx are first paralyzed, but as the tumor 
increases in size paralysis of all the muscles of the larynx 
Fig. 124.-Appearance of the nor- 
mal larynx after death, showing the 
"cadaveric position" of the vocal 
cords. This is also their position in 
quiet breathing (Lennox Browne). 294 
DISEASES OF THE NOSE, THROAT, AND EAR 
results, the cords assuming the "cadaveric position" (Fig. 
124). Paralysis of both posterior crico-arytenoid muscles may 
result also by pressure upon the recurrent laryngeal nerves by 
an aneurysm, a goiter, or carcinoma of the esophagus, or the 
lesion may be located in the muscles themselves. When 
unilateral paralysis only is present, the affected cord will be 
seen to remain in the median line, even during forced inspira- 
tion, but subjective symptoms will be so slight as to hardly 
attract attention. The voice will be perfect and the breath- 
ing space ample, except during violent exercise (Figs. 125, 126). 
Fig. 125.-Bilateral paralysis of 
the abductors (crico-arytenoidei 
postici). Appearance with deep in- 
spiratory effort (Lennox Browne). 
Fig. 126.-Unilateral paralysis 
of the left abductor. Appearance 
in phonation. The affected cord is 
seen to be in the cadaveric posi- 
tion, while the other is advanced 
beyond the median line (Lennox 
Browne). 
Two forms of paralysis of the tensors of the vocal cords are met 
with, one due to paralysis of the cricothyroid muscle, which is 
rare, and the other one to paralysis of the thyro-arytenoids, 
which is not uncommon. Paralysis of the former muscle 
causes the edges of the cords to assume a wavy line, touching 
each other at irregular intervals during phonation (Fig. 127), 
while the voice is coarse and remains always at the same pitch. 
The upper surface of the cords appears convex during expiration 
and concave during inspiration. When the thyro-arytenoids 
are paralyzed, the cords assume a slightly curved appearance 
when an attempt is made to bring them together during DISEASES OF THE LARYNX 
295 
phonation, and a slight space remains between their centers 
(Fig. 128). The voice is husky, high pitched, and weak, the 
air escaping through the elliptic space between the cords, 
necessitating great effort on the part of the patient in order to 
speak. 
Treatment.-The cause of the paralysis should be carefully 
sought and treated, the success of the measures adopted de- 
pending, of course, upon the nature of the primary ailment. 
In suitable cases strychnin should be administered in gradually 
increasing doses until the limit of toleration has been reached, 
and galvanism or faradism used by means of the laryngeal 
Fig. 127.-Bilateral paralysis of 
the thyro-arytenoidei and of the 
arytenoideus (Lennox Browne). 
Fig. 128.-Bilateral paralysis of 
the sphincter of the glottis (thyro- 
arytenoide (Lennox Browne). 
electrode, applied within the larynx as near as possible to the 
affected muscles. An ordinary sponge electrode is held by the 
patient or an assistant upon the skin over the larynx, while the 
operator guides the tip of the electrode into the larynx, watch- 
ing its progress with the laryngoscope, until it is in the desired 
position. The finger-rest on the top of the handle of the in- 
strument is now depressed and the current passes. Each 
application should last but a few seconds, and be repeated 
three or four times at each sitting, at intervals of one or two 
minutes. Electricity may be used in this manner every other 
day, the current used not stronger than is sufficient to secure 296 
DISEASES OF THE NOSE, THROAT, AND EAR 
contraction of the affected muscles. At first the mere intro- 
duction of the electrode into the larynx causes retching and 
gagging, and it may be necessary to apply a io per cent, 
solution of cocain to the interior of the larynx in order to 
anesthetize the parts sufficiently to admit of free manipu- 
lation at the first sitting. After a few trials, however, the 
parts become more tolerant and applications can be borne, in 
the majority of instances, without trouble. 
Diphtheria is an acute infectious disease characterized by a 
pseudomembrane which usually appears in the fauces, and is 
associated with a rapid pulse, moderate elevation of tempera- 
ture, and depression. 
Etiology.-Diphtheria is endemic in all large cities, especially 
in the more crowded localities, and from time to time becomes 
epidemic, spreading to the outlying districts. It is prevalent 
more in the spring, autumn, and winter than in the summer. 
The specific cause is the Klebs-Loffler bacillus. 
Pathology.-The location and extent of the pseudomembrane 
varies in each case. It may be limited to the tonsils or it may 
cover the entire fauces and extend into the nares and the larynx. 
It sometimes extends through the Eustachian tubes to the 
middle ear. When a diphtheritic membrane is forcibly re- 
moved it invatiably leaves a bleeding surface. 
The bacilli are deposited in the fauces first and cause the 
membrane to become red, inflamed, and swollen. The poison 
kills the superficial layer of epithelial cells, which undergo 
coagulation necrosis. There is a migration of white blood- 
cells, which also undergo coagulation necrosis. These pro- 
cesses may only extend through the superficial layer of the 
mucous membrane, but sometimes extend deep into the tissues 
and produce gangrenous ulcers. The color of the pseudo- 
membrane is gray or grayish-white at first. It sometimes 
becomes yellow, but more often is white and flaky, like leaf- 
lard; it may also assume a dirty brown color, due to hemorrhage 
or to the local use of iron solutions. 
Postmortem, the heart and blood-vessels show degenerative DISEASES OF THE LARYNX 
297 
changes. The heart may contain a blood-clot. The lungs 
frequently show evidence of fibrinous pleurisy, broncho- 
pneumonia, or capillary bronchitis. The liver and spleen 
show little, if any, change. The kidneys frequently show 
cloudy swelling. Degenerative processes have also been found 
in the nerve-trunks. 
Classification.-Diphtheria may be classified as mild, well 
marked, severe, and malignant. 
When classified according to location, as faucial, nasal, and 
laryngeal. There nearly always is some evidence of the 
disease in the fauces when either nasal or laryngeal diphtheria 
exists. 
Symptoms.-In some cases of diphtheria there are very few 
or no symptoms at all, except a slight indisposition on the part 
of the child, and the true nature of the disease may never be 
recognized unless by accident. The ordinary attacks of diph- 
theria, however, usually begin with chilly sensations up and 
down the spine; occasionally with a distinct chill and rarely 
with a convulsion. This is followed by a rise in temperature, 
quickened pulse, headache, pains in the limbs, coated tongue, 
and sometimes nausea and vomiting. Frequently there is 
stiffness of the muscles of the neck. Sore throat and painful 
deglutition may or may not be present. 
The temperature rises to ioi° or 103 0 F. by the end of the 
first day. The pulse is rapid and ranges between no and 130. 
The throat looks red and inflamed at first, then there is a 
deposit of exudate on the tonsils, as a rule, and it spreads to 
the adjacent mucous membrane or may limit itself to the 
tonsils. It is first of a gray or grayish-white color, which be- 
comes white or a dirty yellow as it grows older. The glands 
at the angle of the jaw become swollen and sensitive. Con- 
stipation is frequently present. The urine is scanty and high 
colored. It may show albumin and even casts. In the ordi- 
nary cases the depression is never profound and may be absent 
altogether. 
In favorable cases the disease reaches its height by the fifth 298 
DISEASES OF THE NOSE, THROAT, AND EAR 
or sixth day, but the temperature usually falls to normal on the 
third or fourth day. The exudate usually disappears by the 
tenth day and convalescence is well established. Paralysis 
follows but seldom in cases where the exudate is limited to the 
tonsils. 
In severer types of the disease the initial symptoms are more 
pronounced. The depression is marked and comes on early. 
The fauces are greatly inflamed and the tonsils so swollen as 
to meet in the center of the pharynx. They are covered by a 
thick exudate, which impedes respiration and articulation. 
The uvula is swollen and usually covered by exudate, which 
extends forward to the hard palate, and may be nearly | inch 
thick at the junction of the soft and hard palate. The posterior 
nares are involved by extension of membrane up the posterior 
surface of the uvula. This often rapidly extends to the anterior 
nares and both nostrils may become completely plugged by the 
exudate. There is a serous acrid discharge from the anterior 
nares which excoriates the skin of the upper lip. The cervical 
glands are markedly enlarged and the cellular tissues swollen 
and edematous. The edema at times extends down upon the 
sternum for several inches. 
The temperature is usually normal or subnormal after the 
second or third day. The pulse is rapid, but soon becomes 
irregular and intermittent. Depression is marked from the 
beginning. The urine is scanty and high colored. Most 
severe cases show albumin and casts. Vomiting is frequent. 
Epistaxis and hemorrhage from the fauces and buccal mem- 
brane are common. The breath is offensive. The patient 
rapidly grows pale and anemic. The skin on the face has a 
drawn and glossy appearance. The child may die in a few days, 
overwhelmed by the diphtheritic poison, or linger for several 
weeks and die of toxemia or paralysis. Any case of diphtheria, 
however severe, may recover, or death may occur suddenly 
from paralysis of the heart. When recovery takes place, con- 
valescence is usually protracted and very tedious. Paralysis, 
either local or general, often supervenes, DISEASES OF THE LARYNX 
299 
Nasal diphtheria usually occurs in conjunction with the 
faucial variety or it may follow it. Occasionally it occurs as a 
primary disease; then the symptoms are milder and the exu- 
date is not so extensive. There is always a marked tendency 
to systemic infection whenever the nares are secondarily in- 
volved. Convalescence is slow and tedious in cases that 
recover. 
Variations from the above descriptions are numerous, for 
no other disease presents so many phases as diphtheria. 
In laryngeal diphtheria there are hoarseness and a high- 
pitched, metallic cough-the so-called croupy cough-which 
comes on in paroxysms. There is a slight rise in temperature 
and the frequency of respiration is slightly increased. As the 
exudate extends, the hoarseness and aphonia increase. Fin- 
ally, the respiration becomes embarrassed and stridulous. 
The auxiliary muscles of respiration are brought into action. 
There is marked retraction in the supraclavicular and supra- 
sternal spaces; also at the substernal space and at the border of 
the ribs. The alae of the nose dilate with each respiration. 
The inspiration is long, deep, and labored, and more difficult 
than expiration, which may be comparatively easy. The 
child is restless, clutching at the sides of the bed or anything 
to raise itself up. The face is pale and bathed in a profuse 
perspiration. The patient has a wild, hunted expression. As 
the obstruction increases, cyanosis appears, the extremities 
become purple, the lips and face of a livid hue. Sometimes 
during a fit of coughing membrane is expelled as a complete 
cast of the larynx, trachea, and sometimes even of the smaller 
bronchi. This, as a rule, only gives temporary relief, for the 
membrane quickly re-forms and all the symptoms return. 
Unless these cases are relieved by intubation or tracheotomy, 
cyanosis becomes greater until the child dies asphyxiated. 
Diphtheritic paralysis is a neuritis rather than a true paralysis 
due to the absorption of the toxalbumins of the disease, and 
generally is proportionate to the severity and extent of the 
acute condition. Rarely, marked paralysis follows mild attacks 300 
DISEASES OF THE NOSE, THROAT, AND EAR 
•-io to 20 per cent, of diphtheria cases are followed by paral- 
ysis-which may be either local or general. The local variety 
is usually noticed by the end of the first or during the second 
week. The most frequent paralysis is that of the palatal mus- 
cles, giving a nasal sound to the voice. Fluids are regurgit- 
ated during swallowing. Strabismus and ptosis are sometimes 
seen. Paralysis of accommodation is not infrequent and paral- 
ysis of the tensor tympani and stapedius occasionally occur. 
Facial paralysis is occasionally seen. Loss of power in the 
lower extremities with inability to walk is quite common. 
General paralysis usually makes its appearance from the 
fourth to the sixth week, and all the muscles of the body may 
be affected except the sphincters, which are usually spared. 
When all the muscle of the body are affected the temperature 
is usually subnormal, the pulse rapid and intermittent or very 
slow. When paralysis is extreme the child lays perfectly 
quiet, unable to move, and frequently unable to swallow. 
There -is usually associated with these conditions a low drag- 
ging cough quite characteristic. 
Systemic Infection or Toxemia.-'Some of the mild cases have 
very little constitutional disturbance. On the other hand, 
some patients are overwhelmed by the poison in a few days. 
More often toxemia comes on later, when acute symptoms have 
subsided and the exudate disappeared. The patient appears 
bright and is apparently convalescing, except that his color is 
noticed to be growing paler. The pallor increases daily until 
the pink hue disappears from the lips, lobes of the ears, the 
palms of the hands, and soles of the feet. Exhaustion is ex- 
treme. The temperature is usually subnormal. The pulse 
may be slow or very rapid. The extremities are cold. The 
stomach is irritable. The least food, even cracked ice, will 
excite vomiting. The mind remains bright and clear. Such 
cases usually die of toxemia and exhaustion, and follow when 
the local disease has been extensive and the depression well 
marked. 
Complications.-'Epistaxis is frequent when the nares are DISEASES OF THE LARYNX 
301 
involved and, in severe cases, hemorrhage from the fauces and 
buccal mucous membrane. Capillary bronchitis or broncho- 
pneumonia is quite common and frequently fatal. It occurs 
during the height of the disease or during convalescence. A 
fibrinous pleurisy is frequently seen postmortem and occurs 
in conjunction with bronchopneumonia. Albuminuria is 
present in nearly all severe cases and occasionally gives rise 
to alarming symptoms. Suppression of urine may follow. 
Otorrhea is not uncommon, and bacilli are found in the dis- 
charges for many weeks or even months after convalescence 
is fully established. Pericarditis and endocarditis may also 
occur, but are rare. 
Diagnosis.-The characteristic pseudomembrane, which 
leaves a bleeding surface when removed, its gray or grayish- 
white color, its tendency to spread to adjacent mucous mem- 
brane, the swelling of the cervical glands, and the presence of 
the bacilli renders the diagnosis in typic cases quite easy. 
Mild cases may be confounded with follicular tonsillitis. 
The anginose variety of scarlatina may present some difficulty, 
but the strawberry-tongue, continued high fever, absence of the 
Klebs-Loffler bacilli, and the presence of the characteristic 
scarlatinal rash will exclude diphtheria. 
Bronchopneumonia may be mistaken for the laryngeal 
variety. In pneumonia the respirations are panting and rapid; 
in laryngeal diphtheria they are long, deep, and labored, and 
the stridor usually well marked. The history of a faucial or 
nasal diphtheria will often clear the diagnosis. 
Prognosis depends upon the character of the epidemic, the 
type of the disease, and the age of the patient. The death-rate 
depends upon the number of laryngeal cases requiring operative 
interference. From this class alone the death-rate varies from 
30 to 75 per cent. The age of the patient also influences the 
prognosis. Under one year of age, from 50 to 90 per cent, die; 
from one to five years of age, about 40 per cent.; from five to 
ten years, 26 per cent.; from ten to fifteen years, 12 per cent.; 
over fifteen years, 3 to 4 per cent. 302 
DISEASES OF THE NOSE, THROAT, AND EAR 
Treatment is divided into (1) prophylactic; (2) local; (3) 
constitutional; (4) serum; and (5) operative. 
Prophylactic treatment consists in adopting those measures 
that will prevent the spread of the disease. This is best 
obtained by placing the patient in a well-ventilated room, 
preferably on the top floor, and having it isolated. All bed- 
linen, towels, garments, and eating utensils used by the patient 
should be disinfected with a carbolic acid solution (5 per cent.) 
before leaving the room. The attendant's clothing should be 
changed before mingling with other people. The physician 
should wear a linen duster or gown when visiting the patient. 
After the patient has recovered the room and its contents 
should be disinfected thoroughly with formaldehyd gas. 
Local treatment is to reduce the inflammation, prevent the 
spread of the exudate, and remove what has already formed. 
For this purpose hydrogen peroxid, either in full strength or 
diluted to suit the case, is the best local application. It should 
be used in the form of a spray or upon a cotton swab. 
Many favor astringent solutions, preferably of the iron salts; 
as, 
B. Acidi carbolici, TTlxv; 
Ferri perchloridi, f 3 ij; 
Glycerin, 
Aqua, aafgj.-M. 
Sig.-To be used every hour or two by means of a swab. 
The solvents-'lactic acid, peptin, caroid, trypsin-'have 
many advocates. Lennox Browne was very partial to lactic 
acid applied pure twice daily, and diluted to three or four 
times its bulk with water, applied by the attendant every two 
or three hours. Lbffler's toluol solution gives good results in 
some cases, but care must be used in applying it. Applications 
of a solution of 12 per cent, nitrate of silver carefully to the 
tonsils, palate, and lateral walls of the pharynx twice or thrice 
a day when they are alone affected seems to check the extension 
of the membrane, but whatever remedy is selected, the practi- 
tioner should see that it does not increase the inflammation 
or else it will do more harm than good. DISEASES OF THE LARYNX 
303 
Constitutional Treatment.-Iron and mercury are the two 
drugs we have to rely upon in fhe treatment of this disease. 
They may be used alone or combined as follows: 
I|. Tr. ferri chloridi, 3ij; 
Syr. acidi citrici, 
Glycerin, aa 5iij; 
Aqua, q. s. ad. fgiij.-M. 
Sig.-1 teaspoonful every hour or two for a child four years old. 
1$. Hydrarg. chlor, corros., gr. iss; 
Tr. ferri chlor., f 3 ij; 
Syr. acidi citrici, 
Glycerin, aa f giij; 
Aqua, q. s. ad. f§iij.-M. 
Sig.-1 teaspoonful every hour or two for a child four years old. 
Instead of the bichlorid, calomel may be given (A-gr. doses 
every two hours). 
Stimulants are indicated from the beginning; alcohol is 
undoubtedly the best and should be pushed to its physiologic 
limit in severe cases. After the exudate disappears the whisky 
should be gradually withdrawn and digitalis substituted. 
When the stomach is irritable, digitalin should be given. A 
child five years old can be given to A gr. or more if 
necessary. 
Strychnin is also useful, especially in the later stages. It 
can be given in larger doses than is ordinarily employed. 
The Serum Therapy.-To obtain the best results, antitoxin 
should be used early in the disease, and should be used in all 
cases of suspected diphtheria. 
In mild cases 1000 units, repeated the next day, will be all 
that is necessary. 
In severe cases it is well to begin with 2000 units as the initial 
dose and repeat every six, twelve, or twenty-four hours, until 
the symptoms begin to subside. When the disease persists it 
is sometimes necessary to give as high as 20,000 units in divided 
doses. Antitoxin of the highest potency should always be 
selected, for this gives the maximum number of units and the 
minimum amount of serum. It should be injected under an- 304 
DISEASES OF THE NOSE, THROAT, AND EAR 
tiseptic precautions to prevent abscesses, which occur in spite 
of antiseptic precautions in about 1 case in 500. 
Operative intervention is indicated: (1) When the patient is 
cyanosed, together with marked retraction of the supracla- 
vicular, substernal, and subcostal spaces, great restlessness, 
cold and clammy sweats. (2) When the symptoms of obstruc- 
tion in the larynx are not so marked, but are rapidly growing 
Fig. 129.-O'Dwyer's intubation set. 
worse, intubation preserves the strength of the patient. (3) 
When the symptoms of obstruction are not progressing, but 
are sufficient to prevent the patient obtaining rest. (4) In 
severe cases of nasal and faucial diphtheria which develop 
laryngeal symptoms, intubation permits the patient to die 
easy. 
Intubation.-Select a tube suitable for the age of the patient, 
pass a strong silk thread through the eye of the tube (about 20 DISEASES OF THE LARYNX 
305 
inches long), and tie the two ends together. Then screw the ob- 
turator on the introducer and place the tube on the obturator. 
Next, wrap the patient tightly in a sheet with his hands at the 
side to prevent them from interfering with the operator. Have 
the nurse sit in a chair and hold the patient upon her lap with 
his back to her left chest and his legs between her knees. The 
operator should sit in a chair facing the patient and place the 
Fig. 130.-Intubation: inserting the tube {American Text-book of Diseases of 
Children). 
gag in the left corner of the mouth. An assistant standing 
behind the nurse holds the gag and steadies the patient's 
head between his hands. Then the operator, taking the 
introducer in his right hand and holding the thread attached 
to the tube on one finger, rapidly introduces the index-finger 
of the left hand over the tongue until it is behind the epiglottis 
and the laryngeal orifice is felt. Then the tube is introduced 306 
DISEASES OF THE NOSE, THROAT, AND EAR 
over the tongue, being careful to keep it in the median line, 
until the tip of the finger at the opening of the larynx is felt 
(Fig. 130). Next, elevate the handle of the introducer until 
the tube is in a vertical position and it readily slips into the 
larynx. When the tube is in the larynx, press forward the 
button on the top of the introducer, which releases the obtu- 
rator. The finger should be placed on the head of the tube 
until the obturator is entirely withdrawn. Next, remove the 
gag, but hold the end of the string until you are satisfied the 
tube is in the larynx and the child has obtained relief. This 
usually requires three or four minutes. After respirations 
become easy, the string should be removed or plastered on the 
side of the face. To remove the string the gag should be placed 
in the mouth and the finger should be held on the top of the tube 
until the thread is removed, to prevent removing the tube also. 
Accident Following Intubation.-Occasionally the membrane 
of the larynx becomes detached and is pushed down before the 
tube, completely obstructing respiration. It does not often 
happen, but when it does the tube should be removed at once 
by pulling on the thread attached to the tube. This is fol- 
lowed by a forced expiratory effort, which, as a rule, expels the 
membrane. When it does not, tracheotomy should be per- 
formed immediately. 
After intubation, deglutition is difficult, the patient being 
able to swallow only liquids and semisolids. The temperature 
may remain normal, but, as a rule, it rises to 1020 to 1030 F., 
and remains from 1 to 2 degress above normal while the tube is 
in the larynx. When intubation gives perfect relief, the 
respirations are free and easy and the child is entirely com- 
fortable. The coughing attendant upon deglutition is suffi- 
cient to keep the tube patulous; but should it become occluded 
or the respirations labored, the tube should be removed and 
cleansed. The reintroduction should depend on the character 
of the respirations after removal of the tube. In some cases 
the patient coughs up the tube when it becomes occluded, but 
when the tube is being constantly coughed up it indicates that DISEASES OE THE LARYNX 
307 
it is too small and a larger size should be used. In favorable 
cases the time for removal of the tube will depend to a 
great extent upon the age of the patient. In children six or 
seven years old the tube may be removed in four or five 
days; in younger children it should remain five to seven days. 
When death results after intubation it is almost always due 
either to the extension downward of the membrane or to 
bronchopneumonia. 
An amazing and distressing complication that sometimes 
arises is the inability of the patient to breathe without the tube. 
Children sometimes are obliged to wear the tube one hundred 
and ten days, being entirely well, except that they could not 
breathe without it. The prolonged wearing of the tube some- 
times produces ulcers in the larynx, which may result in com- 
plete occlusion of that organ or so constrict the lumen that a 
tracheotomy is necessary. 
Extubation.-The patient is prepared in the same manner as 
for intubation. The gag is introduced and an assistant 
steadies the head of the patient. The operator introduces the 
left index-finger in the mouth until the tube is felt behind the 
epiglottis. Then, with the extractor in his right hand, the 
beak is glided over the tongue until the tip of the finger is felt 
at the opening of the tube, when the handle is elevated and the 
beak of the extractor slips into the tube. Then, pressing the 
lever on the top of the handle, the blades of the beak separate 
and hold the tube securely until it is withdrawn. 
7 reatment for Intubation Patient.-When the nares are in- 
volved they should be syringed several times daily with the 
normal salt solution, otherwise local treatment is unnecessary 
and may be harmful. Steam generated in the presence of the 
patient is no longer considered necessary. Constitutionally, 
stimulants should be given as required, preference being given 
to alcohol and strychnin. Calomel in small doses often seems 
to do good in limiting the inflammation and preventing broncho- 
pneumonia. Iron mixtures are difficult to swallow and are just 
as well omitted. A simple cough mixture containing am- 308 
DISEASES OF THE NOSE, THROAT, AND EAR 
monium carbonas and syrup of ipecac often aids in liquefying 
and expelling the mucus from the throat. The most important 
element in the treatment is the nourishment. Milk should be 
given freely. Broths of all kinds, beef-tea, milk-toast, and 
ice-cream may be given freely. 
The method of administration of food and medicines is a 
much-mooted question. Nursing infants take nourishment 
readily from the nursing bottle. In such cases lowering the 
head makes swallowing easier, as none of the food gets into the 
tube. In older patients it is best to permit them to take 
their food from a glass or in any way they prefer. Struggling 
to make the patient take it in a specified way produces ex- 
haustion and is harmful. When children will not take food, 
they should be fed by introducing a soft-rubber catheter 
through the nose into the stomach. 
Tracheotomy is indicated in the same cases as intubation and 
for the same reasons. In addition, it is indicated in those cases 
of intubation where the membrane has extended below the tube. 
It is also performed in cases of foreign bodies in the larynx or 
lower air-passages, malignant or benign growths in the larynx, 
edema of the larynx, fracture, gumma, tuberculosis, and 
spasm of the larynx. 
High and Low Operations.-The high operation is an opening 
into the trachea through the cricothyroid membrane, including, 
in some instances, the cricoid cartilage and the first ring of the 
trachea. The incision into the trachea is above the thyroid 
isthmus. The low operation is an incision of the trachea below 
the thyroid isthmus. In this situation the opening into the 
trachea can be made longer, and for this and other reasons is 
usually the preferable operation. 
Tracheotomy has been characterized as one of the most easy 
or one of the most difficult of surgical operations. The 
difficulties of the operation are enormously increased by the 
presence of a fat short neck and venous congestion. 
Anesthetic.-In diphtheria and where there is stenosis of the 
larynx from any cause or great inflammation or irritability of DISEASES OF THE LARYNX 
309 
the larynx and trachea, choloroform is the preferable anesthetic. 
In cases where the supply of oxygen has been deficient for 
some time it seldom requires more than a few whiffs of chloro- 
form to produce unconsciousness. The chloroform, therefore, 
should be used with great care. 
Cocain may be employed locally in adults by injecting one- 
quarter of a 1 per cent, solution subcutaneously along the line 
of incision. From 2 drams to | ounce of the solution should be 
necessary to produce local anesthesia. 
Fig. 131.-Position of patient for tracheotomy {American Text-book of Diseases 
of Children). 
Instruments Required.-The instruments required are a 
small scalpel, a bistoury, stout angular scissors, dissecting 
forceps, one-half dozen hemostats, grooved director, catgut 
ligatures, tenaculum, two blunt retractors, and tracheotomy 
tubes (Fig. 132). 
Preparation of the Patient.-The patient is placed on the table 
with a small pillow, filled with sand, under his shoulders in such 
a manner as to bring the trachea prominently into view (Fig. 
131). However, it is best not to adjust the sand-pillow until 
after the anesthetic has been given. The skin of the neck is 310 
DISEASES OF THE NOSE, THROAT, AND EAR 
scrubbed with green soap and washed with benzene and then 
with alcohol. Wet bichlorid towels are then placed over the 
chest and scalp and under the neck and shoulders. 
The High Operation or Laryngotracheotomy.-For the high 
operation an incision is made in the median line ftom the top of 
the thyroid cartilage to the second tracheal ring. The handle 
of the scalpel is used to uncover the cricothyroid membrane 
(Fig. 102), on which will be seen, extending transversely across 
the cricothyroid artery and vein. Pushing these to one side, a 
transverse incision is made through the membrane and mucous 
membrane of the larynx. A tracheotomy tube is then inserted. 
This is the simplest and easiest form of the "high operation" 
and is properly called laryngotomy. It is useful in cases of im- 
minent suffocation, when there is not time to perform a de- 
liberate low tracheotomy. 
In cases where sufficient room is not secured by a transverse 
incision of the cricothyroid membrane, laryngotracheotomy is 
necessary. This consists in dividing the cricoid cartilage and 
the first ring of the trachea. Below this point there is danger of 
wounding the isthmus of the thyroid gland and causing 
profuse hemorrhage. The cricoid and first ring of the trachea 
are divided either by the scissors, one blade being inserted 
within the trachea through the incision in the cricothyroid 
membrane, or the trachea is steadied by the tenaculum 
and a bistoury is inserted in the wound and made to cut 
through the cartilage. In adults the cricoid is not infre- 
quently partially ossified, so that a somewhat stout pair of 
scissors is required to sever it. 
The Low Operation.-The incision should extend from the 
cricoid cartilage to within 1 inch of the sternum. When the 
skin is divided the transverse fascia will be brought into view. 
An opening is made in this near the middle of the wound by 
lifting it up with the dissecting forceps and incising it suffi- 
ciently to permit the introduction of a grooved director, which 
is thrust upward to the upper border of the wound. No 
vessel of any size being visible over-the director, the fascia is DISEASES OF THE LARYNX 
311 
incised. This is repeated in the lower half of the wound. 
The deep fascia uniting the two pairs of muscles, the sterno- 
hyoid and sternothyroid, is now brought into view and is 
treated in the same manner, but care should be exercised in 
using the knife and grooved director that the cuts in the fascia 
extend completely to each angle of the wound to prevent it 
becoming funnel shaped by the time the trachea is reached. 
A layer of areolar tissue and fat is now encountered contain- 
ing many engorged veins. These, if possible, are pushed to 
one £lde as the operator proceeds with grooved director and 
knife to uncover the trachea. If it is impossible to push a vein 
to one side, two ligatures are passed under it and tied some dis- 
tance apart, after which the vein is cut. 
'The wound is now widely opened by means of blunt re- 
tractors in the hands of an assistant. Its depth, especially at 
the lower extremity, may perhaps appall the inexperienced 
operator, who, however, can assure himself that he has not 
"missed the trachea" by tracing its course in the wound from 
above downward with his finger-tip. His fears will be quieted 
when, after carefully separating the fat and loose connective 
tissue in the median line, the trachea finally is uncovered, 
first at the upper end of the wound, where it lies most super- 
ficially. In this locality also during the operation will prob- 
ably appear the isthmus of the thyroid gland. This should 
be pulled upward out of the way by an assistant or, should 
that prove impossible, the isthmus can be cut between two 
ligatures. 
The trachea having been reached and the wound dry and 
free from blood, the tenaculum is inserted in it in the median 
line near the upper portion of the wound with the point of the 
tenaculum directed upward. The use of the tenaculum is 
necessary because of the constant movement of the trachea. 
The trachea being steadied by the tenaculum, the point of a 
bistoury or scalpel is inserted in the trachea in such a manner 
as to pierce its mucous membrane, but not to cut the posterior 
wall of the trachea. Cutting carefully and avoiding long 312 
DISEASES OF THE NOSE, THROAT, AND EAR 
sweeps of the knife, which might endanger the posterior wall, 
three rings are cut, one after the other, with a perceptible snap, 
yielding in an adult an incision in the trachea about | inch in 
length. The knife is now withdrawn and a hemostat inserted 
and opened, widely separating the edges of the tracheal 
incision. 
The moment the trachea is opened, any blood in the wound 
is sucked into the trachea and immediately violently expelled 
together with any mucus contained in the trachea. The lungs 
Fig. 132.-Tracheotomy; A, Tracheotomy-tube with pilot; B, tracheotomy-tube in 
position (Stoney). 
then seem to empty themselves of air and the patient stops 
breathing for a period which may be an anxious one to an inex- 
perienced operator. Finally, a long deep breath is taken, and 
from then on the respiration is normal. The tracheotomy- 
tube should now be inserted and be secured by tapes (Fig. 
132, b). The upper end of the wound is secured by sutures, a 
portion at least of the lower end being allowed to remain open 
for drainage. A rectangular piece of iodoform gauze suffi- 
ciently large to cover the wound is slit in such a manner that it 
can be inserted underneath the shield of the tube next the skin, DISEASES OF THE LARYNX 
313 
and is held in place by the tape. A handkerchief is tied 
loosely about the neck in such a manner that a flap falls down 
over the tube and prevents the entrance of dust and other 
materials, and also receives secretions which are coughed out 
through the tube and immediately sucked back into the 
trachea unless absorbed by the handkerchief or gauze and 
removed by the attendant. In diphtheria cases the inner tube 
should be removed and cleansed by the nurse every two hours 
or oftener should the circumstances require it. When neces- 
sary the outer tube should be removed and cleansed by the 
surgeon. The reintroduction of the tube is facilitated by the 
pilot (Fig. 132, a). 
After tracheotomy, during the time the patient is confined to 
his room, generally a week or two, the air of the room should 
be kept at a temperature of 8o° F. and impregnated with 
steam from boiling water. In diphtheria cases the steam aids 
in keeping the secretions moist and liquid and tends to prevent 
the occurrence of tracheotomy bronchitis or pneumonia. 
A liquid diet should be maintained for a few days after the 
operation. 
The wound above and below the tube usually heals rapidly, 
but exuberant granulations about the tube may require re- 
moval by scissors or curette. THE EAR 
ANATOMY OF THE EAR 
The ear is divided into the external ear, comprising the au- 
ricle or pinna and the external auditory canal; the middle ear, 
Comprising the membrana tympani, cavity of the tympanum, 
Roof of Sony 
Meatus 
Sead o/"Malleus 
ftoofof Tyfnpanurn 
Semicircular Canals 
facia/ Aerae 
Acous/ic 
Aerie 
Cerume- 
nous 
Glands 
Cochlea 
floor of Bony Meatus 
EustacAAm Tide 
laid open 
Short Irocess 
frikmus'' 
'%>orqf7ympaJi'^ 
Fig. 133.-Front view of the organ of hearing (Randall). 
the mastoid cells, and Eustachian tube; the internal ear, or 
labyrinth, comprising the vestibule, the semicircular canals, 
the cochlea, and the auditory nerve (Fig. 133). 
THE EXTERNAL EAR 
The Auricle or Pinna.-The auricle is an irregular mass 
of reticular cartilage deficient at certain parts, where it is con- 
nected by fibrous tissue and muscles. The cartilage is covered 
314 ANATOMY OF THE EAR 
315 
by perichondrium, outside of which is firmly adherent skin, 
containing sweat and sebaceous glands. 
The names given to the elevations and depressions of the pinna 
are the helix, antihelix, fossa of the helix, fossa of the antihelix, 
tragus, antitragus, concha, and lobule (Fig. 134). 
Muscles of the Auricle.-Those on the anterior surface are 
the tragicus, the antitragicus, the helix major, and the helix 
minor. Those on the posterior surface are the transversus 
auriculae and the obliquus auriculae. 
Those which connect the auricle with 
the side of the head and move the 
pinna as a whole are the attolens, at- 
trahens, and retrahens aurem. 
The lobule of the ear is the inferior, 
soft, pendulous part of the pinna, 
consisting of fat and connective tis- 
sue covered by skin (Fig. 134). 
Vessels and Nerves.-The arteries 
are the anterior auricular branch of 
the temporal artery; the posterior 
auricular artery; a branch of the ex- 
ternal carotid; and the auricular 
branch of the occipital artery. Corresponding veins accom- 
pany the arteries. The posterior auricular artery is some- 
times cut by the first incision in mastoid operations and causes 
a somewhat profuse hemorrhage, which is readily controlled. 
The nerves are the auricularis magnus, from the cervical 
plexus; posterior auricular, from the facial nerve; the auricular 
branch (Arnold's), from the pneumogastric; the auricular 
temporal, from the inferior maxillary division of the fifth nerve; 
and branches from the occipitalis major and minor. 
The external auditory canal is composed of a cartilaginous 
and a bony portion. It is about i| inches in length, the carti- 
laginous portion being about | inch in length, and forming 
rather less than one-half the canal, which extends from the 
concha to the drum-head. The external auditory meatus is 
Fig. 134.--Pinna or auricle 
(Gray). 316 
DISEASES OF THE NOSE, THROAT, AND EAR 
lined with a continuation of the skin of the auricle, which 
within the canal contains hair-follicles and ceruminous glands. 
These glands are most numerous at the junction of the carti- 
laginous and bony portions. The course of the canal is gen- 
erally described as that of a spiral turned anteriorly inward 
and downward; but in some individuals the canal is so straight 
that the drum-head may be inspected by simply illuminating 
the canal by reflected light. 
It should be borne in mind that the auditory canal is narrow- 
est near its central portion, beyond which it again expands into 
a sort of pouch terminating at the drum-head-an anatomic 
construction which adds to the difficulties of removing a foreign 
body should it penetrate beyond the narrowest portion of the 
canal. 
Pressure in front of the tragus usually closes the lumen of the 
canal; and, owing to this valve-like arrangement, the entrance 
of foreign bodies into the canal is rendered more difficult. The 
striking feature of the cartilaginous meatus is the incisurae 
Santorini, which completely divide the cartilage into three 
half rings, united by fibro-elastic tissue. 
THE MIDDLE EAR 
The membrana tympani is a thin, elastic membrane stretched 
obliquely across the fundus of the external auditory canal in 
such a manner that its upper and posterior portion is most 
external. It is divided horizontally by the anterior and pos- 
terior folds into two unequal portions-the membrana flaccida 
or Shrapnell's membrane and the membrana tensor or mem- 
brana vibrans (Fig. 135). 
ShrapnelVs membrane is composed of skin from the auditory 
canal, and of loose cellular tissue, covered by the mucous mem- 
brane of the tympanum, on its inner surface. Bridging a 
notch in the bony ring, the incisura Rivini, to which it is at- 
tached, it passes downward in front of the attic or upper cham- 
ber of the tympanum. Between Shrapnell's membrane and ANATOMY OF THE EAR 
317 
the neck of the malleus is a pouch or space called "Prussak's 
space," which sometimes becomes distended with pus during 
attacks of acute catarrh of the middle ear. Under such cir- 
cumstances a puncture through Shrap- 
nell's membrane, just above the short 
process, will evacuate the pus contained 
in Prussak's space and relieve the pain. 
The membrana iribrans or membrana 
tensor is pearly white in color and is 
polished on its outer surface. It consists 
of three layers-a dermic, formed by a 
continuation of the skin of the auditory 
canal; a fibrous (membrana propria), 
consisting of fibers radiating from a point 
near the center to the circumference, 
and circular fibers, which are so numerous at the periphery as to 
form a dense ring around the attached margin of the membrana 
vibrans and a mucous layer continuous with the mucous mem- 
brane of the tympanum. The handle or manubrium of the 
Fig. 135.-Outer surface 
of the right membrana tym- 
pani: a, Membrana flaccida 
or Shrapnell's membrane; b, 
posterior fold; c, short proc- 
ess; D, incudostapedial artic- 
ulation; E, malleus handle; 
F, umbo; G, cone of light. 
Fig. 136.--Outer half of sagittal section of entire left middle ear: o, Anterior 
and p, posterior, pouches of von Troltsch; op, ostium pharyngeum tubae; te, Eusta- 
chian tube; it, isthmus tubas; mt, membrana tympani, with the malleus and incus 
and the chorda tympani nerve; n, attic or recessus epitympanicus; an, mastoid 
antrum; w, w, mastoid cells (Politzer). 
malleus is fixed between the radiating and circular fibers of the 
membrana propria. The outer surface of the drum-head faces 
downward, forward, and outward at an angle of 55 degrees 318 
DISEASES OF THE NOSE, THROAT, AND EAR 
with the axis of the auditory canal. Its outer surface is con- 
cave. From above, the malleus handle may be seen extend- 
ing downward and somewhat backward from the tubercle, its 
short process, and ending near the center of the drum-head at 
a depression, the umbo. During life, when illuminated, the 
membrana tympani generally presents a triangular light spot 
or "cone of light," having its apex at the umbo and extending 
downward and forward to the periphery (Fig. 135). The mu- 
cous membrane of the inner surface of the drum-head is folded 
upon itself as it passes over the chorda tympani nerve, so that 
two pouches are formed, opening downward, one in front of 
and the other behind the manubrium (Fig. 136). 
Vessels of the Membrana Tympani.-The dermoid layer is 
supplied with arterioles by the deep auricular branch of the 
internal maxillary artery; the mucous membrane, by the tym- 
panic branches of the internal maxillary, internal carotid, and 
stylomastoid arteries. 
Nerves of the Membrana Tympani.-To the external layer 
are distributed filaments from the superficial branch of the fifth 
nerve, while the mucous layer is supplied by the tympanic 
plexus. 
The cavity of the tympanum is of irregular shape. It meas- 
ures about | inch anteroposteriorly,| inch vertically, and I inch 
transversely. It is situated in the petrous portion of the tem- 
poral bone above the jugular fossa, having the catroid canal in 
front, the mastoid cells behind, the auditory canal externally, 
and the labyrinth internally. It communicates with the phar- 
ynx by means of the Eustachian tube and with the mastoid 
antrum by means of the aditus ad antrum. The upper portion 
of the tympanum is called the attic or recessus epitympanicus. 
It extends outward over the auditory meatus, from which it is 
separated by a wedge-shaped mass of bone, sometimes called 
the scute. On the scute lie the head of the malleus and body of 
the incus. The handle of the malleus and long process of the 
incus descend through the narrow opening from the attic into 
the atrium or lower cavity of the tympanum. ANATOMY OF THE EAR 
319 
The roof of the tympanum consists of a thin plate of bone, 
the tegmen tympani, which separates the tympanic cavity from 
the meninges of the brain. The floor of the tympanum is nar- 
Figs. 137 and 138.-Sections through the tympanum parallel to its inner wall: 
median aspect of the specimens: H, Horizontal semicircular canal; H.N, horizontal 
portion of aquaeductus Fallopii; V.N, vertical portion. In the upper specimen the 
section is somewhat more median than in the lower, in order to open the horizontal 
semicircular canal of the aquaeductus Fallopii. It will be observed that in the 
lower specimen, the tubercle, H, containing the semicircular canal is more lateral 
than the hard ridges of the bones below it, HN, containing the facial canal. In 
the upper specimen the stapes is in the oval window, and the topography of the 
inner wall of the tympanum, the aditus, and the mastoid antrum is well shown in 
both specimens (Author's specimens). 
row and separates the cavity of the tympanum from the jugu- 
lar fossa beneath. Nearer the inner wall is a small foramen 
for the passage of Jacobson -s nerve. The outer wall consists of 320 
DISEASES OF THE NOSE, THROAT, AND EAR 
the membrana tympani and the bony ring into which it is in- 
serted. In this bony ring, the annulus tympanicus, are two 
small orifices, the iter chordae posterius and iter chodae anterius, 
for the entrance and exit of the chorda tympani nerve. Just in 
front of and above this bony ring is the Glaserian fissure, in 
which is lodged the long process of the malleus, and which also 
gives passage to some tympanic vessels and the anterior liga- 
ment of the malleus. 
The inner tympanic wall (Figs. 137 and 138), which is 
nearly vertical, bulges outward as an eminence, the promon- 
tory corresponding to the first turn of the cochlea. Below, 
posteriorly, is the niche, at the bottom 
of which lies the fenestra rotunda or 
"round window," closed by the mem- 
brana tympani secundaria. This mem- 
brane is protected by the external wall 
of the niche, in which it so lies that it is 
impossible to injure it by means of a 
straight instrument thrust from with- 
out through the membrana tympani. 
Above, posteriorly, is the fenestra ovalis or " oval window," 
closed by the foot-plate of the stapes. Above the oval win- 
dow is the eminence of the aqueductus Fallopii, which trans- 
mits the facial nerve. The pyramid is a hollow conic pro- 
jection containing the stapedius, muscle, whose tendon escapes 
by an opening at its summit. 
In the posterior wall above is the opening into the mastoid 
antrum, the aditus ad antrum. The anterior wall separates 
the cavity of the tympanum from the carotid canal, which 
lies immediately below and in front of it. In the upper por- 
tion of the anterior wall is the orifice of the Eustachian tube. 
Just above is the canal for the tensor tympani muscle. The 
Eustachian tube is separated from the canal for tensor tym- 
pani muscle by a thin bony plate, the processus cochleariformis. 
The ossicles are three small bones so arranged as to form a 
movable chain connecting the membrana tympani with the 
Fig. 139.-The malleus, 
incus, and stapes of left 
ear: A, Malleus; B, incus; 
C, stapes. ANATOMY OF THE EAR 
321 
fenestra ovalis. These three bonelets are the malleus or ham- 
mer; the incus or anvil; and the stapes or stirrup (Fig. 139). 
The malleus is a somewhat irregularly shaped bone, con- 
sisting of an oval head, articulating with the incus; a neck, a 
short and long process; and a manubrium or handle, imbedded 
in the membrana tympani. The head and neck of the mal- 
leus, which project into the tympanic cavity, are entirely 
free from the membrana tympani, the surface of the head, 
which articulates with the incus, being directed backward. 
The long and short processes are situated at the junction of 
Fig. 140.-Ligamentous support of ossicles, viewed from above: l-h, Attach- 
ment of the ligamentum mallei externum; k, head of hammer; i, body of incus; 
f, point of its short process; a, entrance to the Eustachian tube from the tympanum; 
c, stapes; d, tendon of stapedius muscle; b, tendon of the tensor tympani leaving 
the cochlear process; g-g, chorda tympani, marking the free edge of the folds of 
mucous membrane bounding the pouches; n, the upper tendinous fibers of the 
ligamentum mallei anterius, originating above the spina tympanica major, tn; j, 
malleo-incudal joint (Helmholtz). 
the neck and handle of the malleus. The short process 
pushes the membrana tympani outward before it and is gen- 
erally plainly visible during life as a tubercle at the upper 
extremity of the malleus handle. The long process passes 
forward into the Glaserian fissure, with the under wall of 
which it unites in adult life. The malleus is held in position 
within the tympanum by four ligaments-the anterior, su- 
perior, external, and posterior. Of these ligaments the anterior 
is by far the strongest, the posterior and external ligaments 
being, in a mechanical sense, but one ligament, to which 
Helmholtz has given the name "axial ligament of the malleus." 322 
DISEASES OF THE NOSE, THROAT, AND EAR 
The incus is the middle one of the three ossicles, its name 
being derived from the shape of its upper part. This bonelet 
consists of a body, a short or horizontal process, and a long 
or descending process. The incus is attached at the extrem- 
ity of its horizontal process to the posterior tympanic wall 
by somewhat weak ligaments (Fig. 140). The long process 
of the incus curves downward, and at first somewhat outward, 
toward the auditory meatus, its tip bending sharply inward to 
articulate with the head of the stapes by means of the lenticular 
process. 
The malleo-incudal joint is a ginglymus or hinge-joint, like 
that of the knee or elbow. The ligaments of the malleus are 
so arranged that the bone performs the part of a lever whose 
fulcrum is just below the short process. The manubrium is 
the long arm of the lever and, consequently, all its movements 
are repeated in an opposite direction by the head of the malleus. 
Each inward movement of the membrana tympani and manu- 
brium causes a slight outward movement of the head of the 
malleus. The incus being also suspended as a lever, when its 
upper part moves outward with the head of the malleus its 
long process swings inward and pushes the stapes before it, so 
that the foot-plate is forced into the oval window. 
The stapes is the smallest bone in the body. It consists of a 
head, articulating with the lenticular process of the incus, two 
branches, or crura, joining the base, which is connected by 
ligamentous fibers with the margin of the oval window. The 
stapes (Fig. 139, C) measures 4 mm. from its head to the foot- 
plate, the latter measuring 2| mm. in its horizontal diameter. 
The foot-plate of the stapes is somewhat kidney shaped. 
When in position its long axis is nearly horizontal, with its 
convex edge looking upward and its concave edge looking 
downward. A thin membrane, the ligamentum obturatorium 
stapedius, stretches across the space between the base and the 
crura. 
Muscles of the Tympanum.-The tensor tympani originates 
from the under surface of the petrous bone, the cartilaginous ANATOMY OF THE EAR 
323 
Eustachian tube, and its own osseous canal. It is inserted into 
the handle of the malleus near its root. Its action is to draw 
the membrana inward and increase its tension. The tensor 
tympani muscle is supplied by a nerve from the otic ganglion. 
The laxator tympani major and minor have already been 
described as anterior and posterior ligaments of the malleus. 
The stapedius muscle originates from the interior of the 
pyramid and is inserted into the head of the stapes. Its 
action is to lift the anterior part of the foot-plate of the stapes 
out of the oval window, thus antagonizing to a certain extent 
the action of the tensor tympani muscle. The stapedius 
obtains its nerve supply by a filament of the facial nerve. 
Arteries of the Tympanum.-The tympanic branch of the in- 
ternal maxillary enters the Glaserian fissure and is distributed 
to the membrana tympani. The tympanic branch of the in- 
ternal carotid also supplies the membrana tympani. The 
stylomastoid extends from the posterior auricular to the back 
part of the tympanum and mastoid cells. The petrosal 
artery-a branch of the middle meningeal, enters the ear 
through the haitus Fallopii, and a branch from the ascending 
pharyngeal passes up the Eustachian tube. 
Nerves of the Tympanum.-The tympanic branch of the 
glosso-pharyngeal (Jacobson's nerve) supplies the mucous mem- 
brane of the tympanum and fenestrae. The tympanic branch 
of the facial nerve supplies the stapedius muscle and a branch 
from the otic ganglion supplies the tensor tympani muscle. 
The chorda tympani nerve passes across the tympanum be- 
tween the handle of the malleus and the long process of the 
incus, without branches. It enters the tympanum by the iter 
chordae posterius and emerges through the iter chordae anterius. 
The Tympanic Plexus.-Jacobson's nerve (tympanic branch 
of the glossopharyngeal) divides into three branches, lying in 
grooves upon the promontory: One joins the carotid plexus; 
a second, the greater superficial petrosal nerve; and a third, 
passing upward and forward, finally becomes the lesser super- 
ficial petrosal nerve. 324 
DISEASES OF THE NOSE, THROAT, AND EAR 
The Eustachian tube, which is about i| inches long, passes 
from the middle ear downward, forward, and inward to enter 
the pharynx. It affords communication between the air in 
the pharynx and that contained in the middle ear. The outer 
third consists of bone, commencing at the anterior tympanic 
wall, and gradually narrowing to terminate at the angle of 
junction of the petrous and squamous portions of the temporal 
bones. The inner two-thirds of the Eustachian tube consist 
of elastic cartilage and fibrous tissue, which unite the inferior 
portion of a curved cartilaginous plate so as to form a tube. 
The mucous membrane lining the Eustachian tube is a con- 
tinuation of that of the pharynx and is covered with stratified 
ciliated epithelium. At birth the Eustachian tube is nearly 
horizontal with its pharyngeal orifice at the level of the hard 
palate, until about the ninth month, when it is distinctyl 
higher. At about this age the tube also begins to slant some- 
what upward and outward. During infancy the tube is wider 
at its narrowest point than in the adult. 
The muscles that dilate the Eustachian tube are the levator 
palati muscle, which, arising from the petrous bone and carti- 
laginous portion of the tube, is inserted into the tissues of the 
soft palate, and the tensor palati, a flattened muscle, which, 
arising from the sphenoid bone and the cartilaginous tube, 
passes as a broad tendon around the hamular process to form 
the broad aponeurosis of the soft palate. The action of both 
these muscles is to dilate the tube. Some of the fibers of the 
tensor tympani and tensor palati are blended and an aponeu- 
rotic connection always exists along the Eustachian tube, so 
that probably these two muscles have no action entirely 
independent of each other. When the soft palate is drawn 
upward the membrane is also retracted by the tensor tympani 
and the Eustachian tube is at the same time dilated, so that, 
although a current of air enters the tympanum, it is prevented 
from forcing the membrane too far outward and interfering 
with the equilibrium of auditory tension. The tensor tympani 
and tensor palati receive nerve-filaments from the otic ganglion, ANATOMY OF THE EAR 
325 
but the levator palati is supplied by a branch from Meckel's 
ganglion. 
The Eustachian tube receives its arterial supply by the fol- 
lowing arteries: The ascending pharyngeal, branches from the 
middle meningeal and internal maxillary, and a branch from 
the stylomastoid artery. 
Its nerves are, in addition to those supplying muscles of the 
tube, derived from the fifth and seventh pair and the glosso- 
pharyngeal. 
The Mastoid Process of the Temporal Bone.-At birth the 
mastoid process consists of a small flattened tuberosity con- 
taining but one cell and that of considerable size-the mastoid 
antrum (Fig. 193). At puberty the mastoid process has be- 
come a distinct prominence, conic in shape, with its apex 
downward. The substance of the mastoid process consists 
of small cavities varying greatly in number, size, and shape in 
different individuals. Some of them communicate with each 
other and are lined with a continuation of the mucous mem- 
brane of the tympanum, which is here covered by squamous 
epithelium. 
THE INTERNAL EAR OR LABYRINTH 
Osseous Boundaries.-At all points the various channels 
and cavities of the labyrinth are deeply imbedded in the petrous 
portion of the temporal bone. The bony labyrinth consists of 
a central cavity called the "vestibule," from the walls of which 
spring, like arches, the semicircular canals, while through the 
anterior wall of the vestibule a canal leads into the snail- 
shaped cavity of the cochlea (Fig. 141). 
Contents of the Osseous Labyrinth.-The vestibule contains 
fluid and two distinct membranous sacs, the utricle and saccule 
(Fig. 142). The saccule communicates with one of the mem- 
branous tubes of the cochlea, the ductus cochlearis, by means 
of a slender membranous tube, the canalis reuniens, while the 
cavity of the utricle is continuous with that of the mem- 326 
DISEASES OF THE NOSE, THROAT, AND EAR 
branous semicircular canals, so that the membranous labyrinth 
may be said to consist of a system of cavities with membran- 
Fig. 141.-The bony labyrinth laid open by removal of lateral wall: I, Recessus 
ellipticus for utricle; 2, recessus sphasricus for saccule; 3, recessus cochlea; 4, pyramus 
vestibuli; 5, round window; 6, posterior semicircular canal; 7, external semicircular 
canal; 8, cupola of the cochlea; 9, superior semicircular canal; 10, lamina spiralis 
ossea projecting from the modiolus into the caliber of the canal of the cochlea, and 
terminating in the cupola as a hook-like process called the "hamulus." 
ous walls containing a fluid, the endolymph, and nearly sur- 
rounded by another fluid, the perilymph. 
A diaphragm consisting partly of bone (lamina spiralis ossea) 
^Macula acus- 
lica saccuiu 
„Sacculus. 
„Utriculosac- 
cular canal. 
-Macula acus- 
tica utriculi. 
-Ampulla, 
■Ant. semicircular canal. 
Auditory nerve 
with its vestibu- 
Jar and cochlear 
branches. 
Ampulla. 
zUtriculus. 
Post, semicircular canal. 
Fig. 142.-Membranous labyrinth of the right ear from five-months'-old human 
embryo (from Schwalbe, after Retzius). 
Cochlear duct. 
Canalis reuniens. 
Ductus 
endolvmohaticus 
Ampulla. 
Horizontal semicir- 
cular canal. 
and partly of membrane (membrana basilaris) divides the 
cavity of the cochlea into an upper and lower space of nearly 
equal size (Fig. 143). The upper, the scala vestibuli, com- ANATOMY OF THE EAR 
327 
municates with the cavity of the vestibule, and the lower, the 
scala tympani ends abruptly at the round window. The upper 
Fig. 143.-Longitudinal section of the cochlea, showing the relations. of the 
seal®, the ganglion spirale, etc.: S.V, Scala vestibuli; S.T, scala tympani; S.M, 
scala media; L.S, ligamentum spirale; G.S, ganglion spirale (Gray). 
space (scala vestibuli) is divided by a diaphragm (Reissner's 
membrane) placed at an angle of 45 degrees with the mem- 
brana basilaris, into the scala vestibuli proper and the scala 
Fig. 144.-Transverse vertical section of Corti's organ of a man twenty-nine 
years old; es, Limbus laminse spiralis; me, membrana tectoria; Hb, Hensen's striae; 
mf, fibers of attachment of the membrana tectoria to the zona tecta; si, sulcus 
spiralis; siz, epithelium of the sulcus spiralis; is, inner supporting cells; ic, inner 
rod cells in connection with the outer rod cells, between which is seen the tunnel 
(7) of Corti; ih, inner hair-cell; ah'-ah*, outer hair-cells; dz, Deiters' cells; (is, Hensen's 
supporting cells; rb, nerve-fibers of the ramulus basilaris; w'-w6, outer bundles of 
the spiral nerve-fibers; rf, radiating tunnel, fibers; at, inner part of Nuel's space; 
mb, upper layer of the membrana basilaris; mb', lower layer of the membrana 
basilaris; tb, layer covering the tympanic surface of the membrana basilaris; Us, 
ligamentum spirale (Gruber, after Retzius). 
media or ductus cochlearis, which, as already described (Fig. 
142), communicates with the saccule by means of the canalis 328 
DISEASES OF THE NOSE, THROAT, AND EAR 
reuniens. The sacla media or ductus cochlearis contains 
endolymph and the organ of Corti (Fig. 144). 
The organ of Corti rests upon the membrana basilaris about 
midway between the lamina spiralis ossea and the outer wall of 
the ductus cochlearis. It extends from the vestibule to the 
cupola of the cochlea, and to it are distributed nerve-fibers 
from the cochlear branch of the auditory nerve. Corti's organ 
is made up of a nearly central arch, formed by the inner and 
outer rods or pillars of Corti (Fig. 144), the bases of which are 
farther apart as the organ of Corti 
ascends from the vestibule to the 
cupola. There are at the outside 
of the arch four rows of ciliated 
cells and at the inner side one 
row, which receive terminal fila- 
ments from the cochlear branch 
of the auditory nerve. The name 
"hearing cells" is sometimes ap- 
plied to these hair-cells. There is 
a peculiar fenestrated membrane, 
the lamina reticularis, into whose 
net-like structure project the cilia 
of the outer hearing cells, which 
are covered and protected by a 
glue-like substance, the membrana 
tectoria. The rods of Corti have 
been estimated at about 10,500, 
while the number of hair-cells is estimated to be about 21,300. 
The membranous semicircular canals occupy scarcely one- 
third of the space inside the bony canals, except at the ampullae, 
where they hug the bony walls more closely. The space be- 
tween the membranous canals and the bony wall is occupied by 
connective tissue rich in blood-vessels rather than with free 
fluid, as in the cochlea (Fig. 145). 
The otoliths are granular, amorphous, sometimes crystal- 
line particles found along the walls of the utricle, saccule, am- 
Fig. 145.-Section through the 
osseous and membranous semicirct^* 
lar canals: a, Osseous semicircular 
canal; b, place of attachment of the 
membranous semicircular canal; c, 
elevations on the inner surface of the 
membranous semicircular canal; d, 
vascular bands of connective tissue 
(Poiitzer). ANATOMY OF THE EAR 
329 
pullae, membranous canals, on the periosteum of the osseous 
semicircular canals, and in the fluid of the cochlea. They con- 
sist of about 75 per cent, mineral matter, mostly carbonate of 
lime, and organic material resembling mucous in its physical 
and chemic characteristics. In some of the lower animals they 
are huge in size compared with those of man and assume 
fantastic shapes. 
The auditory nerve originates by three fasiculse from the 
superior vermiform process of the cerebellum and from the in- 
ner and outer nuclei, formed chiefly by the gray substance of 
the posterior pyramid and restiform body. The nerve emerges, 
superfically, from a groove between the olivary and restiform 
bodies at the lower border of the pons. At the bottom of the 
internal auditory canal it divides into the cochlear and ves- 
tibular divisions, both of which contain ganglion cells. The 
cochlear nerve divides into numerous filaments to enter the 
modiolus and sends branches to each of the hair-cells (Fig. 144). 
The vestibular nerve divides into three branches: The filaments 
from the upper branch enter the vestibule through the macula 
cribrosa at the bottom of the internal meatus, and are distrib- 
uted to the utricle and the ampulla of the external and superior 
semicircular canals; the middle branch is distributed to the 
saccule, and the inferior branch passes to the ampulla of the 
posterior semicircular canals. 
Function of Vestibular Apparatus including the Semicircular 
Canals.-They are peripheral space-organs, and through centers 
in the brain regulate the movements of the muscles of the eye 
and probably all the muscles of the body for the preservation 
of equilibrium. The power of maintaining equilibrium is de- 
rived from the education of touch and sight and information 
derived from the peripheral space-organ within the ear, which 
informs the brain of the position of the head and regulates the 
movements of the muscles for the preservation of equilibrium. 
Function of the Cochlea.-The cochlea has to do with the 
sense of hearing. It is supposed that the individual hair- 
cells and rods of Corti vibrate to single tones, and that a 330 
DISEASES OF THE NOSE, THROAT, AND EAR 
compound sound causes the vibration of a number of hair- 
cells proportionate to its composite character. 
TESTS FOR HEARING 
Hearing is the faculty of the perception of sound. 
Sound is a peculiar sensation excited in the organs of hear- 
ing by the vibratory motion of bodies, the effects of which are 
transmitted to the ear through an elastic medium. 
Sound is a sensation and should be distinguished carefully 
from the vibrations that produce it; which vibrations, of course, 
may exist without the presence of an organized being to per- 
ceive them. 
Sources of Sound.-Sound is produced by the rapid vibra- 
tions that take place in the molecules of bodies when they are 
disturbed by shock or by friction. When a resonant body is 
struck its molecules alternately approach and recede from one 
another with a velocity and amplitude of vibrations corre- 
sponding to the form, size, and molecular composition of the 
body; and this motion is transmitted by contact to any 
surrounding elastic medium, such as air. Sound-waves so 
produced are in part reflected in passing from a rarer to a 
denser medium, as, for example, when passing from air into 
water. If, however, a tense membrane, free to vibrate, is 
interposed between the air and any fluid or solid medium, the 
aerial vibrations are not reflected, but are transmitted into 
the more solid medium with little loss of their intensity. 
But for the membranes of the middle ear, sound-waves trans- 
mitted from the ear to the lymph of the labyrinth would lose 
intensity to such a degree as to be inaudible. 
Acoustics is that department of physics which treats of 
sounds. A rudimentary knowledge of the laws of acoustics 
is essential to an understanding of the physiology of the ear. 
The science of music treats of a peculiar class of sounds and 
combination of sounds calculated to produce pleasurable 
emotions. Such sounds are distinguished from noises, which ANATOMY OF THE EAR 
331 
are sounds either of very short duration, like the reports of fire- 
arms, or are a mixture of many discordant sounds. 
Pendulum Vibration.-If a needle be attached to one arm of 
a vibrating tuning-fork, and if in contact with the end of the 
needle a piece of smoked paper be moved at a uniform velocity, 
a tracing of the vibrations of the needle will be scratched upon 
the paper (Fig. 146). This tracing is a record of the number of 
vibrations of the fork during a given time and of the amplitude 
of the vibrations. The record is regular and uniform, and so 
similar to that produced by a pendulum under similar circum- 
stances that Huxley has described this form of vibration under 
the name of pendulum vibration. 
A tone is a sound produced by a simple pendulum vibration. 
It has the characteristics of quality or "timbre"; intensity, 
volume or loudness; and pitch (high or low tone). 
The quality of a tone depends largely upon the material of the 
Fig. 146.-Tracing on smoked paper produced by the vibrations of a tuning-fork. 
substance which produces the tone. The quality of the note 
emitted by striking a strip of wood is entirely different as 
regards its quality or "timbre" from that produced by striking 
a rod of metal. A note produced from an organ, a violin, and 
a cornet may in each case have the same pitch and volume, 
but will differ widely from one another as regards quality or 
timbre. 
The intensity of a tone depends upon the force and amplitude 
of the vibrations which produce it. When a tuning-fork is 
first made to vibrate, its tone is comparatively intense or loud, 
because the force and amplitude of its vibrations are compara- 
tively great, but as it continues to vibrate its tone is heard less 
and less distinctly, because the force and amplitude of its vibra- 332 
DISEASES OE THE NOSE, THROAT, AND EAR 
tions are becoming less and less. The pitch of the tone, 
however, remains the same until the fork ceases to vibrate. 
The pitch of a tone depends upon the rapidity of the vibra- 
tions that produce it. The more rapid the vibrations, the 
higher the pitch. The human ear is generally able to distin- 
guish the tone produced by a tuning-fork vibrating only 16 
times during a second, and also that of a fork vibrating 38,000 
times a second. The capacity, however, to distinguish sounds 
of very low or very high pitch varies greatly in individuals, but 
the ears of most persons are more sensitive to sounds of low 
than to those of high pitch. 
The inability to hear high notes increases with age, and 
generally also as the result of disease of the labyrinth or acous- 
Fig. 147.-The Edelmann-Galton whistle with rubber bulb. The pipe below 
the opening is filled with a plunger advanced or withdrawn by a screw, each turn 
being shown by the scale upon the enlarged tube, and its tenths by that on the 
revolving collar. It gives an audible sound from 0.5 (theoretically, 84,000 v. s.) 
to 10 or 12 (4200 or 3500). 
tic nerve; and in testing the acuteness of hearing by means of 
tuning-forks and the Edelmann-Galton whistle it is well to 
bear this fact in mind. For careful tests as to the sensitiveness 
of the perceptive apparatus it is well for the aurist to be pro- 
vided with at least five forks, the lowest (c-2) giving 32 vibra- 
tions during a second and the highest (C4) yielding 2048 
vibrations in a second. The Edelmann-Galton whistle (Fig. 
147) is used also for making tests of this kind. 
The Edelmann-Galton whistle, for testing the higher tones of 
the scale, consists of a metal tube so perforated as to cause a 
whistle when air is blown through it by means of a rubber 
bulb. The distal extremity is closed by a metal rod capable 
of being moved backward and forward within the tube by a ANATOMY OF THE EAR 
333 
micrometer screw. The length of the column of air within 
the tube beyond the perforation, and consequently the pitch 
of the note emitted by the whistle, are determined by the posi- 
tion of the rod within the tube. The micrometer screw is 
graduated to indicate single numbers, while on the side of the 
tube is a scale to show tens; so that by turning the micrometer 
screw the metal rod within the hollow cylinder can be placed 
in any position indicated by a number on the scale. The pitch 
of the whistle notes have a range of from about 7000 to 80,000 
vibrations. 
Helmholtz states that the human ear is able to distinguish as 
musical notes tones lying between 16 and 38,000 vibrations 
per second, or a range of about 11 octaves, but that the lowest 
note used in orchestral music is E-2 or one of 40 vibrations per 
second. In pianos the lowest note in general use is C-2, 32 
vibrations per second; and the highest, 7 octaves above it, is 
c5, 4096 vibrations during a second. 
Harmony.-If the rates of vibration in a second of two notes 
simultaneously produced stand to each other in the ratio of 
simple multiples, so that while the low note makes 1 vibration 
the high note makes 2, 3, 4, etc., the notes are said to be in 
harmony or concord, as the result is consonance. These are 
the ratios of the human voice in ordinary speaking or singing, 
and, according to Wolf, speech has a compass of 5 octaves, 
from c to c5. The simplest ratio is f, and to this the name 
octave is given. In this case the higher note has double the 
number of vibrations of the lower. The ratio of the notes in 
the diatomic major scale is as follows: 
c. 
D. 
E. 
F. 
G. 
A. 
B. 
C 
9 
5 
4 
3 
5 
1 5 
1 
I 
K 
J 
7 
■J 
-r 
2 
The tuning-fork used to test the hearing should be large 
enough to secure sufficient intensity or loudness of tone. It 
is desirable to have the tuning-fork provided with movable 
clamps, so as to deaden overtones. While it is more con- 
venient, as stated, for the aurist to be provided with at least 334 
DISEASES OF THE NOSE, THROAT, AND EAR 
five or more forks of different pitch, yet one sounding the note 
C (256 vibrations per second) is the most useful for ordinary 
clinical investigations. It is convenient to have at hand a 
small tuning-fork emitting a tone of feeble intensity in order 
to confine the sound to one ear; because when a very heavy 
tuning-fork is employed in examining patients whose hearing 
is greatly impaired only in one ear, it is impossible to be certain 
that the sound of a large fork is not heard by the ear in which 
the hearing is better. However, a large fork, provided with 
movable clamps, can generally be made to answer the same 
purpose by placing the clamps sufficiently low down upon the 
tines of the instrument. 
When it is necessary to be certain that no sound is heard by 
the ear not being examined, a noise apparatus should be con- 
nected with it in such a manner that other sounds cannot be 
heard by it. 
Weber's Testr-Any obstruction to the exit of sound- 
waves from the middle ear when a tuning-fork is vibrating 
with its handle in contact with the teeth or at a point upon the 
cranium midway between each ear, will cause the sound of the 
fork to be heard most distinctly in the obstructed ear. The 
cause of the obstruction may be impacted cerumen in the 
external auditory meatus, occlusion of the Eustachian tube, 
mucus within the tympanum, or thickening of the membrana 
tympani as the result of catarrh of the middle ear. Hence, if 
a patient is deaf in only one ear from any of these causes, a 
vibrating tuning-fork, with its handle in contact with the teeth 
or on a point on the cranium midway between the ears, will 
be heard by him better in the deaf ear. If, however, the hard- 
ness of hearing is due to impairment of the labyrinth or the 
auditory nerve, the note of the tuning-fork will be heard less 
distinctly in the deaf ear. Weber's test is most reliable in cases 
of unilateral tympanic disease, less so in labyrinthine disease 
and in bilateral chronic middle-ear catarrh. 
In practising Weber's method of examining the hearing, the 
observer should bear in mind that the answers of some patients ANATOMY OF THE EAR 
335 
are largely determined by their imagination, and that they 
will say at first that they hear the sound of the fork most 
distinctly in that ear in which the hearing is better simply 
because they think they should do so. The test should be 
repeated sufficiently often to convince the observer that his 
patient's answers are reliable. It will, in all instances, be 
judicious to request the patient, while the fork is still vibrating 
upon the cranium, to close first one ear and then the other with 
a finger, and only after this has been done to ask him in which 
ear he now hears the sound of the fork most distinctly. 
Rinne's Test.-Rinne observed that when a vibrating tun- 
ing-fork, with its handle in contact with the tissues over the 
mastoid process, ceased to be heard, the sound of the fork reap- 
peared if it was held in front of the ear; the C2 fork is usually 
heard about twice as long. Aerial conduction is superior to 
tissue-conduction in individuals with normal ears. If the tuning- 
fork is heard best by aerial conduction, the fact may be noted 
as Rinne+; or Rinne- if the contrary is the case; or, to be 
more exact, the number of seconds that the tuning-fork is 
heard upon the mastoid and in front of the auditory meatus 
may be given in the form of a fraction, the numerator of which 
will be less than the denominator if Rinne's method yields a 
positive result, and the contrary will be the case if Rinne's 
method gives a negative result. Thus, if a note of a C2 tuning- 
fork whose handle is in contact with the mastoid process is 
heard for twenty seconds, and for fifty seconds when its tines 
are held close to the external auditory meatus, the fact may be 
noted thus: Rinne If, however, the fork is heard for 
thirty seconds when its handle is in contact with the tissues over 
the mastoid process, and only ten seconds when its prongs are 
held close to the meatus, the fact should be noted as Rinne - 
(R. - 1^). In the first instance any hardness of hearing is due 
to impairment of the nervous part of the ear; in the latter case 
it is due to the result of disease or to imperfection of the exter- 
nal or middle ear, or both. 
It is a well-known fact that any rigidity of the conducting 336 
DISEASES OF THE NOSE, THROAT, AND EAR 
apparatus so alters the relation of tissue to aerial conduction 
that the former finally exceeds the latter. This change begins 
with the low notes. If Rinne's method be employed on a 
patient in whom there is only a slight impairment of the patency 
of the Eustachian tubes, with congestion of the mucous mem- 
brane of the tympanum, the result will be negative with forks 
emitting a very low-pitched note and positive for that of a 
higher pitch. That is, the sound of the fork of low pitch will 
be heard louder and longer when its handle is firmly pressed 
upon the mastoid process than when the tines of the fork are 
held in front of the meatus. This, however, will not be the case 
if a fork emitting a high-pitched tone be employed. In con- 
ditions in which there is great rigidity of the transmitting ap- 
paratus of the ear, the receptive apparatus remaining healthy, 
Rinne's test will yield a negative result with forks of high as 
well as low pitch. Generally under such circumstances tissue- 
conduction will be apparently increased; that is, a tuning-fork 
with its handle pressed upon the tissues over the mastoid will 
be heard louder and longer than normal. When, instead of 
this being the case, tissue-conduction as well as aerial conduc- 
tion is decreased, impairment of the functions of the internal 
ear should be suspected, although it should be borne in mind, 
when testing the hearing of patients past middle life, that 
tissue-conduction of sound is always decreased as the result 
of senility, and sometimes as the result of other causes besides 
disease of the internal ear. It also should be borne in mind 
that in unilateral nerve deafness Rinne's test is frequently 
negative because the sound of the fork by tissue-conduction is 
transmitted from the mastoid of the diseased ear to the normal 
as well as the diseased ear unless a noise apparatus is used. 
The test is only reliable when hearing for whispers is reduced 
to i meter, and the more profound the deafness, the more 
reliable the test. It cannot be depended upon in old age. 
In any case, however, in which the acuteness of hearing is 
reduced to the perception of words spoken in a loud voice close 
to the ear, if tissue-conduction is greater than aerial conduction ANATOMY OF THE EAR 
337 
only for forks of low pitch (Cx to c), while those of high pitch 
(C3, C4) are heard very imperfectly if at all, either by aerial or 
tissue-conduction, the receptive apparatus, as well as the mid- 
dle ear, is impaired. 
In such cases, although the tension of the structures of the 
middle ear can doubtless be removed by operative procedures, 
the performing of such an operation will not result in a great 
improvement in the patient's hearing. 
In cases where middle-ear deafness can be excluded, defective 
hearing for high tones is suggestive of labyrinthine disease ff or 
low tones of disease of the central nervous system; for the mid- 
dle notes of the scale, of disease of the auditory nerve trunk. _ 
Schwabach's Test.-This test consists in comparing the 
number of seconds a fork is heard on the mastoid and at the 
meatus in a normal ear with the time the fork is heard in these 
positions by the ear being examined. The difference in time 
a patient hears a fork vibrating on his mastoid and the physi- 
cian hears it,is ascertained by the oscultation tube (Fig. 148), 
which connects the meati of observer and patient so that both 
hear the sound of the fork vibrating on the patient's mastoid. 
Gelle's Test (Pressions Centripetes}.-If the air within the 
auditory canal be compressed by means of Siegle's speculum 
or any suitable instrument, a normal ear will hear the sound of 
a tuning-fork vibrating on the cranial bones with diminished 
intensity. This phenomenon is due to increased labyrinthine 
pressure, because when the air within the auditory canal is con- 
densed the chain of bonelets with the foot-plate of the stapes is 
pressed inward. If ankylosis of the stapes exists or if there 
is great immobility of the ossicles the tone of the tuning-fork 
will remain unchanged during the test, while if the labyrinth is 
diseased and the stapes is movable the application of Gelle's 
test will produce dizziness. 
Bing's Test.-If a tuning-fork is vibrated upon the mastoid 
process of a normal ear, after its sound is no longer audible it 
can be made to reappear if the meatus is tightly closed with the 
moistened finger. In cases of severe deafness, according to 338 
DISEASES OF THE NOSE, THROAT, AND EAR 
Bing, if this test yields a negative result, the hardness of hear- 
ing is due to a middle-ear affection, while if the result of the 
test is positive, the deafness is the consequence of a labyrinthine 
affection. 
Dr. Bing uses also, as an aid to diagnosis, what he terms the 
" entotic" use of the speaking-trumpet, which consists in speak- 
ing into the speaking-tube connected by means of an air-tight 
joint with a catheter introduced into the mouth of the Eustach- 
ian tube. If the voice is heard better by this method than 
when the speaking-tube is used in the external meatus, there 
is hindrance to sound-conduction at the malleus or the incus, 
and the foot-plate of the stapes is freely movable in the oval 
window. 
To test the hearing by a watch the patient should be seated 
with his face so covered by a napkin or towel that it is impos- 
sible for him to see the watch, because many patients imagine 
that they hear a watch which they see held close to their ear. 
It is well also to request the patient to close firmly with his 
forefinger the ear that is not being tested. The aurist should 
hold the watch in his hand with its case open close to the 
patient's ear until the latter hears it distinctly, then move his 
hand to a considerable distance and slowly bring the watch 
toward the ear being examined, observing the exact distance 
the watch is when^s/ heard. The result of the examination 
may be expressed by a fraction, the numerator of which is the 
distance at which the patient hears the watch and the denomi- 
nator the distance at which the watch can be heard by a nor- 
mal ear. For example, if the watch used in making the test 
is heard by a normal ear at 40 inches, and the patient hears 
it only at 15 inches, the fact may be recorded thus: Hearing 
for watch is H (H. W. - If the watch is heard only on 
contact with the auricle, the record should read, Hearing for 
watch is ; or, if it is only heard by exerting considerable 
pressure with it upon the auricle, Hearing for watch is 
pressure. 
40 
The room in which the hearing is being tested by the watch PATHOLOGIC CONDITIONS OF NOSE AND PHARYNX 
339 
should be as free from noise as possible, and the watch should 
invariably be made to approach the patient's ear from a dis- 
tance, as directed above, and the point be noted at which it is 
first heard, because, while the patient still hears the watch if 
it is slowly carried away from his ear, it will be found that he 
will continue to hear it at a much greater distance than that at 
which he would first hear it if it were made to approach his ear 
from a distance. The hearing may be tested in a similar man- 
ner by means of the acoumeter, an instrument devised by 
Politzer. The acoumeter gives the note c with about the same 
loudness as the sound of a loud-ticking watch. A stop watch 
is more convenient than an ordinary watch for testing the 
hearing. 
In testing the hearing by the voice the patient should close 
the ear not being tested firmly with his forefinger, and either 
close his eyes or look in such a direction that it will be impos- 
sible to see the motion of the aurist's lips; the distance in feet 
should then be observed at which words are heard when spoken 
in a whisper, ordinary conversational tone, or a loud voice if the 
patient be very deaf. In making this test of the hearing- 
power it is best, in most instances, to employ single words of 
only one syllable. The result of the examination may be noted 
as a fraction, the numerator of which is the distance in feet at 
which the patient hears the words and the denominator the 
distance in feet at which a normal ear can hear the same words. 
For example, if the patient hears whispered words 3 feet from 
his ear, and should hear them at 10 feet, the fact may be re- 
corded thus: Whisper tV 
PATHOLOGIC CONDITIONS OF NOSE AND 
PHARYNX CAUSING DISEASE OF EAR 
Anatomically the Eustachian tube, tympanum and mastoid 
cells are more closely related to the nasopharynx than the 
internal ear, being an extension from the oro-nasal cavity, an 
accessory sinus as a matter of fact of the nose; and only inci- 340 
DISEASES OF THE NOSE, THROAT, AND EAR 
dentally related to the ear proper which is developed from a 
separate otocyst. The arterial, venous and lymphatic cir- 
culation of the middle ear are closely related to those of the 
nose and pharynx; and hence its pathology at least has its 
origin in most cases from a nasal or pharyngeal disease. 
As the result of chronic nasopharyngeal catarrh the Eusta- 
chian tubes and middle ear become affected in a proportion of 
cases. Especially if the catarrh be of the hypertrophic 
variety, so that nasal respiration is interfered with by the 
presence of anterior and posterior hypertrophies, ecchondroses 
or exostoses from the septum, etc., disease of the Eustachian 
tubes may result. The same is true of a deflection of the sep- 
tum sufficiently great to cause marked obstruction of one nos- 
tril. In many instances catarrh of the Eustachian tube and 
middle ear is the result of the extension by continuity of sur- 
face of a similar affection of the nasopharynx. However, 
when one or both nasal chambers are obstructed other causes 
probably bring about the same result. Posterior to the ob- 
struction, in nearly all cases of nasal stenosis, a partial vacuum 
is formed during inspiration; as the result, the nasal mucous 
membrane is constantly engorged with blood in this locality. 
This condition may extend back far enough to involve the 
pharyngeal mouth of the Eustachian tube. Probably most 
cases of one-sided deafness on the same side as an obstructed 
nostril may be explained in this manner. The hearing in such 
cases frequently improves rapidly after the removal of the 
nasal stenosis, but a posterior hypertrophy may be so situated 
as to produce venous stasis in that locality. By far the com- 
monest cause of Eustachian salpingitis, in children at least, is 
hypertrophy of the pharyngeal tonsil. When the adenoid 
overgrowth is situated so as to interfere with the return of 
blood from the mucous membrane of the Eustachian tubes, 
stenosis results because of engorgement and inflammation, and 
the hearing deteriorates more and more as the result of each 
succeeding attack of coryza. Under such circumstances, if 
the hypertrophy has not existed too long, a complete restora- PATHOLOGIC CONDITIONS OF NOSE AND PHARYNX 
341 
tion of the hearing may be expected to follow the removal of a 
portion of the hypertrophied gland. Occasionally cicatricial 
bands in Rosenmuller's fossa present the proper movement of 
the tube mouths and when present should be broken down. 
However, it must not be supposed that by removing the nasal 
disease which produced the aural affection a complete restora- 
tion of the hearing will result in every instance. In most cases 
of this kind careful treatment of the tubal or middle-ear dis- 
ease is absolutely necessary. 
The pharyngeal mouths of the Eustachian tubes, bordered 
by their cartilaginous lips, appear as crater-shaped elevations 
in front of Rosenmuller's fossa. The mucous membrane at the 
entrance of the tube is, in the normal state, paler than that in 
its vicinity, which is of a deep-red color over the cartilaginous 
lips which may be congested, anemic, hypertrophied with or 
without lymphoid excrescences, atrophic with or without mucus 
or crusts protruding from them and perhaps overhung by ade- 
noid tissue from the fossa of Rosenmuller. . The tube mouths 
may be inspected either by posterior rhinoscopy or with the 
nasopharyngbscope, by means of which not only the patho- 
logic condition of the tubal mucous membrane but also the 
movements of the tube mouths can be seen. 
Patency of Eustachian Tubes.-The methods most com- 
monly used to test the patency of the Eustachian tubes and 
introduce air into the middle ear are Valsalva's, Politzer's, and 
catheterization of the Eustachian tubes. 
Valsalva's method consists in a forced expiration, the mouth 
and nose being closed. In this method air is forced from the 
pharynx through the Eustachian tubes into the middle ear. If 
the aurist examines the membrana tympani while the patient 
inflates the middle ear by Valsalva's method the drum-head 
will be observed to move outward, and in most instances it 
will become slightly congested. If an aural stethoscope be 
used, a slight noise will be heard as the air enters the patient's 
middle ear. 
The aural stethoscope or auscultation-tube consists of about 342 
DISEASES OF THE NOSE, THROAT, AND EAR 
3 feet of thin rubber tubing, into the ends of which appropriate 
ear-pieces are inserted. One ear-piece should be of white bone 
for the aurist's own ear, and the other end of hard rubber, to be 
inserted into the auditory canals of his patient's ears. 
In Politzer's method the patient is directed to hold a small 
quantity of water in his mouth until he is told to swallow. The 
aurist then takes the nose-piece of Politzer's air-bag (Fig. 149) 
between his thumb and finger and inserts it into one of the 
patient's nostrils, and closes both nostrils firmly about the nose- 
piece by pressure with his middle finger and forefinger. The 
patient is then told to swallow; as the patient's larynx is seen 
to rise at the commencement of the act of swallowing the aurist 
Fig. 148.-Toynbee's auscultation-tube. 
quickly compresses the air-bag held in his right hand, thus 
forcing air through the nose and Eustachian tubes into the mid- 
dle ear. If the auscultation-tube is used during this procedure, 
the air will be heard to enter the middle ear with the same audi- 
ble click observed when Valsalva's method of inflating the mid- 
dle ear is employed. 
During the act of swallowing the soft palate rises, thus cut- 
ting off all communication between the posterior nasal chamber 
and the mouth, and at the same time the Eustachian tubes are 
rendered more patulous by the action of the levator palati and 
other muscles, so that air forced into the nose by Politzer's 
method, having no other way of exit, readily finds its way into 
the middle ear through the tubes. The same thing may be 
accomplished with greater convenience by requesting the PATHOLOGIC CONDITIONS OF NOSE AND PHARYNX 
343 
patient to "puff out his cheeks" and compressing the air-bag 
while the mouth is thus inflated with air. Pronouncing cer- 
tain syllables, like the words hick, hack, hock, also causes an 
elevation of the soft palate and a dilatation of the Eustachian 
tubes, so that the middle ear can readily be inflated by means 
of Politzer's air-bag. The middle ear of young children is 
usually more easily inflated by means of Politzer's air-bag than 
those of adults, while in the case of infants air readily enters 
the middle ear if Politzer's air- 
bag be used while the child is 
crying. 
No more force should ever be 
employed in compressing the 
rubber bag than is absolutely 
necessary to force air into the 
middle ear, and it is far better 
for the aurist to make several 
unsuccessful efforts to accom- 
plish this purpose than to drive 
air into the middle ear with 
sufficient force to cause pain. 
It is probably impossible to 
rupture a normal membrana 
tympani with Politzer's air- 
bag, but atrophied or diseased 
drum-membranes have been ruptured by the incautious use 
of this instrument. 
The Eustachian catheter is a tube of rubber or metal curved 
at its distal extremity, as shown in Fig. 150. The proximal 
end of the instrument is so constructed that the nozzle of 
Politzer's air-bag will fit loosely into it, and it is provided with a 
ring or mark of some sort by which the aurist is informed of the 
position of the beak of the instrument when it has been 
inserted in the nose. At least three sizes of this catheter should 
be in possession of the aurist-'respectively 1, 2, and 3 milli- 
meters in diameter. The hard-rubber catheters have the 
Fig. 149.-Politzer's air-bag 344 
DISEASES OF THE NOSE, THROAT, AND EAR 
advantage of cheapness, but they are not so easily disinfected 
as are the metal ones, which can be dropped into water and 
boiled or sterilized by pouring some alcohol over them and 
setting it on fire. Moreover, the hard-rubber instruments 
have a diameter larger in proportion to the size of their caliber 
than that of the silver catheters. The best catheters are made 
of pure or, as it sometimes is called, "virgin" (in contradis- 
tinction to "coin") silver, which insures a certain degree of 
flexibility. The cheap brass, nickel, or silver-plated instru- 
ments are clumsy, and are so hard, brittle, and inflexible that 
the curve of the beak cannot be slightly changed readily, as 
in the case of the softer pure silver instruments. The distal 
extremity should be slightly knobbed, smooth, and round. 
What is known as Hartmann's catheter is probably the best 
model (Fig. 150). 
Fig. 150.-Hartmann's silver Eustachian catheter. 
Introduction of the Beak of the Catheter into the Eustachian 
Tube.-'The operator should first inspect the anterior narium 
and note the position, size, and shape of any obstruction, such 
as a septal exostosis, which will interfere with the passage of 
the catheter. The operator should hold the proximal extrem- 
ity of the catheter between the thumb and fingers of his right 
hand, somewhat in the manner of a penholder, and lift up the 
tip of the patient's nose with the thumb of his left hand. The 
beak or distal extremity of the catheter is then inserted within 
the nares and is made to rest upon the floor of the nose, while 
the proximal end of the instrument is elevated until it is parallel 
with the floor of the nose. Still keeping the beak of the instru- 
ment in contact with the floor of the nose, the catheter is pushed 
gently inward until the beak of the instrument is felt to be in 
contact with the posterior wall of the pharynx. At this stage PATHOLOGIC CONDITIONS OP NOSE AND PHARYNX 
345 
the operator has the choice of the three methods of procedure 
in common use. 
Probably the one most frequently employed is that of Ldwen- 
burg, who directs that when the beak of the instrument is felt 
to be in contact with the pharyngeal wall the catheter should 
be rotated medianly through an angle of 45 degrees, and drawn 
forward until the beak of the instrument is felt to touch the 
posterior edge of the septum, when it is rotated outward 
through rather more than an angle of 90 degrees, and should 
then be in the mouth of the Eustachian tube. The operator 
may feel satisfied that this is the case if the beak of the catheter 
is found to be somewhat firmly fixed in the position it has 
assumed, so that it is impossible to rotate the beak of the 
instrument upward or carry it backward or forward without 
exerting considerable force. 
Gruber directs that when the beak of the catheter is felt to be 
in contact with the pharyngeal wall it should be withdrawn 
until its curved portion comes into contact with the posterior 
margin of the hard palate. It should then be again pushed 
inward a distance of about J inch, and rotated outward toward 
the ear through an angle of a little more than 45 degrees, when, 
if these maneuvers have been successful, the beak of the instru- 
ment will be within the mouth of the Eustachian tube. 
When the beak of the instrument is felt to be in contact with 
the pharyngeal wall it may be immediately rotated outward 45 
degrees, which will carry the beak of the instrument into Rosen- 
muller's fossa. The catheter should now be drawn gently out- 
ward until its beak is felt to slip over the posterior lip and into 
the mouth of the tube. An operator soon learns by the sensa- 
tion imparted to his hand whether the beak of the instrument 
is or is not in the Eustachian tube. 
Obstacles to Catheterization of the Eustachian Tubes.-'Devia- 
tion of the septum may render the passage of a Eustachian 
catheter through that side of the nose impossible. Under such 
circumstances both Eustachian tubes may be catheterized 
through the unoccluded nostril. To reach the tube of the op- 346 
DISEASES OF THE NOSE, THROAT, AND EAR 
posite side it will be necessary to bend the beak of the catheter 
at a somewhat longer curve than that of the instrument shown 
in Fig. 150. 
Ecchondroses or exostoses of the septum frequently interfere 
with the easy passage of the catheter through the inferior 
meatus of the nose. Under such circumstances the beak of the 
catheter can sometimes be passed over them and made to rest 
upon the floor of the nose or the soft palate behind. 
In passing the catheter through the nose the instrument 
Fig. 151.-Auscultation of the ear. 
should be held very lightly between the thumb and finger, and 
a tendency to rotate on its long axis should not be resisted, 
because by allowing the instrument to rotate its beak will 
sometimes glide around an obstruction and finally find its 
way into the pharynx. 
Another obstacle to catheterization of the Eustachian tubes 
results from spasmodic contraction of the muscles of the palate 
and pharynx, which tightly grasp the beak of the instrument 
and interfere with its proper manipulation. Gentleness and 
patience on the part of the surgeon will generally overcome this PATHOLOGIC CONDITIONS OF NOSE AND PHARYNX 
347 
difficulty. The patient should be requested to inhale deeply 
through his nose, to "swallow," or say "One," and thus pro- 
duce a temporary relaxation of the parts, which, if repeated 
from time to time, will enable the surgeon to guide the beak of 
the catheter into the mouth of the Eustachian tube. 
When the beak of the catheter is felt to be within the mouth 
of the Eustachian tube it should be held in position with the 
thumb and forefinger of the left hand and steadied by two 
fingers resting upon the patient's face (Fig. 151). The nozzle 
of the air-bag is then fitted loosely into the proximal end of the 
catheter and compressed with the right hand. If the auscul- 
tation-tube be employed at the same time, air will be heard to 
enter the patient's middle ear with a sound somewhat similar 
to that produced by inflating the middle ear by Valsalva's or 
Politzer's method. However, when the catheter is employed 
the sound seems as if produced nearer the surgeon's ear. 
The inflation of the middle ear by means of the Eustachian 
catheter is not altogether devoid of risk. Deaths have been 
reported. The fatal results in these instances may have 
resulted from injection of air through a rent in the mucous 
membrane made by the beak of the catheter, which subse- 
quently found its way beneath the mucous membrane to a 
position where the emphysema caused sufficient obstruction 
to respiration to occasion suffocation. 
The writer saw two cases where young and inexperienced 
operators had injected a sufficient amount of the air contained 
in a Politzer bag through a Eustachian catheter into the cellu- 
lar tissue to cause decided swelling of the tissues of the neck. 
In these two cases the patients simply suffered a certain amount 
of discomfort for a few hours, the air in the tissues being finally 
absorbed. 
Solutions may be sprayed through the catheter by means of 
an ordinary atomizer by inserting the nozzle of the atomizer 
into the catheter. Either the compressed-air apparatus or the 
hand-bulb may be used to produce the spray. Under ordinary 
circumstances the spray probably does not penetrate the tube 348 
DISEASES OF THE NOSE, THROAT, AND EAR 
further than the isthmus, except the patient be told to swallow, 
when the spray may be heard through the auscultation-tube to 
enter the tympanum, sounding not unlike drops of rain falling 
on a tin roof. When compressed air is used to produce the 
spray it should be employed gently and with due caution. The 
automatic cut-off should be manipulated in such a manner as 
to throw the spray gently and by successive puffs into the 
Eustachian tube orifices. The drip of the solution that con- 
denses in the catheter should, at the completion of the treat- 
ment, be blown into the Eustachian tube by means of Politzer's 
bag. 
Instead of employing an atomizer, fluid may be inserted 
within the catheter by an ordinary glass medicine-dropper and 
thrown into the tube with Politzer's bag, or fluid may be 
syringed through the catheter into the Eustachian tube, and 
when the drum-head is perforated, through the Eustachian tube 
and tympanum into the external auditory canal. 
When the drum-head is intact, fluid enters a narrow Eusta- 
chian tube beyond the isthmus only with great difficulty, 
having to compress before it the air contained in the middle ear. 
As soon as the pressure is relaxed the spring or rebound of the 
compressed air generally throws into the pharynx fluid con- 
tained in the tube. However, during the act of swallowing 
fluid may be made to penetrate into the cavity of the tym- 
panum through the Eustachian tube even when the drum-head 
is intact, the muscular action in opening and shutting the tube 
during swallowing doubtless playing an important role under 
such circumstances. In this manner sea-water or fresh water 
introduced into the pharynx while bathing sometimes reaches 
the tympanum and almost invariably produces an acute otitis 
media. The writer has observed the same thing occur during 
the use of the Birmingham douche or even from sniffing normal 
salt solution into the nose from the hollow of the hand. 
The introduction of watery solutions, even of the blandest 
character, is not devoid of risk unless the drum-head is lacking 
or contains a large perforation. Bland oily fluids, on the other PATHOLOGIC CONDITIONS OF NOSE AND PHARYNX 
349 
hand, can be sprayed or syringed into the middle ear with 
impunity. When the watery fluid is used to wash out the 
Eustachian tube the operator should be careful to inflate the 
middle ear several times by means of Politzer's method in 
order to remove any excess of fluid that might otherwise 
remain. 
Solutions of one or two drops of argyrol, io to 50 per 
cent., nitrate of silver, | to 1 per cent., potassium iodid, 1 
per cent, (in syphilis), may safely be introduced into the 
mouth of the Eustachian tube. 
An Allen's probe (Fig. 26), sufficiently long to extend | inch 
beyond the catheter mouth, may be used as an applicator by 
wrapping a few fibers of cotton about its tip and dipping the 
end of the probe into the solution to be used. After the beak 
of the catheter is in position the cotton-tipped probe is passed 
through it and an application of the remedy made to the first 
| inch of the Eustachian tube, or the end of a cotton-tipped 
Allen's probe, after being dipped into any appropriate solution, 
may be passed like a catheter through the nose into the naso- 
pharynx and the cotton-tipped end inserted into the mouth of 
the Eustachian tube. 
Eustachian bougies are occasionally used for the dilation of 
strictures of the Eustachian tube and other purposes. They 
are filiform in character and a number of sizes are obtainable, 
made of whalebone, hard rubber, celluloid, or gold, for electro- 
lysis of stricture. They are inserted into the Eustachian tube 
through a catheter. Great gentleness should be used in passing 
a Eustachian bougie for the first time through an inflamed tube, 
for it is easy to penetrate tissue with so small an instrument and 
make a false passage. The length of the catheter employed 
should be marked upon the bougie and also the length of the 
Eustachian tube, which is about i| inches; and this last mark 
cannot be passed without danger of injury to the tympanic 
contents. 
Not much force is necessary to pass a Eustachian bougie 
through a normal tube. When a stricture is encountered, 350 
DISEASES OF THE NOSE, THROAT, AND EAR 
gentle pressure will usually finally overcome the obstruction, 
after which the bougie passes readily onward. The most fre- 
quent position of stricture is at the isthmus. 
Before attempting to pass the bougie a few drops of liquid 
albolene should be inserted in the catheter and blown into the 
Eustachian tube by means of Politzer's bag. If a stricture is 
passed, a bougie should be allowed to remain in position for five 
or ten minutes. After the bougie is withdrawn the middle ear 
should be gently and cautiously inflated. If there be reason to 
suppose that during the passage of the bougie the mucous mem- 
brane has been torn, it will be safer to dispense with inflation, 
lest air penetrate the cellular tissue. 
Electrolysis of Eustachian strictures has been done by means 
of an insulated Eustachian catheter and gold bougies. The 
amount of current necessary to overcome an obstruction and 
promote absorption of a stricture is 3 to 5 milliamperes, which 
should be turned on as soon as an obstruction is felt and con- 
tinued for not longer than three to five minutes. The negative 
pole of the battery is attached to the bougie, the positive held 
in the patient's hand or applied to the nape of his neck. There 
is little pain produced by the procedure, which may be repeated 
at intervals of a week. Inflation should not be practised 
immediately after the use of the electric bougie, but the patient 
may return the next day to have his middle ear inflated. 
DISEASES OF THE EXTERNAL EAR 
Congenital Defects.-The auricle may be wanting entirely 
or there may be a plurality of auricles (Fig. 152). The auricle 
may be abnormal as regards position or shape or it may only 
be partially developed. Malformations of the auricle are 
generally associated with defects or absence of the external 
auditory canal (Fig. 153), and sometimes imperfect development 
of the deeper portions of the auditory apparatus. A congenital 
fistula is sometimes seen about the external ear and may com- 
municate with the tympanic cavity (Fig. 154). Excessive DISEASES OF THE EXTERNAL EAR 
351 
development or lack of development of the external ear is due 
to excessive or imperfect development in the closure of the first 
branchial cleft during embryonic life. Various operations 
Fig. 152.-Supernumerary auricle in the neck (Lancet, 1888) 
have been devised to correct deformities of the auricle and open 
a way down to the tympanum in cases of stenosis of the external 
auditory canal. Plastic operations in this locality do well 
Fig. 153. - Congenital 
deformity of the auricle 
(Sexton). 
Fig. 154.-Convoluted 
auricle with congenital fis- 
tula (Sexton). 
as regards the healing process. Operations for the correction 
of atresia or stenosis of the external auditory canal hitherto 
have not been successful. 352 
DISEASES OF THE NOSE, THROAT, AND EAR 
Othematoma or perichondritis of the auricle (Fig. 155) is 
generally the result of direct violence-self-inflicted in the 
insane, among whom the disease is not uncommon. This 
affection is characterized by an effusion beneath the perichon- 
drium of the auricle, causing swelling, tension, and pain in the 
part. The effusion may finally escape through an external 
opening which it has made for itself, remain as a swelling for an 
indefinite time, or slowly be absorbed. Even when reabsorp- 
tion of the effusion does occur, considerable deformity of the 
auricle may result (Fig. 156). 
Fig. 155.-Mumied-sized othe- 
matoma of the auricle (Sexton). 
Fig. 156.-Deformity of the auri- 
cle due to othematoma (Sexton). 
Treatment.--In the insane, hematoma of the auricle is best 
let alone, unless the local inflammation is sufficiently great to 
indicate that infection has occurred and that the effusion has 
become purulent. If necessary inflammation should be com- 
bated by the application of ichthyol ointment (20 per cent.) 
in lanolin (adeps lanae hydrosus), and progressive effusion by 
painting the affected parts with contractile collodion and the 
use of a pressure bandage. Absorbent cotton is placed between 
the auricle and the head and a pad of cotton over the auricle, 
and pressure maintained by means of a roller bandage over the DISEASES OF THE EXTERNAL EAR 
353 
auricle and around the head. The bandage should not be 
applied with sufficient firmness to cause pain or great discom- 
fort. If, notwithstanding these measures, the collection of 
fluid beneath the perichondrium increases, the parts should be 
aspirated with antiseptic precautions-a measure that will 
probably need repetition from time to time. In cases where the 
inflammation is great and the effusion beneath the perichon- 
drium is evidently purulent, it is best to lay the parts freely 
open, wash out the pus-cavity with sublimate solution, and 
pack with iodoform gauze. The incision should be sufficiently 
free to permit of easy dressing and the ready removal of 
sloughing cartilage as soon as separated from the living tissue. 
Fortunately the number of cases where the injury to the auricle 
is sufficiently severe to cause sloughing of even a small portion 
of the cartilage are comparatively few. 
Chronic perichondritis is a chronic inflammation of the car- 
tilage of the auricle observed in boxers and others whose ears 
are constantly subjected to irritation or slight traumatism. 
Treatment consists in gentle massage and applications of 20 
per cent, ichthyol ointment at bedtime, with the avoidance of 
the cause of the irritation. 
Incised and punctured wounds, after thorough cleansing, 
should be sutured in such a manner as to leave as little scar as 
possible upon the lateral surface of the auricle. In contused 
and lacerated wounds perichondritis almost invariably occurs, 
and it is well to anticipate such an attack by the application of 
a wet bichlorid dressing for twelve to twenty-four hours. An 
attempt should be made to save as much tissue as possible and 
no part which possibly may have sufficient vitality to live 
should be removed. As a primary measure but few sutures 
should be used, as after the circulation has been thoroughly 
established it is ordinarily a simple matter to secure more 
perfect coaptation of the parts and prevent deformity. The 
sutures should not be passed through the cartilage unless abso- 
lutely necessary, although no great harm usually results from a 
suture through the cartilage of the auricle. 354 
DISEASES OF THE NOSE, THROAT, AND EAR 
Fracture of the base of the skull involving the temporal bone 
may extend into the auditory canal in some cases without rup- 
ture of the membrana tympani. Hemorrhage from the ear 
may be somewhat profuse or scanty. In addition to the gen- 
eral treatment the ear should be thoroughly cleansed of clots by 
gentle syringing with a warm bichlorid solution (i: 5000), dried, 
and covered with powdered boric acid, except where oozing 
persists, when the auditory canal should be very lightly packed 
with sterile iodoform gauze. The ear should be gently cleansed 
once a day with the bichlorid solution and packed with gauze 
as long as oozing persists; after which the parts are best kept 
as dry as possible by cleansing when necessary with bichlorid 
solution, thoroughly drying the parts, and insufflating powdered 
boric acid. Boric acid in sufficient quantity to cover the wound 
is apparently sufficient to prevent infection. Packing the 
canal maintains a warm and moist condition of the wound that 
should be avoided. 
Cleft lobule, which is generally the result of the tearing out 
of an earring, may be- remedied by the following opera- 
tion : The sides of the cleft are freshened in the same man- 
ner as for a hare-lip operation; but, to avoid as far as possible 
the formation of a conspicuous scar, the sutures should be in- 
troduced and tied on the inner side of the lobule, and should 
involve only the deeper layers of the skin of its outer surface. 
Keloid of the auricle originating in the scar resulting from 
piercing the ear for earrings is not uncommon, especially in the 
negro. The growth consists of a hard nodule of fibrous tissue, 
generally tender on pressure. If large, it shoud be removed by 
the knife. There is a tendency for the growth to recur. En- 
couraging results have been reported from the application of 
the x-ray in cases where the growth has recurred after removal 
by the knife. 
The cutaneous diseases which sometimes attack the auricle 
are hyperemia, frost-bite, burns, eczema, dermatitis, comedo, 
cyst, erysipelas, syphiloderma, herpes, lupus, and impetigo 
contagiosa. DISEASES OF THE EXTERNAL EAR 
355 
Hyperemia may be either active or passive, transient or 
chronic in character. There is an increase in the blood-supply 
of the auricle and generally of the canal, so that the skin ap- 
pears redder than normal and feels hot to the patient. Mild 
cases are due to some transient vasomotor disturbance that 
usually soon passes away without treatment. In some indi- 
viduals a single comparatively small dose of quinin, salicylic 
acid, or of chlorid of calcium will produce hyperemia of the 
auricle and canal that may persist for some time. 
Active hyperemia of the auricle may result from exposure 
to cold, sunburn, or other irritants. Passive hyperemia of the 
auricle and canal are sometimes present as the result of gout, 
valvular disease of the heart, or any organic disease capable of 
producing localized blood stasis. 
Treatment.-The best local application is probably liquor 
plumbi subacetatis, which may be painted on the parts once 
or twice a day. Nervous cases will need building up; the gouty, 
a correction of the constitutional dyscrasia. 
Dermatitis is an inflammation of the skin generally resulting 
from some injury, such as the bite of an insect, a blow, fall, stab, 
wound, etc. 
The symptoms vary from slight inflammation of the skin at 
the point of injury to localized gangrene. 
Treatment.-This varies with the severity of the inflamma- 
tion and the character of the infection. Mild cases do well 
by simply painting with liquor plumbi subacetatis. The severer 
cases require a wet dressing of bichlorid of mercury, as in in- 
fected wounds of other parts of the body. The dermatitis 
following the sting of insects is treated by a wet dressing of 20 
per cent, bicarbonate of sodium. 
Frost-bite.-In cold climates frost-bite of the auricle is by 
no means uncommon. At first the auricle is cold and numb 
and sometimes stiff, as if actually frozen solid. Later on the 
symptoms are those of traumatism, involving only the skin or 
the skin and deeper structures. The skin is hot and swollen, 
frequently excoriated or covered by vesicles. In the severer 356 
DISEASES OF THE NOSE, THROAT, AND EAR 
cases the symptoms are those of perichondritis, followed some- 
times by cartilaginous necrosis and the formation of sinuses 
upon either surface of the auricle. 
Treatment.-When the auricle is frozen its temperature 
should be restored gradually by gentle friction with snow or 
pounded ice, and afterward by gentle manipulation with the 
fingers. If only the skin is involved by the subsequent in- 
flammation satisfactory results will follow the application of a 
io per cent, ichthyol ointment, which should be applied suffi- 
ciently often to keep the parts constantly covered and pro- 
tected. In some cases pain and soreness are greatly relieved by 
wrapping the auricle in absorbent cotton after using the oint- 
ment and applying gentle pressure by means of a bandage. 
When perichondritis follows frost-bite of the auricle it should 
be treated in the manner already described. When sinuses 
have formed, they should be laid open, the necrosed tissues re- 
moved, and the wounds allowed to heal by granulation. If 
care is taken to keep the parts properly supported but little 
deformity sometimes results. 
Cystic tumors are not uncommon and are best dissected out. 
When this is inadvisable, the cyst should be freely laid open, 
thoroughly curetted, and its interior painted with tincture of 
iodin. The wound is then closed with sutures and a wet 
bichlorid dressing applied. 
Bums.-The auricle is liable to burns, sometimes severe, 
and involving not only the surrounding neck and scalp but also 
the auditory canal. A common cause of slight burn of the 
auricle sufficient to raise a blister is hot applications for the 
relief of the pain of otitis media. 
Treatment.-Pain is best relieved by the local use of cold, 
applied either in the form of an ice-bag or napkins wrung out 
of ice-water. The application of cold should be continued as 
long as it affords relief. 
Charred and dead tissue, if the burn is a severe one, should 
be at once removed, and the parts cleansed from soot and dirt 
by means of copious washings with a solution of bicarbonate of DISEASES OF THE EXTERNAL EAR 
357 
sodium. The parts are then dusted with orthoform or smeared 
with a 3 per cent, carbolized petroleum, a bandage applied, and 
over this an ice-bag is placed as long as the cold seems necessary 
for the relief of pain. Excessive pain if not quickly relieved by 
these measures will require a hypodermic of morphin. 
When the skin is unbroken the best dressing is the so-called 
carron oil (equal parts of linseed oil and lime-water). This is 
smeared thickly on patent lint and applied to parts after they 
have been cleansed with bicarbonate of sodium solution. 
Herpes of the auricle is similar to the disease in other locali- 
ties. It is characterized by vesicles filled with a clear serum, 
appearing singly or in groups, upon the helix or about the 
lobule. The surrounding skin is reddened, slightly swollen, and 
tender to the touch. There may be slight fever, pain, and 
itching of the auricle. The affection is due to some nervous 
disturbance. The vesicles ordinarily dry up and disappear by 
the end of ten days or two weeks. 
Treatment.-The milder cases are best treated by gentle pur- 
gation with citrate of magnesia or one of the other salines. 
The vesicles should be painted three or four times a day with 
camphorated tincture of opium (paregoric). This application 
seems to allay the slight itching and burning better than most 
others and hastens absorption. Should the contents of the 
vesicles become purulent, the vesicles should be opened and 
the parts washed with bichlorid solution and dusted with pow- 
dered calomel. 
Impetigo contagiosa is an acute contagious disease of the 
skin sometimes encountered upon the skin of the auricle or nose 
in dispensary practice. It begins as small discrete or confluent 
vesicles, which rupture and leave a granular surface resembling 
closely a vaccination sore. It is contagious. Recovery 
usually occurs within a week under antiseptic treatment. 
Treatment consists in keeping the parts clean by washing 
with bichlorid solution and applying either powdered calomel or 
an ointment of ammoniated mercury. 
Lupus vulgaris is a chronic tuberculosis of the skin of the 358 
DISEASES OF THE NOSE, THROAT, AND EAR 
auricle, either primary or extending to the auricle from the skin 
of the face. The disease begins as a tubercle deep in the skin. 
The dull reddish tubercles are sometimes years in developing, 
but finally break down into a characteristic ulceration which 
may heal at one extremity while it is spreading in another 
direction. The disease is exceedingly chronic and years may 
go before a large portion of the auricle is involved. After heal- 
ing has occurred the auricle is shriveled, shrunken, and 
deformed. 
The diagnosis is usually made by the appearance of the 
ulcer and the history of extreme chronicity. The disease might 
be mistaken for either syphilis or epithelioma, but each is 
much more rapid in its course. 
Treatment.-The internal medication consists in the admin- 
istration of cod-liver oil and arsenic. The local treatment 
consists in a thorough curetting of the ulceration and the appli- 
cation of the solid stick of nitrate of silver. This should be 
followed by applications of the £-ray. 
Syphilis.-Primary syphilis of the auricle is naturally rare, 
but the auricle may become inoculated by a bite or other cause. 
Chancre of the auricle differs in nowise from the primary 
lesion elsewhere upon the skin. It is an ulcer with indurated 
edges and a hard base, generally conforming to the papular 
type. The lymphatics of the neck are swollen. 
Secondary syphilis of the auricle is generally part of a syphi- 
loderm involving more or less of the whole body. 
Tertiary syphilis of the auricle consists of a gumma either 
before or during the stage of ulceration. 
The diagnosis of the primary lesion is sometimes difficult 
unless there is a history of a bite or injury by a syphilitic 
individual. The diagnosis in the secondary stage is usually 
easy. In the tertiary stage, however, an ulcerating gumma 
may be mistaken for either lupus or epithelioma. 
Treatment.-The constitutional treatment differs in nowise 
from that of syphilis of the nose, pharynx, or larynx already 
described. DISEASES OF THE EXTERNAL EAR 
359 
Congenital syphilis is usually of the tertiary variety. Its 
treatment differs in no respect from the acquired disease. The 
writer remembers only one case observed by him, that of an in- 
fant about eight months old, with an ulcerating gumma of the 
meatus. The external orifice of the meatus was nearly oc- 
cluded by exuberant granulations, which were snared away 
and the parts kept clean and dusted with calomel powder. 
The internal treatment consisted of gray powder and inunc- 
tions of mercury. The infant made a good recovery. 
Erysipelas is the result of infection of the skin with the strep- 
tococcus erysipelatosa of Fehleisen. It is presumed to only in- 
vade the skin through some traumatism, possibly so minute 
as to be overlooked. The writer saw in consultation two cases 
that had their origin in a blister produced by painting the 
mastoid process with cantharidal collodion. In both these 
cases, occurring in old men, the erysipelas extended to the 
scalp; in one with a fatal result. Erysipelas of the auricle 
may extend along the canal and involve the drum-head. 
The symptoms are those of erysipelas in other localities. 
The disease is usually ushered in by a chill and high tempera- 
ture. There is headache and anorexia. The infected area is 
red and swollen and the swelling and redness somewhat rapidly 
spread until sometimes the entire auricle is involved and the 
disease has attacked adjacent skin areas. Vesicles filled with 
serum may or may not appear. 
Treatment- The patient, if in a hospital, should be isolated 
from other surgical cases. It is well to begin treatment with 
a calomel purge (f gr. every hour until i| gr. have been taken), 
followed by a bottle of the solution of citrate of magnesia. 
As soon as the bowels have acted freely the patient should 
take 20 drops of the tincture of the chlorid of iron every two or 
three hours and gr. of strychnin every four hours. It is 
said that some cases can be aborted by painting the infected 
and adjacent skin area with carbolic acid, which is allowed to 
remain until it has blanched the skin surface. The excess of 
acid is then washed off with alcohol. Most of the writer's 360 
DISEASES OF THE NOSE, THROAT, AND EAR 
cases have been treated locally by application of 20 per cent, 
ichthyol in lanolin, which was smeared thickly on patent lint 
and applied to the parts. The treatment is effective, but some- 
what dirty. Those cases of facial erysipelas seen in the 
Philadelphia Hospital during his terms of service there were 
treated locally by applications of patent lint kept moist with 
a 10 per cent, solution of protargol. Apparently one treat- 
ment was about as effective in controlling the local symptoms 
as the other. 
Phlegmonous erysipelas is a severe form of erysipelas in- 
volving the deeper structures beneath the skin, with the forma- 
tion of abscesses. It is generally the result of mixed infection, 
the streptococcus erysipelatosa and the streptococcus or sta- 
phylococcus pyogenes being found in the discharges. 
The symptoms are those of severe erysipelas--high fever, 
redness, pain, and great swelling of the auricle, with formation 
of pus and exfoliation of cartilage. 
Treatment.-The auricle should be covered with a dressing 
kept constantly wet with bichlorid solution (1: 2000). As soon 
as the presence of pus is suspected the parts should be freely 
incised down to the cartilage. The wound should be syringed 
daily with a bichlorid solution and, if necessary, packed with 
gauze in such a manner as to secure perfect drainage. 
Gangrene is, in modern times, an extremely rare disease, 
but is said to occur occasionally either in the moist or dry 
form. 
Treatment.-This is similar to that of phlegmonous erysipe- 
las. Iron and strychnin should be given internally. The 
parts should be kept covered with a wet bichlorid dressing and 
every effort made to secure asepsis. The necrotic tissue 
should be removed as soon as possible. Localized pain can 
be controlled by dusting with iodoform and, when this is in- 
effective, with orthoform. 
The disease is very contagious, at least to other surgical cases. 
Therefore the patient should be carefully quarantined and 
all dressings, towels, etc., used about the case destroyed. DISEASES OF THE EXTERNAL EAR 
361 
Eczema is by far the commonest of the skin diseases affect- 
ing the auricle. It may also involve the auditory canal and 
even the dermoid layer of the membrana tympani. Intertrigo 
resulting fro the invasion by the disease of the fissure formed 
by the junction of the auricle with the mastoid region is of 
frequent occurrence in infants and young children. 
Treatment.-In adults the disease is sometimes the result of 
the rheumatic or gouty diathesis, and, in addition to local 
treatment, such cases require the administration of alkalis, 
with iodid of potassium, salicylate of sodium, or arsenic. In 
children the disease is frequently associated with struma, and 
for such cases cod-liver oil or syrup of the iodid of iron should 
be prescribed. Eczema intertrigo is best treated by the fre- 
quent application of powders, and oxid of zinc or subnitrate 
of bismuth may be prescribed for this purpose. 
The commonest cause of eczema of the auricle in children is 
an irritating discharge from the middle ear. In the neglected 
infants of the poor the discharges resulting from purulent 
inflammation of the tympanum are frequently smeared by the 
fingers of the child over the entire auricle and over the skin in 
front of and behind the ear. Under such circumstances the 
auricle and surrounding skin become covered by eczematous 
scabs and crusts. These the surgeon should carefully remove 
by means of pledgets of cotton saturated with hydrogen 
peroxid, and rub well into the affected parts an ointment con- 
sisting of 6 or 8 gr. of the yellow oxid of mercury to i ounce of 
petrolatum. A single thorough application of this remedy is 
sometimes sufficient to bring about great improvement, even 
in cases in which the disease has existed for several months. 
Perfect cleanliness in all cases should be enjoined, and if fre- 
quent cleansing of the auditory canal with absorbent cotton, 
followed by insufflations of powdered boric acid, is not suffi- 
cient to keep the concha dry and free from the discharge, the 
skin of this part of the ear should be protected by some bland 
ointment. Benzoated zinc ointment, if fresh and properly 
made, answers very well for this purpose. 362 
DISEASES OF THE NOSE, THROAT, AND EAR 
The new growths that occur on the auricle are sebaceous cyst, 
fibroid tumor, epithelioma, nevus, sarcoma, and cornu 
cutaneum. 
The treatment is the same as if the new growths occurred 
elsewhere. Nevi in suitable cases should be treated by electrol- 
ysis. The other growths ordinarily require excision. 
DISEASES OF THE EXTERNAL AUDITORY CANAL 
The more common affections of the external auditory canal 
are acute circumscribed inflammation or furunculosis, acute 
and chronic diffuse inflammation, diphtheritic inflammation, 
hyperostosis, exostosis, and foreign bodies. 
Furuncle or Acute Circumscribed Inflammation.-Recur- 
rent attacks of furunculosis of the auditory canal seem, in 
many instances, to be the result of irritation from carious teeth 
or from disease of the interior of the nose and throat. The 
affection is commonest in gouty or anemic and debilitated 
individuals and in women suffering from menstrual disorders. 
Pathology.-In most instances the starting-point of the dis- 
ease is a sebaceous gland or a ceruminous follicle, which has 
become inoculated with the staphylococcus pyogenes aureus 
or other pus-forming bacteria by scratching the ear with a 
dirty finger-nail, hairpin, match-stick, etc. Metastatic abscess 
in the canal is said to sometimes occur in gonorrhea. The in- 
flammation usually soon becomes a circumscribed perichon- 
dritis or periostitis of the auditory canal. The pathology of 
acute circumscribed inflammation of the external auditory 
canal is similar to that of boils and felons occurring elsewhere 
on the body. 
Symptoms.-There is at first an itching within the canal, a 
portion of which is found tender to the touch, and soon becomes 
painful. The pain and tenderness increase, until in some 
instances the patient's sufferings become almost unendurable. 
In severe cases the pain, which at first was confined to the ear, 
extends to the whole side of the head, is throbbing in character, DISEASES OF THE EXTERNAL EAR 
363 
and is increased by movements of the jaw in talking, eating, 
etc. There is some elevation of temperature in the severest 
cases. Deafness is not a marked symptom until the swelling 
is large enough to close the canal at the part involved, but 
tinnitus is present in the majority of cases. The furuncle will 
rupture spontaneously in from two to eight days, according 
as the inflammation is superficial or deep seated. The dis- 
charge is purulent, sometimes quite profuse, and its appearance 
is speedily followed by a subsidence of acute pain; the parts, 
however, remain sore for several days. A "core" or small 
slough of the skin, as in boils elsewhere, usually exfoliates 
before the parts heal. 
Treatment.-Speedy relief generally follows a free incision 
Fig. 157.-Method of wrapping cotton about the end of an Allen probe to form 
a brush for cleansing the canal, applying pigments, etc. 
through the swollen parts down to the cartilage or bone, even 
though no pus be found. The incision should be followed by 
syringing the canal with hot boric acid solution, the insertion 
into the canal of a cone of absorbent cotton covered with a io 
per cent, ointment of cocain in lanolin, and the application 
of heat. 
In cases where incision is not advisable, a cone of cotton 
should be well covered with an ointment of the yellow oxid of 
mercury, 6 gr. to an ounce of vaselin, and so placed within the 
canal that it will exert pressure upon the swollen parts. For 
a few moments this procedure increases the pain somewhat, 
but it is followed by a feeling of decided relief and comfort. 
The ointment is rubbed into the skin of the canal by each 
movement of the jaw in talking and eating, and if the treat- 364 
DISEASES OF THE NOSE, THROAT, AND EAR 
ment is applied early enough many cases of furunculosis of the 
auditory canal may be aborted before suppuration has occurred. 
Cotton cones are readily made by selecting a piece of absorbent 
cotton about 2 inches long and about f inch wide. The two 
ends of the piece of cotton are then frayed out until the center 
of the cotton is thicker than the edges. The cotton is then 
folded through its thick central portion, so that the thin edges 
are brought together and a wedge is thus formed, one edge 
being very thick and the other thin. This wedge is now 
wrapped somewhat firmly about the end of an Allen ear probe 
(Fig. 158), the thick edge of the cotton wedge toward the handle 
of the instrument, in such a manner that the thin edge of the 
Fig. 158.-Method of wrapping cotton about the end of an Allen probe so as 
to form a cone for applying pressure within the auditory canal. A piece of absorb- 
ent cotton is frayed out to thin edges, folded through the center (dotted line a), 
and wrapped about the end of the probe. 
cotton wedge forms the pointed end of the cone. The cone 
thus made should be firmly enough wrapped about the probe 
to be smooth and taper evenly from apex to base. When 
made it is coated thickly with the appropriate ointment and 
inserted gently into the canal until its wedge-like pressure 
begins to cause pain. The probe is then dislodged from the 
cone by turning it in the opposite direction to that in which 
the cotton was wrapped about it and steadying the cone with 
a touch of the left forefinger so that the cone is not withdrawn 
from the canal with the probe. If after a few moments the 
pressure of the cone instead of affording relief causes increased 
pain, the patient can withdraw it slightly and after an interval 
again push it more deeply into the canal. 
Some relief from pain follows the application of a io per cent. DISEASES OF THE EXTERNAL EAR 
365 
ointment of cocain in lanolin or a i per cent, ointment of atro- 
pin. Heat, however, generally gives speedy relief from pain. 
It may be applied by gently syringing the canal with hot water, 
or by resting the head upon a hot-water bag or a bag of hot 
salt or of hops. In severe cases it is advisable to secure a free 
evacuation of the bowels by means of small, frequently repeated 
doses of calomel and bicarbonate of sodium; i-drop doses 
(U. S. P., 1890) of tincture of aconite-root, repeated every 
hour, will control to a certain extent fever and pain. In all 
case the cause of the attack should carefully be sought and 
measures adopted to prevent a recurrence. To prevent in- 
oculation of other parts of the canal and producing a so-called 
"crop" of boils, the canal should be carefully cleansed either 
by syringing gently each day with a warm 1 :5000 bichlorid 
solution or by simply wiping out the pus with absorbent cotton 
and afterward sterilizing the skin of the canal by painting it 
with a 12 per cent, solution of silver nitrate. 
Otitis Externa Diffusa Acuta.-Diffuse inflammation of the 
auditory canal varies in character from a simple erythema of 
the skin of the auditory canal to severe periostitis. The dis- 
ease usually attacks the osseous portion of the canal, but it 
may extend to the auricle, and, by periosteal continuity, to the 
periauricular and mastoid regions, causing abscess and necrosis. 
Etiology.-'The disease usually occurs in persons whose gen- 
eral health is impaired. It is sometimes consecutive to an 
attack of otitis media acuta or it may be caused by an irritating 
discharge from the middle ear. The affection, which usually 
begins in the skin or cellular tissue, may extend to the peri- 
osteum and bone. 
The symptoms are similar to those of furuncle of the auditory 
canal, except that the pain is usually more intense and appears 
at an earlier stage of the disease, while deafness and tinnitus are 
more marked and long continued. On inspection the tissues of 
the auditory canal appear red and swollen. The swelling is 
usually greatest in the bony portion of the canal, where it may 
be so great as to completely obliterate the canal and prevent a 366 
DISEASES OF THE NOSE, THROAT, AND EAR 
view of the drum-head from being obtained. Generally the 
skin is excoriated at points where the inflammation is great- 
est, and usually there is desquamation and a slight watery 
discharge. 
Treatment.-Incision of the swollen tissues is rarely necessary 
unless an abscess has formed. Pain can generally be alleviated 
very much, if the case is seen early, by the application of a large 
leech to the skin in front of the tip of the mastoid, as closely as 
possible beneath the auditory canal. A leech also may be 
applied in front of the tragus and one on the mastoid, as close 
to the canal as possible. 
In many cases it will be necessary to prescribe morphin to 
completely control the pain and secure sleep; but heat, applied 
in the manner already described, will be all that is necessary in 
the majority of instances. The canal should be cleansed and 
carefully dried with absorbent cotton and the parts painted 
with a 12 per cent, solution of nitrate of silver and dusted with 
powdered calomel. This should be done every day as long as 
the symptoms are acute, and afterward, as the disease subsides, 
at longer intervals. In using an insoluble powder like calomel 
within the canal care should be exercised not to employ a 
quantity sufficient to form a hard crust and cause pain. 
Otitis Externa Haemorrhagica.-Hemorrhagic blebs some- 
times occur in the canal from traumatism or as a complication 
of influenza or otitis media. The blebs are bluish, easily rup- 
tured, and contain bloody serum. They should be broken with 
a cotton-tipped Allen applicator, touched with a 12 per cent, 
solution of silver nitrate, and then dusted with calomel or 
powdered boric acid. 
Otitis externa diffusa chronica occurs in individuals whose 
health is impaired, or it may be the result of the gouty or rheu- 
matic diathesis, or the irritation caused by carious teeth, or dis- 
ease of the nose and throat. The growth of aspergillus within 
the inflamed canal may be a complication or a cause of disease. 
Symptoms.-Patients complain of itching and a sense of 
heat within the canal. Pain is usually absent, except during DISEASES OF THE EXTERNAL EAR 
367 
acute exacerbations. Upon inspection the skin of the auditory 
canal is found to be red and swollen, especially in the deeper 
portions. The inflammation may be of the eczematous or 
desquamative type and accompanied by a watery discharge or 
seborrhea. 
Treatment.-The cause of the affection should be carefully 
sought. Patients of the strumous diathesis or in feeble health 
will require cod-liver oil and tonics, and appropriate remedies 
should be prescribed for those in whom the disease seems to be 
the result of the rheumatic or gouty diathesis. If carious teeth 
are present they should receive the attention of a skilful den- 
tist, and any disease of the nose or throat that may be present 
Fig. 159.-A, Aspergillus glaucus; B, Aspergillus niger; C, ripe fructiferous head 
of Aspergillus niger throwing off spores (Burnett). 
should be properly treated. The local treatment of chronic 
diffuse inflammation of the external auditory canal varies 
according to the stage and variety of the disease. When the 
disease is of the eczematous type, all scales and scabs should be 
removed with a pledget of absorbent cotton wrapped about a 
probe and dipped into a solution of hydrogen peroxid, and yel- 
low oxid of mercury ointment (Formula 108) well rubbed into 
the parts. When there is considerable secretion of watery 
fluid the canal should be dried thoroughly and brushed with a 
solution of silver nitrate (12 per cent.) and covered with pow- 
dered calomel. 368 
DISEASES OF THE NOSE, THROAT, AND EAR 
Mycosis or otomycosis is an inflammation of the external 
auditory canal due to the presence of a fungus. Aspergillus 
glaucus (Fig. 159, a) and Aspergillus niger (Fig. 159, b, c) 
are the varieties most frequently met with. The presence of 
moulds in chronic inflammation of the external auditory canal 
may be the cause of the inflammation or only a complication of 
the disease. 
The symptoms are those of an acute or chronic inflammation 
of the canal, except that when there is a large mass of mould 
present filling the fundus of the canal the patient will be deaf 
from the accumulation. This is usually a pasty, whitish mate- 
rial interspersed with black spots looking not unlike a wad of 
wet newspaper. The microscope will detect the presence of 
either or both the Aspergillus glaucus or niger or some other 
species of aspergillus or mucor. 
Treatment.-When aspergillus is present, the canal should 
be cleansed thoroughly each day with hydrogen peroxid and 
an application made of a 12 per cent, solution of silver nitrate 
or of alcohol. It is essential that the canal should at all times 
be kept absolutely dry, because nothing more favors the growth 
of the aspergillus than moisture. Discharges should be 
absorbed by the application of powdered boric acid. 
Otitis Externa Diphtheritica.-Diphtheritic inflammation 
of the integument of the external auditory canal is an inflam- 
mation characterized by the presence of a pseudomembrane, 
which when removed leaves a bleeding surface. The pseudo- 
membrane should contain the Klebs-Loffler bacillus character- 
istic of true diphtheria, as other bacteria are capable of causing 
a pseudomembrane within the auditory canal and upon 
mucous surfaces. 
Etiology.-The disease occurs usually as a complication of 
diphtheria of the throat and middle ear. Primary diphtheria 
of the walls of the external auditory canal has been observed 
during epidemics of diphtheria. 
Symptoms.-In the primary form there are deafness and tin- 
nitus, with pain. The meatus is greatly swollen. The lym- DISEASES OF THE EXTERNAL EAR 
369 
phatics at the angle of the jaw are swollen and tender to the 
touch. There is usually systemic depression and slight ele- 
vation of temperature. Examination discloses the pseudo- 
membrane covering the swollen skin bathed in discharges, so 
that the canal is nearly occluded, or, if the disease has occurred 
in a case where the drum-head has been previously destroyed, 
only the mucous membrane of the tympanum may be occupied 
by the diphtheritic membrane. 
The secondary form of the disease sometimes causes destruc- 
tion of the membrana tympani and the tympanic contents. 
Occasionally, as in scarlet fever, necrosis of portions of the tem- 
poral bone occurs. 
Treatment.-The canal should be syringed with a warm bi- 
chlorid solution (1:1000). The pseudomembrane should then 
be removed with the forceps and hydrogen peroxid. After 
the parts have been cleansed of membrane they are dried with 
absorbent cotton and painted with a 12 per cent, solution of 
nitrate of silver and covered with a thick coating of boric 
acid. 
Pepsin, trypsin, caroid, and other substances will dissolve 
the pseudomembrane, but their use is not desirable in the ear 
because the pseudomembrane soon ceases to re-form when the 
parts are constantly covered by antiseptics. 
Otitis externa crouposa is an acute inflammation of the 
external auditory canal characterized by the presence of a pseu- 
domembrane which does not contain the characteristic bacilli 
of diphtheria. 
Diagnosis.-The membrane when removed commonly leaves 
a bleeding surface, as is the case with the pseudomembrane of 
diphtheria, because croupous membranes rarely if ever occur 
except upon a skin not already excoriated. 
The bacteria are those of a mixed infection, usually strepto- 
coccus and staphylococcus. 
The symptoms are practically those of diphtheria of the ex- 
ternal auditory canal, except that the cervical glands are 
rarely as much swollen and inflamed. There is earache, 370 
DISEASES OF THE NOSE, THROAT, AND EAR 
tinnitus, and a greatly swollen meatus, with purulent dis- 
charge and, generally, slight fever. 
The treatment is the same as in diphtheritic otitis. 
Extostosis and Hyperostosis (Osteomata).-Exostoses of the 
meatus are usually single and pedunculated. Hyperostoses are 
situated at the inner end of the meatus close to the membrane, 
are sessile, and generally multiple (Fig. 160). Both exostoses 
and hyperostoses are whitish prominences, firm and hard when 
touched with a probe. 
Etiology.-Hyperostoses in most instances are probably 
congenital, and in all cases their presence and growth are 
painless, while an exostosis is always 
preceded by inflammation. A sub- 
periosteal abscess forms over the 
mastoid, the pus finding its way 
into the meatus at the junction of 
the cartilaginous and bony portions 
of the canal. The mouth of the 
sinus in this position becomes occupied by exuberant granula- 
tions from the bone, which become converted into bone. 
Symptoms.-Hearing is not impaired unless the bony growth 
or growths are large enough to entirely block the lumen of the 
meatus. The smallest opening is sufficient to transmit sound- 
waves. If, however, such a small opening is occluded by a drop 
of fluid, or by a few scales of epithelium, or by a small mass of 
cerumen, the hearing at once is greatly impaired. When 
purulent disease of the middle ear is present the presence of 
hyperostoses will greatly interfere with drainage and render the 
disease difficult to cure. 
Treatment.-If an exostosis is large and attached by a rather 
small pedicle to the auditory canal, especially if the growth be 
slightly movable, it can readily be detached by means of a small 
chisel and extracted with a pair of forceps. Exostoses of this 
character should always be removed. 
Occasionally sessile exostoses are encountered that extend the 
whole length of the bony canal and encroach upon the position 
Fig, 160.-Exostoses and hyper- 
ostoses (Spalding). DISEASES OF THE EXTERNAL EAR 
371 
of the drum-head. Under such circumstances it is best to 
secure additional room for the necessary chiseling by detaching 
the auricle and cartilaginous canal and pushing it forward out 
of the way in the same manner as in the radical mastoid opera- 
tion. The bony canal should be enlarged by the removal of 
rather more bone than that comprising the exostosis, in order 
to provide for cicatricial contraction during the healing process. 
If the cartilaginous portion of the canal is contracted, it should 
be slit up and the parts adjusted in position in the same manner 
as after a radical mastoid operation. The more superficial 
parts of the exostosis are very readily removed by a suitable 
gouge or chisel; but when the neighborhood of the drum-head 
is reached it is well to employ a dental burr if the bone is 
found to lie closely in contact with the drum-head. 
Hyperostoses are best let alone, even in those cases in which 
they encroach upon the canal to such an extent as to decrease 
greatly its lumen. If from time to time the patient becomes 
deaf from an accumulation of cerumen between the hyper- 
ostoses, this should be picked carefully away by means of an 
appropriate instrument. The syringe should not be used unless 
absolutely necessary, for it is often difficult to remove fluid 
from behind the hyperostoses after syringing, and it may be the 
cause of an inflammation of the auditory canal and drum- 
head exceedingly difficult to control. Where the presence of 
hyperostoses seriously interferes with proper drainage in cases 
of purulent otitis an attempt should be made to effect a removal 
of one or more of the growths by means of a drill propelled by 
an electric motor. 
Foreign Bodies.-Animate and inanimate objects, impacted 
cerumen, and laminated epithelial plugs are found in the audi- 
tory canal. 
Animate objects that may enter the auditory canal are flies 
and other insects, the larvae of insects, and various moulds. 
The treatment when the auditory canal is involved by a 
growth of aspergillus, mucor, or other moulds has already been 
detailed (p. 368). Insects can generally be removed readily 372 
DISEASES OF THE NOSE, THROAT, AND EAR 
by means of the syringe. The larvae of insects are not usually 
present unless there be suppuration of the middle ear, but 
cases have been reported of the presence of maggots within the 
auditory canal when the drum-head was intact and no suppura- 
tion existed. Larvae can be killed with chloroform vapor 
and then removed by means of the syringe. 
It is not permissible to drop chloroform into the auditory 
canal, as a blister may result. A part of a drop may be ab- 
sorbed by a small amount of cotton, which in turn is surrounded 
by sufficient cotton to make the plug fit snugly into the canal. 
Used in this manner the chloroform evaporates from the cotton 
into the canal, and the vapor produces a sensation of warmth 
and comfort. 
Generally the pain caused by the movements of the insects 
ceases within a few seconds after the use of the chloroform 
vapor, and the insect may then be removed by syringing or, 
if necessary, with the forceps. In the case of ants, wood-ticks, 
or other insects that sometimes attach themselves to the canal 
of the drum-head by their strong mandibles or jaws, the 
death of the insect is not always followed by a release of its 
hold upon the tissues. Under such circumstances the dead 
body of the insect can be removed by a pair of forceps. In the 
case of the wood-tick a portion of the tissue to which it has 
attached itself may be drawn out with the insect. This 
is a matter of no great consequence when the insect has 
attached itself to a portion of the canal; but irreparable mis- 
chief might be done by ill-considered efforts at removal when 
the insect has attached itself to the drum-head. It is said that 
the insect will unclasp its mandibles if touched with a drop of 
turpentine. In cases where, because of the nervousness of the 
patient or swelling of the canal, it is impossible at once to 
remove an insect that has been cholroformed, the canal should 
be filled with fluid vaselin or some other bland oil to prevent the 
resuscitation of the insect should the amount of chloroform 
vapor have proved insufficient to have caused its death. 
Inanimate Objects.-Shoe-buttons, pebbles, glass beads, the DISEASES OF THE EXTERNAL EAR 
373 
end of lead- and slate-pencils, and other objects are sometimes 
placed by children with n their ears in a spirit of mischief. It 
is not rare to find parts of an onion or pieces of cotton that were 
placed within the auditory canal by patients perhaps months 
or years before and forgotten. The writer removed from an 
old gentleman's ear three little wads of cotton which had been 
placed there several years before when he was treating himself 
for what he stated was "a boil in his ear." On one occasion, 
having demonstrated the removal of a foreign body from the 
ear of a dispensary patient before a ward class of ten or twelve 
senior students, the writer was requested by one of these 
students to examine his ear, as he thought he had got sand in 
it while bathing at Atlantic City the previous summer. There 
was removed not only a small amount of sand but also a cherry 
stone, black from age, which the student stated he dimly 
remembered having placed in his ear when a child. From the 
ear of another member of this same class was removed a small 
wad of cotton which the student stated must have been placed 
there the winter before. 
These stories illustrate how little annoyance foreign bodies 
in the ear sometimes cause. On the other hand, impacted 
cerumen and other foreign bodies are said to have been the 
cause of persistent cough, nausea, and even epilepsy. As 
some sensitive patients cough almost continually while their 
ear is being cleansed and more especially when the floor of 
the canal at the junction of the cartilaginous and bony portion 
is rubbed with a probe, while others become faint and nauseated 
under similar circumstances, it is readily understood how in a 
neurotic or hysteric individual the presence of a foreign body 
in the ear might be the cause of such unusual symptoms. 
Among the foreign bodies may be classed impacted cerumen 
and laminated epithelial plugs. 
Removal of Foreign Bodies.-Leaves of the onion, wads of 
cotton, and other soft objects are readily grasped by mouse- 
toothed forceps and extracted. Hard round objects, such as 
shoe-buttons and glass beads, should at first be attacked by 374 
DISEASES OF THE NOSE, THROAT, AND EAR 
means of a syringe. A fine cannula should be placed in such a 
position that a stream of fluid can be thrown into the auditory 
canal past the object. If careful syringing in this manner fails 
to dislodge the foreign body, a delicate hook, made by bending 
the end of an Allen probe at a right angle (Fig. 161), should 
be introduced into the canal between its wall and the object, 
and an effort made to roll the object outward through the canal. 
Hard, irregularly shaped bodies that cannot be rolled out with 
a hook or grasped with the forceps will often tax the ingenuity 
of the surgeon to effect their removal. In such cases strong 
cement or glue may be smeared on the outer surface of the 
foreign body and then a small mass of cotton applied. After 
a day or two, when the cotton is firmly attached to the foreign 
body, the cotton can be grasped with forceps and the foreign 
body removed. 
Efforts at removal of foreign bodies should always be made 
Fig. 161.-Allen's probe bent to hook cerumen, etc. 
with extreme gentleness for fear of injuring the drum-head, 
and the surgeon should bear in mind that rather than incur 
the risk of doing so it is preferable to detach the auricle from 
the bony meatus by means of an incision posterior to the 
auricle, and turn the auricle and cartilaginous meatus forward 
upon the cheek. 
In children it is generally necessary to give an anesthetic to 
secure that perfect quiescence of the patient necessary for the 
delicate and careful manipulation of instruments. In difficult 
cases it is best not to prolong unsuccessful efforts to remove a 
foreign body, for often it will remain in the auditory canal for 
years without producing any serious symptoms. In cases 
where it has been impossible to remove the foreign body at the 
first sitting, time should be given for the inflammation to sub- 
side, and after all swelling of the auditory canal has disappeared, 
efforts for the extraction of the foreign body will finally prove DISEASES OF THE EXTERNAL EAR 
375 
successful. Seeds and other objects that have swollen by the 
absorption of water may be dehydrated and shrunken by the 
instillation of alcohol. 
Cases in which the uninitiated, by injudicious and unsuccess- 
ful efforts to remove a foreign body, have ruptured the drum- 
membrane and caused acute purulent inflammation of the 
middle ear, and in which so much swelling of the canal has 
arisen that nothing can be seen, should be treated by frequent 
syringings with warm water and by the use of a hot-water bag, 
if necessary to relieve pain, until the inflammatory symptoms 
have subsided and the foreign body can be seen. No attempt 
at its removal should be made until swelling has subsided and the 
speculum can be used without causing pain. 
Impacted Cerumen.-Subjective Symptoms.-There usually 
is a sense of fulness and itching, and the patient complains that 
he has suddenly become deaf in one ear without any previous 
symptoms of inflammation. The explanation of this fact is 
that so long as there is the smallest conceivable opening through 
a mass of cerumen it will be sufficient to transmit sound-waves 
and the hearing will not be greatly impaired. Sometimes a 
small opening through a mass of cerumen will close from time to 
time during damp weather and open again when the atmos- 
phere becomes dry. This phenomenon may be repeated many 
times, the patient being deaf only during damp weather. Even 
when impacted cerumen is present in both auditory canals the 
patient usually becomes deaf in one ear first. Under such 
circumstances the larger amount of inspissated cerumen may be 
removed from the ear in which the hearing is most nearly per- 
fect, sometimes after the patient has protested that "there is 
nothing the matter with that ear." 
Etiology.-Increased secretion of cerumen is usually the re- 
sult of disease of the middle ear or of catarrh of the nose and 
throat. It is rather unusual to find the hearing perfect after 
the removal of a mass of impacted cerumen. The introduction 
of irritants within the auditory canal increases the secretion of 
cerumen. 376 
DISEASES OF THE NOSE, THROAT, AND EAR 
This is true of dusty employments, like coal-mining, stoking, 
or milling. Under such circumstances the mass of cerumen 
removed may consist partly of coal-dust or flour introduced into 
the canal by the dirty fingers of the workman while endeavoring 
to relieve the irritation of the canal by scratching it. Impac- 
tions result from ill-advised efforts to cleanse the canal by in- 
serting into it the screwed-up corner of a towel or the clumsy 
use of a match-stick or ear-spoon. When such articles are used 
dead epithelial scales and inspissated cerumen are thrust deep 
into the canal, which, if left to themselves, would have scaled 
off or exfoliated and dropped out of the canal. 
Treatment.-If the mass be soft, syringing with warm water 
will quickly remove it. Although inspissated cerumen is 
perhaps as readily soluble in water as any other bland fluid ex- 
cept hydrogen peroxid, a 5 per cent, solution of sodium bi- 
carbonate in glycerin and water is sometimes prescribed to 
be dropped into the ear several times a day to soften inspis- 
sated cerumen before efforts are made to extract the mass by 
syringing. 
However, it should be borne in mind that the hearing will 
be temporarily impaired as the result of dropping any fluid into 
the auditory canal when it contains a considerable quantity of 
cerumen, for reasons stated above. After the lapse of a few 
hours the wax may in rare instances have been increased in 
bulk sufficiently to cause pressure pain. When the surgeon is 
sufficiently expert with hook and syringe, it is never necessary 
to employ any fluid to soften the cerumen, the removal of the 
hardest and largest specimens being the work of only a few 
moments. 
When the impacted cerumen is very hard and firmly fixed 
within the auditory canal it is probably best not to attempt to 
remove it by syringing until the mass has been rendered mova- 
ble by manipulation with instruments. For this purpose the 
tip of an Allen steel probe, bent at a right angle (Fig. 161), 
should be introduced flatwise between the wall of the canal and 
the cerumen until it has penetrated a short distance, when the DISEASES OF THE EXTERNAL EAR 
377 
hook should be turned into the mass of cerumen and gentle 
traction exerted. Generally there will be detached a small 
portion of the impacted cerumen, which can easily be removed 
from the canal. Proceeding carefully in this manner it is 
sometimes possible to remove, even in those cases in which 
the wall of the canal is very sensitive, the entire mass of im- 
pacted cerumen without causing even the slightest pain or 
congestion of the drum-head, the procedure being vastly less 
Fig. 162.-Washing impacted cerumen from canal. Showing how to hold auricle 
to straighten canal and where to direct the stream of water. 
disagreeable to the patient than syringing. However, it is 
best in many instances to desist as soon as the mass of cerumen 
is felt to be movable, and resort to the syringe. The syringe 
used by dentists to cleanse carious cavities in teeth (Fig. 28, c 
with nozzle 8) is an admirable instrument for syringing cerumen 
from the ear. The stream of fluid should be thrown behind the 
impacted cerumen through the opening that has been made by 
an instrument (Fig. 162). One or two syringefuls of warm 
water will probably suffice to remove the greater portion of the 378 
DISEASES OF THE NOSE, THROAT, AND EAR 
cerumen, after which the auditory canal should carefully be 
cleansed of any remaining flakes by a dossil of absorbent cot- 
ton wrapped about the end of an Allen probe and dipped into 
the solution of hydrogen peroxid. 
A metal ear-spout (Fig. 163) will be found convenient to 
receive the fluid from the auditory canal during the syringing. 
It should be borne in mind that syringing an ear is at best a 
disagreeable procedure, and that the injection of water either 
too cold or too hot or with too much force into the auditory 
canal is usuallv followed by syncope. Where the quantity of 
cerumen is so large that it is impossible for the 
first syringeful to reach the drum-head, it is 
justifiable to inject with considerable force, but 
as the tympanum is approached judicious gen- 
tleness should be employed. Especially where 
the drum-head is lacking, syringing the ear may 
be made absolutely intolerable by want of gen- 
tleness and judgment on the part of the operator. 
Keratosis Obturans or Epithelial Plug.-In 
masses of impacted cerumen there are more 
or less epithelial laminae. However, the typic 
laminated epithelial plug consists almost en- 
tirely of laminae of epithelium packed one about 
the other. The external end of such a mass 
is generally covered by inspissated cerumen 
which, of course, is easily removed by syringing when the 
laminae of closely packed epithelial scales are exposed to view, 
looking not unlike a plug of wet chamois skin. It is impos- 
sible to remove such an accumulation by syringing. It is 
necessary to effect its removal layer by layer by means of a 
hook, a curette, or by forceps. A laminated epithelial plug is 
composed of the horny layer of the cutis of the auditory canal, 
which accumulates, layer by layer, within the canal as the 
result of desquamative inflammation. After the removal of a 
laminated epithelial plug the membrana tympani will probably 
be found normal in appearance and the hearing be perfect. 
Fig. 163.- Metal 
ear-spout. DISEASES OF THE MIDDLE EAR 
379 
Usually this is not the case when the collection within the 
ear consists of a cholesteatomatous mass. 
DISEASES OF THE MIDDLE EAR 
THE MEMBRANA TYMPANI 
When inspecting those parts of the ear visible by otoscopy 
the attention of the observer should be particularly directed 
to the size of the auditory canal and the condition of its wall. 
Every little scale of epidermis or mass of cerumen that can 
possibly hide an abnormal condition should carefully be 
removed by means of a cotton-tipped probe. The observer's 
eye should next seek the umbo or depression near the center 
of the drum-head, and the glance should then be directed 
upward along the handle of the malleus until Shrapnell's 
membrane is brought into view. This portion of the membrane 
should receive the most careful scrutiny, an effort being made 
to discover, if possible, the presence of the so-called foramen of 
Rivini or anything abnormal in this region. Attention should 
next be directed to the condition of the anterior and posterior 
folds, after which the glance of the observer should be directed 
around the periphery of the drum-head. By observing always 
this or some other definite plan of examination during otoscopy 
it will hardly be possible that any abnormal condition of im- 
portance will escape the observation. 
Particular attention should be directed to the size, shape, and 
position of the cone of light, the apparent length and position 
of the malleus handle, and the degree of prominence of the short 
process; the color, luster, apparent thickness, curvature, and 
position of the drum-head; as well as the presence or absence 
of perforations, cicatrices, chalk deposits, localized spots of 
atrophy or thickening, polypi, abscesses, exudation-cysts, or 
other pathologic conditions. 
Changes Occurring in the Curvature of the Membrana 
Tympani.-The membrana may bulge outward as the result of 
pressure from fluid within the tympanum or there may be a 380 
DISEASES OF THE NOSE, THROAT, AND EAR 
localized "pointing" of pus at any position on the drum-head. 
The normal curvature of the drum-membrane depends largely 
upon the tension of the tensor tympani muscle. It is claimed 
that the retractile effect of this muscle is increased after death 
by rigor mortis and in certain conditions the muscle is con- 
stantly contracted during life to an extreme degree. 
An unduly depressed condition of the membrana tympani 
also occurs as the result of unequal pneumatic pressure upon 
its two surfaces when obstruction of the Eustachian tube inter- 
feres with the proper ventilation of the tympanic cavity. 
Sometimes the retraction of the membrane is quite abrupt at 
points near the periphery, so that a sort of terrace is formed at 
Fig. 164.-Retracted membrane of a girl of ten years, with long-standing nasal 
and tubal obstruction, showing foreshortening of malleus handle, prominence of the 
posterior fold, and visibility of the margin of the pocket of von Troltsch as it passes 
forward to the manubrium. The light spot is shortened, and beyond it anteriorly 
are two parallel curvilinear bright lines, marking the edges of abruptly depressed 
areas of the drum-head, one within the other (Randall). 
Fig. 165.-Left membrana tympani of a boy of six years, with nasal and tubal 
obstruction. The manubrium is drawn up almost out of sight; the tip being higher 
than the short process; behind it the incudostapedial joint is visible, and below and 
posteriorly the dark niche of the round window is discernible. There is a faint 
reflection of light near the normal position, and a stronger one on the promontory 
near the stapes (Randall). 
Fig. 164. 
Fig. 165. 
that point. Under such circumstances a bright line will be 
seen at the point where the abrupt change of curvature occurs. 
Should such an abrupt change of curvature occur at the posi- 
tion of the cone of light, it will appear as if broken transversely 
into two parts, that nearest the periphery assuming a cres- 
centic shape. Whenever the membrane is retracted as a whole 
there is usually some change in the light spot. It often loses 
the triangular form, because of which it has received the name 
"cone" or-"pyramid of light," and becomes narrow, reduced 
to a mere point, or perhaps entirely disappears. DISEASES OF THE MIDDLE EAR 
381 
The posterior fold becomes large and prominent when the 
drum-membrane is greatly retracted and the malleus handle 
foreshortened (Fig. 164) or displaced, usually backward (Fig. 
165). The two diagrams (Figs. 166, 167) represent the means 
by which the apparent shortening of the malleus handle is 
produced. 
Myringitis is an inflammation of the membrana tympani, 
characterized by congestion, swelling, and sometimes ulcera- 
tion of the membrana tympani,pain, and tinnitus; but hearing 
is not greatly impaired unless the inflammation also involves 
the entire tympanic cavity. The pain is increased by move- 
ments of the jaw, pressure in front of the tragus, or traction 
Fig. 166.-Diagram of the normal position of the malleus and membrana tym- 
pani. The apparent length of the malleus handle to the eye of an observer is rep- 
resented by the distance a-b. 
Fig. 167.-Diagram of a retracted membrana tympani, showing the malleus 
handle drawn backward until its tip is in contact with the promontory. The 
apparent length of the malleus handle to the eye of an observer is represented by 
the distance a-c, the apparent length of the malleus handle having been "fore- 
shortened" about one-half. 
Fig. 166. 
Fig. 167. 
upon the auricle; it is generally shooting rather than throbbing 
in character. 
Etiology.-'The commonest cause of myringitis is exposure 
to cold, especially the direct impact of a cold wind upon 
the membrana tympani in persons whose auditory meatus is 
unduly open. It is sometimes the result of direct violence, as, 
for example, a blow upon the auricle or the impact of a wave in 
surf-bathing. In some cases the etiology is obscure and the 
disease seems to be the result of struma or of the rheumatic or 
gouty diathesis. 382 
DISEASES OF THE NOSE, THROAT, AND EAR 
Symptoms.--Severe pain, shooting in character, tinnitus, and 
more or less deafness. Upon inspection, if the disease is seen 
in its earlier stages, the membrane will be found markedly 
congested at the periphery and behind the malleus handle. 
Large vessels will be seen in these positions and radiating 
branches will extend from the blood-vessels behind the malleus 
handle to inosculate with those coming from the periphery. 
The surface of the membrane becomes lusterless and rough from 
loosening of its epithelium, and thick and opaque and of a 
uniform reddish color from infiltration 
and increased congestion, until all land- 
marks except the short process of the 
malleus handle are hidden from view, 
this too finally disappearing beneath the 
swelling, the membrane being, at this 
stage of the disease, of a lively red color 
and apparently either flat or actually 
convex in form. As the integument in 
the neighborhood of the drum-head is 
also congested, it is difficult to make 
out its boundaries, the red and convex 
membrane appearing not unlike a polypus projecting into the 
canal, for which it has been mistaken. 
In the course of the disease the epidermis exfoliates, wholly 
or partly, and there appears an abundant secretion, which is at 
first serosanguineous, but later becomes purulent. Exudation- 
cysts, filled with serum or pus, sometimes appear upon the 
surface of the drum-head. Pressure with a probe will indent 
such collections of fluid between the layers of the drum-head, 
and the indentation will remain visible for some time (Fig. 168), 
which is not the case in localized pointings of pus from within 
the tympanum. If abscesses rupture or are incised, ulcers 
result, which may either heal or perforate the drum-head. 
As the inflammation subsides, the portion of the membrane 
at the umbo is the first to resume its normal appearance. The 
periphery of the drum-head and a triangular portion, whose 
Fig. 168.-Interlamellar 
abscesses of right mem- 
brana tympani, one at 
umbo showing the pitting 
caused by pressure of a 
probe. Three others are 
seen down and forward 
(Schwartze). DISEASES OF THE MIDDLE EAR 
383 
base includes Shrapnell's membrane and whose apex is at the 
tip of the malleus handle, remain red and swollen for some days. 
Finally, the swelling and congestion disappear from these parts 
of the membrane, the light spot becomes distinct, and the drum- 
head assumes its normal appearance. 
Relapses are not infrequent or an acute attack may assume 
the chronic form of the disease. 
Treatment.-In acute cases pain may be relieved by the appli- 
cation of leeches and afterward by the use of hot fomenta- 
tions. When a discharge appears the parts should be thor- 
oughly cleansed by means of a dossil of cotton dipped into hy- 
drogen peroxid and the membrane should be covered with a 
thin coating of powdered boric acid. In traumatic cases the 
pain and congestion rapidly subside under i-drop doses of 
tincture of aconite root administered every hour. A 4 per 
cent, solution of cocain should meanwhile also be dropped into 
the auditory canal sufficiently often to keep the parts moistened 
until the pain subsides. 
Chronic Myringitis.-Chronic inflammation of the drum- 
head is practically always present in chronic otorrhea origi- 
nating in the tympanic cavity. In such cases the chronic 
myringitis is part of the intratympanic inflammation and gen- 
erally subsides after the discharge has ceased. The perforation, 
if not too large, then closes spontaneously or can be made to 
close by one of the methods described in the section on Per- 
forations of the Membrana Tympani. 
However, chronic myringitis is occasionally encountered 
without a history of previous middle-ear otorrhea, and then 
generally is part of a chronic inflammation involving at least 
the deeper portion of the auditory canal. 
Etiology.-Gout, rheumatism, or struma may account for the 
cases of chronic myringitis when there is no history of a previous 
otorrhea. Most cases are, however, the heritage of a middle- 
ear suppuration, and in cases where there is a scanty fetid dis- 
charge in the fundus of the canal it is well to inspect the poste- 
rior upper quadrant of Shrapnell's membrane closely for a 384 
DISEASES OF THE NOSE, THROAT, AND EAR 
fistula leading into the attic before being satisfied that the 
drum-head is intact. 
Symptoms.-The subjective symptoms are a sensation of 
fulness and itching within the ear. As the drum-head has little 
to do with the function of hearing, the hearing in these cases is 
only slightly impaired unless the intratympanic structures are 
involved. There is sometimes a very scanty fetid discharge. 
This discharge adheres to the drum-head and collects in small 
amounts upon the adjacent lower portions of the canal. When 
wiped away with cotton and peroxid the drum-head is reddened, 
either as a whole or in spots where the epithelium has ex- 
foliated. Some of these areas mark the position where a 
minute abscess has ruptured and may be covered with granu- 
lations or minute polypi. In cases where there is no discharge 
the drum-head lacks luster and is rough from the loosening of 
its epithelium. The color of the drum-head varies, according 
to the degree of the inflammation, from a dull red to a yellow or 
dirty white. It is no longer translucent, but is thick and 
opaque. The cone of light is absent or small and distorted. 
Prognosis.-'The course of the disease is slow. Chalk de- 
posits and areas of localized thickening or atrophy are not un- 
commonly seen when the disease has run its course. 
Treatment.-When chronic myringitis is part of an inflamma- 
tion of the other anatomic structures of the tympanum the 
treatment is largely that of the intratympanic condition. 
In cases where there is a discharge from the dermic surface 
of an intact drum-head, this should be cleansed carefully by 
syringing first with warm water and afterward with sublimate 
solution. The canal should then be dried thoroughly by 
means of absorbent cotton wrapped about the end of an Allen 
probe and painted with a 12 per cent, solution of silver nitrate. 
Abscesses, if present on the drum-head, should be evacuated 
and the interior of the abscess touched with silver nitrate by 
means of a bead of the salt fused on the end of a probe. 
Granular spots and small polypi upon the drum-head should 
receive special attention. Where the granulations are small, DISEASES OF THE MIDDLE EAR 
385 
simply thoroughly applying at intervals of three or four days 
a 12 per cent, solution of silver nitrate is sufficient to bring 
about a cure. When the granulations are larger and coarser 
it will be necessary to destroy them with a 50 per cent, solution 
Fig. 169.-Hartmann's foreign body and polyp forceps. 
of chromic acid or by touching them with trichloracetic acid- 
These applications should be made with care, so that no 
drip of acid is allowed to flow or spread beyond the bounds of 
Fig. 170.-Politzer's ear forceps. 
the granular area. Polypi too small to be removed with a snare 
should be scraped away from their place of origin on the mem- 
brana with Buck's sharp curette or removed by means of Hart- 
mann's curette forceps (Fig. 169). 386 
DISEASES OF THE NOSE, THROAT, AND EAR 
In cases where the granulations on the drum-head are coarse 
or a small polypus has been removed, the patient should be in- 
structed to drop into his ear 95 per cent, alcohol (Formula 16), 
diluted if necessary, every three hours between his visits to the 
aurist. 
Silver nitrate in strong solutions was extensively used by the 
aurists of half a century ago as an application to the drum- 
head. Wilde believed that it brought about exfoliation of the 
dermic layer of the membrana and thus diminished its thick- 
ness. While the views of this distin- 
guished Dublin aurist are not in harmony 
with modern teaching, yet it is probable 
that the silver oxid deposited upon the 
dermic layer of the drumhead as the result 
of applications of nitrate is partly absorbed 
by the deeper structures, acts as a seda- 
tive, and promotes the absorption of in- 
flammatory products. 
For cases that result from a rheumatic 
or gouty diathesis, alkalis, with iodid of 
potassium or salicylate of sodium, should be prescribed, while 
for cases where the disease results from struma or debility, 
the use of tonics and cod-liver oil and the employment of hy- 
gienic measures should be advised. 
Deposits of chalk (Fig. 171) are usually the result of long- 
continued inflammation of the membrana tympani. Their 
presence does not indicate that the patient has the gouty dia- 
thesis. Only when large do they greatly interfere with 
the acuteness of hearing by stiffening the drum-head and inter- 
fering with its vibrations. 
Rupture of the drum-head may result from the direct impact 
of a foreign body or from the instruments used in extracting a 
foreign body. Many cases are the result of the sudden com- 
pression of the air in the auditory canal produced by falls or 
blows upon the ear: during war the discharge of large cannon 
when the patient occupies a position near the mouth of the 
Fig. 171.-Calcareous 
deposits in the drum- 
head after middle-ear 
inflammation (Spald- 
ing). DISEASES OF THE MIDDLE EAR 
387 
gun; and when the membrane is diseased, from the use (abuse) 
of Politzer's air-douche, Siegle's pneumatic speculum (probably 
the more dangerous instrument), and even from violently blow- 
ing the nose. The writer observed a case of this kind in an 
old lady of about seventy, whose drum-head, aside from the 
usual senile changes, so far as could be judged by her history 
and the appearance of the other drum, was normal previous to 
the accident. Another case was that of a robust young man 
who attributed his ruptured drum-head to a kiss on his ear. 
The drum-head may or may not be ruptured in fractures 
of the base of the skull. Even in such 
cases, where there is hemorrhage from the 
meatus, the blood may come through the 
roof of the canal and the membrana tym- 
pani be intact. 
Injury to the drum-head may result from 
contrecoup or be explained by the irradia- 
tion theory of Aran. 
One of the writer's cases, a lad of about 
sixteen years, exhibited rupture of both 
drum-heads as the result of a blow from a 
baseball received on the left mastoid. It is stated that gunshot 
wounds of the mastoid may cause rupture of the drum-head 
apparently as the result of the jar from the impact of the bullet. 
However, it should be remarked in this connection that a hard 
blow from the bare fist on the ear is far less likely to produce 
rupture of the drum-head than a lighter blow from the palm of 
the hand or a boxing glove, the rupture in the latter case 
resulting from the condensation of air in the canal. 
In rupture of the drum-head resulting from the concussion of 
cannon shots, bursting shells, etc., there is apparently, if one 
may judge by the stellate scars seen in cases where the victims 
have escaped with their lives, actually a tearing out of a portion 
of the drum-head, usually just below the tip of the malleus. 
The subjective symptoms are sudden deafness, tinnitus, 
vertigo, and hemorrhage or a serous discharge from the ear. 
Fig. 172.-Rupture 
of the antero-inferior 
half of the drum-head, 
caused by a box on the 
ear (after Politzer). 388 
DISEASES OE THE NOSE, THROAT, AND EAR 
The prognosis as regards the restoration of hearing depends 
upon the amount of damage done to the other structures of the 
ear. Most uncomplicated cases recover satisfactorily and 
speedily, but sometimes purulent inflammation of the middle 
ear follows as the result of the injury or injudicious treatment. 
Treatment.-Cleanse the external auditory canal carefully, 
so as to remove all blood-clots or other material that might 
favor the growth of bacteria. Use Politzer's air-douche if 
necessary to remove blood from the middle ear or little shreds 
remaining between the edges of the wound to retard union; 
apply by means of the powder-blower a thin layer of boric acid 
upon the drum-head, and let the ear entirely alone until the heal- 
ing process is complete, unless pain or the appearance of a 
purulent discharge renders further interference necessary. 
Perforation of the membrana tympani sometimes occurs as 
the result of ulceration from the dermic surface of the drum- 
head during an attack of acute myringitis. Under such cir- 
cumstances the ulcer is usually central. The commonest cause, 
however, of perforation of the membrane is ulceration from 
within, the result of otitis media purulenta. 
Symptoms.-'Examinations by means of the concave mirror 
and speculum usually discloses the presence of the perforation, 
which, if large, is readily seen. In most cases inflation of the 
middle ear by the Politzer method produces a characteristic 
"perforation whistle," heard by means of the auscultation-tube 
(Fig. 148). Indeed, the perforation whistle is often so loud 
that it can be heard at a distance of many feet from the 
patient. If suppuration of the middle ear is present pus will 
escape through the perforation in the form of bubbles during 
inflation. 
The subjective symptoms vary according to the size and posi- 
tion of the perforation and other diseased conditions of the ear 
that may be present. A perforation of Shrapnell's membrane 
(Fig. 173), when it has been present for some time, is usually 
accompanied by considerable hardness of hearing, because 
purulent inflammation of the attic, the commonest cause of DISEASES OF THE MIDDLE EAR 
389 
perforation in Shrapnell's membrane, generally involves the 
articulations of the ossicles and produces lesions which greatly 
impair the acuteness of hearing. When the perforation is near 
the center of Shrapnell's membrane the neck of the malleus is 
exposed, while the perforation through the anterior portion of 
the drum-head, being directly over the tympanic extremity of 
the Eustachian tube, yields a loud perforation whistle. Rivini 
has described a perforation or foramen existing in the mem- 
brana flaccida as a normal condition. Although such a "fora- 
men" is frequently seen just above the 
process, it is believed by most aurists to 
be pathologic. 
When a large perforation in the 
membrana vibrans involves a consider- 
able part of the malleus handle the tip 
of this process is usually destroyed by 
necrosis; should, however, the malleus 
handle become attached to the promon- 
tory, this does not occur. Large per- 
forations may exist in the membrana 
vibrans without the hearing being 
greatly impaired, unless the perforation 
be so placed as to impair the support 
that the membrana normally gives to 
the ossicles. 
Prognosis.-Perforations of considerable size permit free 
access of dust, cold, moisture, and other irritants into the 
tympanic cavity, and predispose the patient to recurring 
attacks of otitis media. Sometimes the perforation gradually 
becomes closed by cicatricial material. Indeed, nearly the 
whole drum-head may be replaced in this manner. But, 
although the tympanic cavity is by this means protected from 
cold or dust-laden air, the acuteness of hearing is generally more 
or less impaired if the surface of cicatricial tissue be large, and 
such cicatricial areas break down readily during attacks of 
acute catarrh of the middle ear. 
Fig. 173.-Right mem- 
brana tympani of a boy of 
five years, with constant 
discharge for three years. 
A perforation about 1.5 mm. 
in diameter is with difficulty 
seen above the short proc- 
ess, and intratympanic in- 
jections bring away epithe- 
lial flakes and masses of 
fetid secretion. The rest 
of the membrane is slightly 
opaque, thickened, and in- 
jected (Randall). 390 
DISEASES OF THE NOSE, THROAT, AND EAR 
When seen by reflected light cicatricial areas appear some- 
what depressed below the level of the rest of the drum-head, 
and are sometimes so transparent that the structures within 
the tympanum are readily discernible through them (Fig. 174). 
If rarefaction of the air within the auditory canal is produced 
by Siegle's pneumatic speculum, a cicatrix will be seen, to 
move farther outward than the rest of the membrane. When 
large and very thin and lax, a "ballooning" of the cicatrix 
results from inflating the middle ear by means of Politzer's air- 
douche (Fig. 175). 
Fig. 174. 
Fig. 175. 
Fig. 174.-A large rounded loss of substance of the membrana tympani below 
reaches up to the tip of the manubrium, which projects slightly into the upper 
margin. It is closed by a delicate cicatrix applied to the promontory and molded 
upon its inequalities. The edges of the depression are sharp cut and overhang, so 
that the area seems an unclosed perforation (Randall). 
Fig. 175.-Inflation of the middle ear forces the delicate cicatrix out like a bubble 
into the meatus, where it seems larger than the opening and hides its edges and the 
handle of the malleus. In a few minutes the distended sac loses its tension and 
becomes plicated as it collapses, soon to resume its old position in contact with the 
inner tympanic wall (Randall). 
Treatment.-When all discharge has ceased from the tym- 
panum an effort should be made to close the perforation in 
order to prevent the irritating effects of dust and cold upon the 
exposed intratympanic mucous membrane. Closing of the 
perforation, when small, can be brought about by rubbing its 
edge from time to time with a few fibers of absorbent cotton 
wrapped about the end of an Allen probe and saturated with 
fuming nitric acid. The acid destroys the epidermal scales or 
cells which otherwise would extend from the external or dermal 
surface of the drum-head and prevent the growth of granula- 
tions. By keeping the edge of the opening in the drum-head 
"raw"-that is, free from epidermis-by means of the acid, 
the granulations finally unite in the center of the perforation, 
which then becomes closed. The same thing can usually be DISEASES OF THE MIDDLE EAR 
391 
accomplished by the method devised by Blake, which consists 
in placing a little disk of writing-paper over the perforation. 
A disk of sufficient size to cover the opening is cut from ordi- 
nary writing-paper and is soaked for a few moments in corrosive 
sublimate solution (i :5ooo). It is then placed on the end of 
a cotton-tipped Allen probe and carried through a speculum 
to the drum-head over the perforation. It adheres somewhat 
firmly to the edge of the perforation because of the sizing or 
glue which all writing-paper contains. 
The paper disk acts as a stimulant and support to the granu- 
lations springing from the edge of the perforation, so that they 
finally unite in the center and the opening is closed. It is 
somewhat instructive to note from week to week the changing 
position of the disk of paper. Roughly speaking, the epidermal 
scales grow from the center of the drum-head toward its periph- 
ery, and thence outward along the canal, and hence the disk 
or paper which was placed over the perforation in the drum- 
head, within a few weeks is seen to be upon the wall of the canal. 
If, in the meanwhile, the perforation in the drum-head has not 
closed, another disk of paper should be placed over it, and so on 
until the perforation has closed. 
When a perforation is so large that the support of the tym- 
panic membrane to the ossicles is destroyed, the chain of small 
bones tends to sag outward by its own weight, and the acute- 
ness of hearing is considerably impaired. If the Toynbee 
artificial membrana tympani (Fig. 176) be so placed as to give 
the requisite amount of support when this condition exists, 
considerable improvement of the acuteness of hearing will 
result; but little disks of paper, linen, silk, or compressed cot- 
ton answer a still better purpose, and a thread may be passed 
through the center of such a disk to facilitate its removal from 
the auditory canal. Gruber has contrived an apparatus 
(Fig. 177) for the introduction of such artificial drum-mem- 
branes by the patient himself, who, after a little preliminary 
instruction, can usually introduce one in a manner to secure 
the greatest increase of the hearing power. It is astonishing 392 
DISEASES OF THE NOSE, THROAT, AND EAR 
how tolerant the ear sometimes becomes to the presence of 
such objects, which can often be used for a long time without 
any deleterious results. It is not a matter of indifference as 
to the material employed in the manufacture of the artificial 
drum-heads. Some patients hear best with disks made from 
one material, some with those made from another. 
Fig. 176.-Toynbee's 
artificial drum-head. 
Fig.. 177.-Contrivance for intro- 
ducing artificial drums (Gruber). 
When a large cicatrix is present which bulges greatly after 
inflation-i. e., is very freely movable--the hearing can often 
be improved greatly by the application of a small quantity of 
contractile collodion (Formula 78). The collodion is best 
applied by means of a small camels'-hair brush after the infla- 
tion of the tympanum. The application of collodion should 
not be repeated at too frequent intervals or too much applied at 
one time, because pain and myringitis may result. 
Otitis Media Catarrhalis Acuta.-Acute catarrhal inflam- 
mation of the middle ear is an acute inflammation of the mu- 
DISEASES OF THE TYMPANUM DISEASES OF THE MIDDLE EAR 
393 
cous membrane of the tympanum, Eustachian tube, and, some- 
times, of the mastoid cells, characterized by increased secretion 
of serum or mucus, but not of pus. Clinically, cases of acute 
catarrh of the middle ear are divided into two classes: One in 
which the attic of the tympanum and mastoid antrum are 
involved by the diseased process; the other, in which the dis- 
ease is confined to the Eustachian tube and atrium of the tym- 
panum. 
Etiology.-The disease is in almost all instances the result of 
exposure to cold. Chronic catarrhal affections of the upper 
respiratory tract render many individuals susceptible to recur- 
ring attacks of inflammation of the middle ear, while in many 
instances carious teeth have the same effect. Very often pain 
commencing as a toothache extends to the ear. In many cases 
the disease is the result of surf-bathing or of diving into water 
from a considerable height. 
In cases where acute catarrh results from diving and surf- 
bathing the direct impact of water upon the drum-head pro- 
duces sufficient traumatism to cause the disease. A large 
auditory meatus, a cicatricial drum-head, or a perforated drum 
render the middle ear more liable to traumatism while bathing, 
and such individuals should never dive or bathe in the rough 
surf without stopping the ears with absorbent cotton saturated 
with vaselin to exclude the water. All amphibious animals 
have valves which exclude water from the auditory canal dur- 
ing the time the animal is under water, and hunting dogs taught 
to dive sooner or later become deaf. However, it is not always 
the forcible entrance of even cold water into the auditory canal 
that is responsible for an attack of acute aural catarrh. Not 
infrequently in surf-bathing a wave will strike a bather in the 
face at a time when he is swallowing or performing some other 
function that opens the Eustachian tubes, and under such 
circumstances the water sometimes penetrates as far as the 
tympanum, and if not speedily removed is capable of causing 
acute intratympanic inflammation. An accident of this kind 
once occurred to the writer and was accompanied by a certain 394 
DISEASES OF THE NOSE, THROAT, AND EAR 
amount of vertigo and syncope, and it seems not improbable 
that some cases of drowning may be the result of the entrance 
of water into the ears during surf-bathing or swimming in 
rough water. 
Occasionally fluid used as a nose-wash penetrates the 
Eustachian tubes and occasions acute tympanic catarrh or even 
suppuration, although the wash may be as bland and unirri- 
tating to the nasal mucous membrane as the normal salt solu- 
tion. Bland oils may be thrown into the Eustachian tube 
with impunity, but watery solutions frequently cause mischief. 
The use of such contrivances for cleansing the nasal mucous 
membrane as Thudicum's douche, the Bermingham douche, 
etc., are by no means as safe as an atomizer, and acute catarrh 
of the middle ear has resulted from simply sniffing normal salt 
solution into the nose and blowing the nose forcibly immediately 
afterward, so that some of the fluid reached the tympanum. 
Should water reach the tympanum during bathing or a watery 
nose-wash be inadvertently injected into the middle ear while 
cleansing the nose, Politzer's or Valsalva's method of inflation 
immediately should be employed sufficiently often to free the 
middle ear from the fluid. 
The exanthematous fevers, and occasionally typhoid and 
tuberculosis, operations in the posterior portion of the nares, in 
the postnasal space, and even upon the tonsils occasionally 
cause acute otitis. 
Pathology.-The affection in most cases begins as a catarrh 
of the pharyngeal orifices of the Eustachian tubes, accompany- 
ing similar disease of the nose and nasopharynx. If the pharyn- 
geal orifices of the Eustachian tubes are inspected by means of 
the rhinoscope at the beginning of an attack, the mucous mem- 
brane of the tube mouths will be found so congested and swollen 
as to either completely close the tubes or at least greatly inter- 
fere with the proper ventilation of the middle ear. Later on 
the secretions from the tubes are abundant, becoming more 
consistent in most instances as the disease advances, so that a 
bulb of thick glue-like mucus may project from the orifices of DISEASES OF THE MIDDLE EAR 
395 
the Eustachian tubes into the pharynx. The mucous follicles 
are sometimes swollen, giving a granular appearance to the 
tube lips. 
The appearance of the membrana tympani varies somewhat 
at the commencement of the disease. Generally it is pinkish 
in color, as the result of the congestion of the inner or mucous 
layer, and the manubrial plexus of blood-vessels is congested. 
Often the membrana is more dull and opaque than it is nor- 
mally. Often a line as fine as a hair, extending across the 
drum-head, indicates the upper level of the fluid within the 
tympanum (Fig. 178). If the fluid within the tympanum is 
thin and mobile, it will be seen to alter its position with the 
Fig. 178.-Collection of fluid exudate in the lower part of the tympanum, marked 
by a glistening line across the membrane. From the right ear of a young man in 
the middle of an acute coryza. _ Cure by Politzeration (Politzer). 
Fig. 179.-Foamy secretion in the tympanum after inflation, in a case of serous 
accumulation. From a patient with acute nasopharyngeal catarrh (Politzer). 
Fig. 178. 
Fig. 179. 
movements of the patient or during the use of the pneumatic 
speculum. By inflating the middle ear by the Politzer method 
the fluid can sometimes be broken into foam and the dim out- 
lines of minute air-bubbles discerned through the drum-head 
(Fig. 179). 
The bacteria found in the secretion varies. However, there 
is practically never a mixed infection. The staphylococcus and 
the pneumococcus of Friedlander probably are the forms most 
commonly present. 
The prognosis under appropriate treatment is favorable. 
Most cases completely recover. In neglected cases, however, 
the disease often assumes the purulent form or relapses into 
the chronic condition. 396 
DISEASES OF THE NOSE, THROAT, AND EAR 
Symptoms.-Generally, there is pain increased by movements 
of the jaw, pressure over the tragus, or gently pulling the auricle 
outward. Hardness of hearing will be greater than in simple 
myringitis, if, indeed, myringitis ever occurs without the in- 
flammation involving, to a certain extent, the entire mucous 
membrane of the middle ear. There will be present tinnitus 
and perhaps vertigo. The entire membrane may be flattened 
or even bulging as the result of the pressure of fluid within the 
tympanum. The color of the membrane may be nearly 
normal in appearance. There may be more or less congestion 
about the periphery or the region of the malleus handle. In 
the later stages of the disease, if rupture of the drum-head be 
delayed, the swelling of the drum-head is so great that the out- 
line of the malleus handle is lost to view and the drum-head is 
not distinguishable by color from the surrounding red and 
swollen skin of the canal. 
Treatment.-In most cases of acute catarrh of the middle 
ear, if seen early, it is advisable to prescribe | gr. of calomel 
combined with 5 gr. of the bicarbonate of sodium, to be taken 
every hour for six hours, for the double purpose of securing 
free evacuation of the bowels and the alterative effects of the 
calomel, as it has been maintained that small, frequently re- 
peated doses of calomel have the power of controlling inflam- 
mation of mucous membranes. 
The pain is often relieved by the use of leeches. It is cus- 
tomary, in cases where there is severe pain, to apply at least 
three leeches, one in front of the tragus, one on the mastoid as 
close to the auricle as possible, and one just beneath the 
auricle in the angle between the jaw and the mastoid process. 
These points are selected because they are the positions where 
the circulation of the middle ear is most readily depleted. 
The leeches should be the largest procurable and the wounds 
should be encouraged to bleed for a time after their removal. 
A half-century ago leeches were much more freely used in 
the treatment of acute aural catarrh than at present. Some 
writers of this period recommend that as many as ten leeches DISEASES OF THE MIDDLE EAR 
397 
be applied to the margin of the auditory canal in relays; that 
is, as fast as one leech filled and dropped off a fresh leech was 
applied as nearly as possible to the same spot. It is certainly 
true that in order to relieve the pain of acute catarrh of the 
middle ear or myringitis the blood-letting should be somewhat 
free and that little relief will follow the use of less than three 
leeches. The use of leeches in the hyperemic stage of acute 
otitis media when the pain is severe will not only relieve the 
pain but also will often cut short the progress of the inflamma- 
tion. After the use of leeches hot applications should be made 
to the ear. This can be done by filling the auditory canal with 
hot water and afterward applying a hot flaxseed poultice over 
the auricle, but in most cases the pain is more quickly and com- 
pletely relieved by the instillation of anodynes into the ear 
and the application of dry heat. 
The patient may lie with the affected ear upon a hot-water 
bag or a bag of hot salt, or i or more drops of a 4 per cent, 
solution of cocain be placed within the auditory canal from 
time to time. In some cases, however, a combination 
of morphin and atropin seems to act better as an ano- 
dyne than cocain. A hypodermic tablet of atropin and mor- 
phin may be dissolved in a few drops of warm water and 
dropped into the ear. It is best to use a certain amount of 
caution in the use of powerful narcotic poisons within the audi- 
tory canal, as cases of poisoning havebeen reported. It is a safe 
rule never to drop into the auditory canal a larger amount of atro- 
pin or morphin than can safely be administered by the stomach. 
It should be borne in mind in using anodynes within the ear 
that when the mucous membrane of the middle ear is exposed 
watery solutions are more readily absorbed than oily solutions 
or ointments, but that the contrary is the case when the drum- 
head is intact and absorption must take place through the sur- 
face of the skin; also that inflamed surfaces, whether of skin or 
mucous membrane, absorb anodynes much more slowly than 
when no inflammation is present. A 3 per cent, solution of 
cocain painted upon the exposed mucous membrane of the 398 
DISEASES OE THE NOSE, THROAT, AND EAR 
middle ear quickly relieves the pain of tympanic neuralgia, 
and more slowly that of active inflammation, but where the 
drum-head is intact a io per cent, ointment of cocain and lan- 
olin will give greater relief from pain than a watery solution. 
However, painting the drum head with equal parts of cocain, 
menthol and phenol is better than either solutions or oint- 
ments of cocain (Formula n). 
When fluid is present within the tympanum an attempt 
should be made to evacuate it by the use of the Politzer air- 
douche. The nose and nasopharynx should first be cleansed 
by the spray from an atomizer containing an alkaline solution 
and a piece of absorbent cotton, saturated with a 4 per cent, 
solution of cocain, inserted within each nasal chamber. After 
contraction of the turbinated bodies has been secured, the nasal 
chambers and the vault of the pharynx should be sprayed with 
a 4 per cent, solution of antipyrin to maintain the effects of the 
cocain for several hours and relieve congestion of the pharyn- 
geal lips of the Eustachian tubes. The Politzer air-bag should 
now be filled with the vapor of menthol-chloroform and used 
with no more force than is necessary to free the tube and middle 
ear from mucus. This treatment should be repeated once or 
twice a day, omitting the use of the cocain and antipyrin if 
the nasopharyngeal mucous membrane be not sufficiently 
swollen to require it. 
If, notwithstanding antiphlogistic and other measures, there 
is bulging in the tympanic membrane, with indications that a 
perforation is likely to occur, it should be punctured by a para- 
centesis needle at the most prominent point of bulging or in 
the postero-inferior quadrant. This operation is harmless if 
antiseptic precautions be observed. The canal should be 
cleansed by wiping it out with a pledget of cotton wrapped 
about an Allen probe saturated with hydrogen peroxid. It 
should then be syringed gently with warm corrosive sublimate 
solution (1 :2ooo). After being sterilized, a knife (Fig. 189-5) 
should be thrust through the membrane. If the malleus 
handle is not invisible as the result of swelling, the operator DISEASES OF THE MIDDLE EAR 
399 
should make the puncture on a level with the tip of the malleus 
handle midway between it and the periphery of the drum-head, 
and cut downward as far as possible while the knife is being 
withdrawn. If this technic is observed it will tend to avoid 
puncturing the bulb of the jugular vein, which in some cases 
lies immediately beneath the mucous membrane of the floor 
of the tympanum, without an intervening lamina of bone. 
Should the vein accidentally be punctured the hemorrhage for 
a moment may be quite free, but is readily controlled by pack- 
ing the canal with iodoform gauze. 
Puncturing a normal drum-head after the parts have been 
cocainized is not a very painful procedure, but when inflamed, 
paracentesis causes severe pain even after the fundus of the 
canal has been most carefully cocainized (Formula 11). There- 
fore, if the operation is performed without a general anesthetic, 
it should be done with the utmost quickness. The thrusting 
of the knife through the drum-head is sometimes followed by 
the escape of air with an audible hiss. At other times there is 
an escape of fluid which quickly fills the entire canal, but in 
some cases there is little fluid secreted for some hours after the 
operation. The canal in either case should be stopped with 
a loose plug of sterile iodoform gauze, which should be changed 
as often as it becomes saturated by secretions. 
The relief from pain occurs in some cases within a few mo- 
ments after the operation. In other cases an hour or more 
elapses before the pain begins to subside. There are few cases 
where no relief from pain is afforded by the operation. 
Without general anesthesia the simple, straight incision, 
quickly done, is all that most patients will permit. Under 
ether the incision may be made to extend around one-third 
of the posterior periphery, or a large V-shaped flap involving 
the posterior half of the drum-head may be made. These large 
incisions afford better drainage, but, as a matter of fact, they 
close almost as rapidly as smaller incisions. When the attic 
is inflamed and there are symptoms of commencing mastoiditis, 
a thrust upward through Shrapnell's membrane posterior to 400 
DISEASES OF THE NOSE, THROAT, AND EAR 
the short process sometimes affords the relief from pain that 
paracentesis of the membrana tensor failed to secure. As the 
knife is withdrawn, its point should be kept in contact with 
the bone of the roof of the canal for about | inch in order to 
cut periosteum of this region. 
Otitis Media Catarrhalis Subacuta.-The name is some- 
times applied to that stage of catarrhal disease intermediate 
between the acute and chronic forms. However, by subacute 
catarrh of the middle ear or simple acute otitis media is gener- 
ally meant an inflammation less severe in type than the acute. 
Pain is neither severe nor long continued and the patient is deaf 
only for a short time. The attacks occur at frequent intervals. 
Upon examination the membrana tympani is found pinkish in 
color and is decidedly opaque and lacks its usual luster. The 
cone of light is either smaller than normal or has entirely 
disappeared. As the drum-head never ruptures, permitting 
an examination of exudates, the kind of bacteria present if any 
is a matter of conjecture. It is doubtful if any be present. 
Etiology.-The disease is commonest in children as the 
result of disease of the nose andpharynx, hypertrophied pharyn- 
geal tonsil being an exceedingly common cause of the affection. 
Bad nutrition, carious teeth, and frequent attacks of coryza 
are common predisposing causes. 
The treatment should be directed toward improving the pa- 
tient's general health and removing any predisposing cause of 
the affection. If the teeth are carious they should receive the 
attention of a skilful dentist, while the efforts of the aurist 
should be carefully directed toward the removal of any morbid 
condition existing in the nose and nasopharynx, because ex- 
perience has amply demonstrated that in most cases attacks 
of subacute aural catarrh cease to recur as soon as a cure is 
brought about of the concomitant nasopharyngeal disease. 
The knowledge of this fact, however, is not an excuse for neglect- 
ing local treatment of the ears while the nose and nasopharynx 
are receiving attention. 
Adenoid growths and hypertrophied faucial tonsils should re- DISEASES OF THE MIDDLE EAR 
401 
ceive appropriate treatment in the manner already described. 
At each biweekly or triweekly visit of the patient the nose 
and nasopharynx should be cleansed by means of an atomizer 
filled with an alkaline solution, after which the ears should be 
carefully inflated by means of Politzer's air-bag. If the in- 
flammation of the middle ear is not too active, "massage" 
should be applied to the drum-head and the ossicles by the aid 
of Siegle's pneumatic speculum, after which there should be 
made to the interior of the nose and nasopharynx an applica- 
tion of an iodin solution (For ula 112) in the case of children, 
or an astringent solution (Formulas 113, 114) in the case of 
adults, and the parts covered with albolene by means of the 
spray from an atomizer. 
The hygienic surroundings of the patient should receive care- 
ful attention and tonics and cod-liver oil prescribed in suitable 
cases. In children catarrhal inflammation is generally of an 
adenoid character; that is, the lymphatic elements of the 
mucous membrane bear the brunt of the disease, so that chil- 
dren and young adults do well upon iodin compounds applied 
locally and given internally. Syrup of the iodid of iron should 
be prescribed for internal use, with or without cod-liver oil, 
as the circumstances of the case require, while hypertrophy of 
the lymphatic glands underneath the skin of the neck should 
be treated by inunctions at bedtime of a 10 per cent, ointment 
of ichthyol in lanolin. The ointment should be rubbed lightly 
into the skin and the bed-clothing protected by waxed paper and 
a bandage about the child's neck.. 
Catarrh in adults is often characterized by inflammation of 
the mucous glands and interstitial elements of the mucous 
membrane; and it is in such cases that sedative applications and 
astringents are most useful. The vapors of various volatile 
substances are sometimes applied to the middle ear by means of 
Politzer's air-bag. The most useful of these substances are 
iodin, menthol, and chloroform. Glass-stoppered bottles, 
each partly filled with one of these drugs (Formulas 80 to 83), 
should be at hand in the office, so that the Politzer air-bag 402 
DISEASES OF THE NOSE, THROAT, AND EAR 
can readily be filled with the vapor of the drug which it is 
desired to use by inserting the nose-piece of the instrument 
within the neck of the bottle. The vapor can then be made 
to reach the mucous membrane of the middle ear by Politzer's 
method or by the employment of a Eustachian catheter. 
The vapor of iodin, when thrown into the middle ear, acts as an 
alterative and gentle stimulant, that of menthol as a sedative, 
while chloroform vapor is probably simply a stimulant. It 
is generally easier to inflate the middle ear when the air-bag 
is filled with chloroform vapor than when it contains simply air. 
Otitis Media Catarrhalis Chronica.-Chronic catarrh of the 
middle ear is a chronic non-suppurative inflammation of the 
mucous membrane and submucous tissues of the middle ear, 
producing deafness, tinnitus, and sometimes vertigo and other 
symptoms of altered auditory functions. 
Pathology.-There are two forms of the disease, the adhesive 
and the interstitial, where lime deposits occur in the vessels 
and osteomyelitic changes take place in the ossicles and 
labyrinthine capsule, causing ankylosis and closure of the 
fenestra. Gradual progressive changes take place in the 
mucous membrane and submucous tissues of the middle ear, 
similar in character to those that occur in the mucous mem- 
branes of other parts of the body. There is first hyperemia and 
hypertrophy, then hyperplasia, and finally sclerosis. 
The first stage of the disease is a dilatation and engorgement 
of the capillaries, with an exudation of serum and round cells, 
both from the surface of the mucous membrane and also into 
its substance. The capillaries are engorged, the mucous mem- 
brane is swollen and edematous; an exudate is constantly 
moistening its surface. The inflammatory exudate within the 
substance of the mucous membrane contains round cells, 
which proliferate and increase in size by a process of elongation, 
so that they are finally converted into newly formed connective 
tissue, sometimes causing cords, bands, contractions, and 
calcifications similar in appearance to cicatricial tissue follow- 
ing suppuration. DISEASES OF THE MIDDLE EAR 
403 
During the earlier stages of the disease the thickened mucous 
membrane is redder and rougher than normal, soft, and easily 
depressed with the end of a probe. As a result, however, of 
the gradual increase of connective tissue and the absorption of 
the more fluid parts of the exudate the mucous membrane, while 
still much thicker than normal, is pale and quite smooth. This 
condition represents a stage intermediate between hypertrophy 
and atrophy of the tympanic mucous membrane. It is hyper- 
plasia of the mucous membrane. 
As a mechanical result of the contraction of the newly formed 
connective tissue the glandular elements of the mucous mem- 
brane disappear and it finally resembles scar 
tissue. The mucous membrane becomes 
smooth, thin, and secretes but little fluid. 
In some cases atrophy or sclerosis of the mu- 
cous membrane of the tympanum rapidly oc- 
curs without any preexisting stages of hyper- 
trophy. Such cases are often the result of 
syphilis or they follow purulent inflammation 
of the mucous membrane with or without per- 
foration of the drum-head. 
It should not be supposed that the changes 
in structure above described progress evenly throughout the 
entire mucous membrane. Often depressed, scar-like spots 
of atrophy are seen in the midst of the rough, succulent, and 
swollen mucous membrane characteristic of the hypertrophic 
stage of chronic aural catarrh. 
Not only are the mucous and submucous structures involved 
in long-continued catarrh of the middle ear, but also the bony 
structures. The cavity of the tympanum becomes more 
roomy, and as a result of interference with the nutrition of 
the parts, chalk deposits take place in the deeper layers of the 
mucous membrane, in the membrana tympani, the membrane 
of the round and oval windows, and in the ligaments and 
cartilages connected with the ossicles. The ossicles frequently 
become ankylosed, and adhesions form which bind them 
Fig. 180.-Sche- 
matic section of a 
case of attachment 
of the manubrium 
to the promon- 
tory (Politzer). 404 
DISEASES OF THE NOSE, THROAT, AND EAR 
to one another or to the surrounding bony walls of the tym- 
panum, while bands of newly formed connective tissue may 
extend across the tympanum or mastoid antrum. The 
membrana tympani and manubrium occasionally become 
adherent to the promontory (Fig. 180), sometimes as the 
result of newly formed adhesions, or from the degeneration of 
bands of mucous membrane, which normally exist in the 
embryo and frequently persist during life. 
Ordinarily, catarrh of the middle ear is but part of a diseased 
process involving the nose, throat, Eustachian tubes, and mas- 
toid cells. The stage of the disease and the degree of inflamma- 
tion may vary in the different parts affected. In most instances 
the Eustachian tube is the first part of the middle ear affected, 
as the disease progresses by continuity of structure from the 
nose and pharynx to the tube. Stenosis of the tube, from 
swelling of the lining mucous membrane or accumulation of 
seretions, interferes with the proper ventilation of the tym- 
panum, thus producing a partial vacuum within the cavity, a 
constant dry cupping, as it were, of the tympanic mucous 
membrane, with consequent engorgement of its capillaries. 
Otosclerosis, rarefying ostitis, spongifi cation or hyper- 
ostosis of the bony capsule of the labyrinth, is a hyperplasia 
of the bony capsule resulting in the metaplastic transformation 
of cartilage into bone and bony outgrowths or hyperostoses. 
In macerated specimens the newly formed bone is whiter and 
more porous than that surrounding it. The disease is most 
noticeable at the fenestra which gradually become narrowed 
until at the oral window there is complete bony ankylosis of the 
stapes. The deafness is then great, but the drum-head may be 
of normal luster and position, a red reflex indicating the con- 
gestion of the mucous membrane of the capsular or inner wall 
of the tympanum. 
Etiology.-It is generally the result of an extension of a simi- 
lar disease of the nasopharynx through the Eustachian tubes. 
The chronic condition may become established after repeated 
attacks of acute catarrhal inflammation of the middle ear. DISEASES OF THE MIDDLE EAR 
405 
Carious teeth cause chronic catarrh of the middle ear as the 
result of reflex irritation. The similarity of the pathology of 
middle-ear catarrh to rheumatism of the joints was pointed 
out by Toynbee and some of the other aurists of a half cen- 
tury or more ago. Recently, O'Malley has endeavored to 
demonstrate that chronic adhesive paracuses in the middle ear 
is rheumatoid arthritis of the organ of hearing and otosclerosis 
is osteoarthritis of the stapedial articulation and labyrinth cap- 
sule. Those constantly exposed to loud noises, as the result of 
working at certain trades, like boiler-making, are especially 
prone to lose their hearing. Syphilis, scrofula, and any condi- 
tion of lowered vitality, inherited or acquired, may be enumer- 
ated as predisposing causes of the disease. Some observers 
maintain that otosclerosis is simply the result of a primary in- 
flammation of the middle ear. However, the majority seem to 
be of the opinion that the disease of the capsule is primary and 
that concomitant pathological conditions of the middle ear are 
secondary or coincident. Heredity is an important factor; but 
when the tendency to otosclerosis exists, intratympanic inflam- 
mations greatly accelerate the progress of the disease as in 
chronic suppuration following scarlet fever, when the slowly 
increasing deafness is not the result of true otosclerosis. 
Subjective Symptoms.-There is gradually increasing deaf- 
ness. The decrease in the power of hearing is, however, by no 
means uniform. Successive attacks of subacute exacerbations 
of the catarrhal inflammation produce comparatively great 
impairment of the hearing power, which, in turn, somewhat 
improves. In this manner the disease progresses, the hearing 
being better or worse from week to week, but becoming gradu- 
ally more impaired from year to year. Patients hear better 
during clear, dry weather than on rainy or damp days. This is 
not the result of any change in the acuteness of hearing, but 
simply due to the fact that dry, cold air is a better conductor 
of sound than moist air. The acuteness of hearing may not 
decrease to the same degree for all sounds. Many patients 
bear a watch tick at almost the normal distance, but hear 406 
DISEASES OF THE NOSE, THROAT, AND EAR 
spoken words very indistinctly. In other cases the impair- 
ment of hearing is most manifest for musical tones, like those 
emitted by a tuning-fork. A common remark from some 
patients is that they hear the sound of the voice distinctly, 
but are unable to distinguish the words spoken. This slow 
hearing is probably due to the sluggish action of the tensor 
tympani and stapedius muscles, whose action changes the 
tension of the ossicular chain, so that under normal conditions 
it is instantly tuned to the pitch of each sound. Hence most 
deaf persons hear words best not when spoken in a loud voice, 
but when spoken slowly and distinctly. 
A sense of fulness and discomfort within the ear and certain 
modifications of the hearing are not uncommon during the 
course of chronic aural catarrh, the commonest modification 
of the hearing power being paracusis Willisii, or increased 
hearing power in the midst of noise, as, for example, when the 
patient is on a moving railroad train. This phenomenon has 
been ascribed to great rigidity of the ossicles and contraction 
of the tensor tympani muscle, and it is of sinister import as to 
the ultimate effects of treatment. The presence of the condi- 
tion may be demonstrated by placing a large fork of 32 vibra- 
tions per second on the forehead. If, while the fork is vibrating 
a watch is heard more distinctly, paracusis willisii is present. 
Dysacousma or dysesthesia acoustica is a condition in which 
loud noises or even those of moderate intensity cause painful 
sensations. When the patient hears his own voice, somewhat 
altered in character and pitch, as if it came from a distance or 
through the tissues of his head, the symptom is called autophony 
Paracusis duplicata and paracusis diplacusis are names given 
to the phenomenon in which the patient hears sounds as if 
repeated twice, the second sound seeming somewhat like an 
echo of the first. Probably in most cases of chronic catarrhal 
deafness sounds are not only altered in intensity but also in 
pitch and character as well. It is difficult, however, to observe 
any subjective alteration in the character or pitch of musical 
notes, except in the case of musicians who are deaf only in one DISEASES OF THE MIDDLE EAR 
407 
ear. In such cases not infrequently the note of a tuning-fork 
will seem to be of a different character and pitch when sounded 
before the deaf ear from that emitted by the same fork when 
sounded before the patient's normal ear. When subjective 
alteration of the character and pitch of sounds is sufficiently 
manifest to be a source of discomfort to the patient, the name 
pseudacousma, or false hearing, is applied. 
Tinnitus, subjective ringing or hissing sounds heard in the 
ear, is a symptom of aural catarrh rivalling in importance even 
progressive hardness of hearing. It is sometimes the only 
symptom of which the patient complains, the fact being that, 
although he is somewhat deaf, yet his hearing is still sufficiently 
acute for the ordinary purposes of his life, and occasions no 
discomfort. Some such patients are actually surprised when 
tests of their hearing demonstrate that it is defective. This is 
especially the case when only one ear is diseased. Tinnitus is 
usually worse at night and it may not be present at all in some 
cases during the daytime. It is subject to great variations 
in degree in some cases of aural catarrh, disappearing for 
months at a time and then reappearing. Usually tinnitus 
disappears in the later stages of the disease. Involvement of 
the labyrinth may increase or decrease tinnitus, according as 
the nerve-fibers are simply irritated or destroyed. 
The head noises complained of by patients are almost as nu- 
merous as the individuals affected, but may be divided into three 
classes-the pulsating, the continuous, and sounds more or less 
elaborated, like the ringing of bells, music, and words and sen- 
tences uttered with more or less distinctness-the latter class 
only being referred to a point outside the head are the result of 
disease of the ear acting on an easily excitable brain. Some of 
the cases are at least on the border-line of insanity, and not 
only hear voices but see visions. Benefit sometimes results 
from treating the concomitant aural disease. 
Inflammation of the external auditory canal, foreign bodies, 
impacted cerumen, and polypi are capable of producing tinni- 408 
DISEASES OE THE NOSE, THROAT, AND EAR 
tus, and, in rare cases, vertigo, nausea, cough, or even epilepti- 
form convulsions. 
Sometimes the result of anemia or, more rarely, of an aneu- 
rysm, pulsating tinnitus ordinarily indicates arterial congestion 
of the middle ear or of the labyrinth. The differential diagno- 
sis between the two conditions can be made with a limited 
amount of accuracy by pressure upon the carotids or on the 
vertebral arteries at the point where they cross the atlas, 
because a branch of the carotid supplies the tympanum and a 
branch of the vertebral supplies the labyrinth. 
Vertigo is a symptom of chronic otitis media, usually transi- 
tory in character. In all cases it is probable that aural vertigo 
is due to some condition within the semicircular canals of the 
labyrinth: generally it is an alteration of the normal inter- 
labyrinthine pressure produced by increased tension exerted 
through the fenestras or by a contracted tensor tympani 
through a rigid chain of ankylosed ossicles. Only when 
structural changts have occurred to the tissues within the laby- 
rinth should the name "Meniere's disease" be given to a 
condition which otherwise is simply aural vertigo and one of 
the symptoms of disease of the middle ear. 
Although the condition of the membrana is not invariably 
an index of the condition of the tympanum, yet certain infer- 
ences may be drawn from its appearance that are the more 
valuable because it is the only visible part of the tympanum. 
The luster and color of the drum-head may be nearly normal, 
both at the commencement of chronic otitis media and also at 
a stage of the disease when the atrophic changes are far ad- 
vanced. In the latter condition, however, a red reflex from the 
promontory indicates inflammation of the inner tympanic wall 
probably involving the labyrinthine capsule-otosclerosis. 
During the hypertrophic period of catarrh of the middle ear 
evidences of involvement of the drum-head are usually not 
lacking. There may be patches of opacity or the whole drum- 
head may have lost its translucency and appear white, rough, 
thick, and opaque. The light spot may not occupy its normal DISEASES OE THE MIDDLE EAR 
409 
position as the result of an indrawing of the drum-head or it 
may be smaller than normal because of a roughening of its 
surface, and from the same cause or from local depressions it 
may divide into two or more maculae. If the drum-head is 
greatly depressed a light spot sometimes appears over the short 
process, which projects outward through the tightly drawn 
tissues like the knuckle of a finger. The handle of the malleus 
is, under such circumstances, foreshortened, appears shorter 
than normal, or it may be drawn so far backward as to lie 
almost horizontal beneath the posterior fold. Spaces abnor- 
mally white and opaque may be interspersed upon the same 
membrane with spots abnormally thin and translucent. 
Fig. 181. 
Fig. 182. 
Figs. 181 and 182.-Residua of middle-ear suppuration. Fig. 181.-Transverse 
section (schematic), showing adhesions of drum-head to promontory. Fig. 182.- 
Front view, showing old cicatricial center lesions (Spalding). 
It is always a matter of considerable importance to deter- 
mine the resiliency and tension of the membrane. This may 
be effected by observing the movements of the drum through 
Siegle's pneumatic speculum (Fig. 23). When the air within 
the canal is rarefied by means of this instrument a drum-head 
so far indrawn that it rests upon the promontory may be sucked 
outward until it appears like a balloon, a groove upon its 
convex surface indicating the position of the malleus handle. 
Sometimes isolated areas upon the drum-head will exhibit 
abnormal mobility. Ordinarily such spots are cicatrices 
formed by the closure of a perforation. This appearance may 
be produced, however, by localized atrophy. 
Deep localized depressions are found at spots where adhe- 410 
DISEASES OF THE NOSE, THROAT, AND EAR 
sioris have occurred between the membrane and promontory 
(Figs. 181, 182), such spots appearing much darker than the 
surrounding area. Sharply defined deposits of chalk, more 
especially in the posterior half of the drum-head, are not 
uncommonly seen (Fig. 171). 
The patency of the Etistachian tube is tested by the Politzer 
method of inflation. During the earlier stages of the disease 
the tubes are usually somewhat obstructed, but during the later 
stage they are abnormally patulous. A favorable prognosis 
may be given the patient if after inflation of the tympanum the 
hearing is greatly improved. Under such circumstances the 
impairment of hearing is largely due to obstruction of the 
Eustachian tubes-a condition amenable to treatment. If, 
however, the tympanum is easily inflated by the Politzer 
method and there results considerable outward movement 
of the membrana tympani without much improvement in the 
hearing, the prospect of speedily improving acuteness of hear- 
ing is not encouraging. 
In hyperemic and hypertrophic stages of catarrhal deaf- 
ness hearing for the voice is usually proportionately worse than 
for the watch and tuning-fork; in the atrophic form of the 
disease, however, the reverse is usually the case. If only one 
ear be affected a vibrating tuning-fork placed on the vertex, 
forehead, or teeth (Weber's method) is heard best in the affected 
ear so long as the functions of the auditory nerve and laby- 
rinth are unimpaired. Before involvement of the receptive 
apparatus has occurred a vibrating tuning-fork with its handle 
upon the mastoid will be heard better than when its vibrating 
tines are held in front of the ear (Rinn£ negative). Great 
deafness, patulous Eustachian tube, a red reflex though a 
normal drum head and "Bezold's triad," viz; raised lower 
tone limit, lengthened bone conduction and negative Rinne 
indicate otosclerosis. 
The prognosis is only favorable in cases in which the disease 
has not progressed beyond the early hypertrophic stage of the 
disease. Fluid exudates will be absorbed as the result of DISEASES OF THE MIDDLE EAS 
411 
treatment and simple inflammation of the mucous membrane 
of the tympanum will disappear. The prognosis is all the more 
favorable if the disease is the result of pathologic conditions 
within the nose or nasopharynx, because in such cases, when the 
nose and throat are restored to a nearly normal condition, 
chronic aural catarrh of recent origin usually subsides as the 
result of appropriate local treatment. The progress of the 
disease can in most instances be delayed, but when new con- 
nective tissue has formed, it remains, and atrophied parts 
cannot be regenerated. The prognosis is generally hopeless, 
so far as improvement of the hearing is concerned, in cases in 
which the labyrinth is seriously involved. However, this may 
be said for the comfort of those to whom an unfavorable prog- 
nosis is given: Chronic middle-ear catarrh is, to a considerable 
extent, a self-limited disease that progresses irregularly and 
with greater or less rapidity to a certain degree of deafness, 
after which the progress is slow. None become completely 
deaf. 
Treatment.-An effort should be made to improve the 
hygienic surroundings of the patient and to so improve his 
general health as to render him less liable to contract colds. 
The nose and throat, if necessary, should receive appropriate 
treatment. Hypertrophies, ecchondroses, and exostoses of 
the nasal chambers and adenoid vegetations in the pharyngeal 
vault should be removed and cicatricial bands broken down; 
hypertrophied faucial tonsils should be reduced to their normal 
dimensions. While the immediate effect of any measure to 
secure free nasal respiration may not be apparent in improved 
hearing, the freedom from frequent stenosis of the nares from 
colds and consequent irritation of the middle ear will, after a 
month or two, scarcely fail to attract the patient's attention. 
Triweekly or even daily inflation of the Eustachian tubes is 
of great importance. For this purpose Politzer's method, 
when possible, should be employed in hypertrophic cases. In 
atrophic cases, however, the irritation produced by the intro- 
duction of the Eustachian catheter is somtimes of marked 412 
DISEASES OF THE NOSE, THROAT, AND EAR 
benefit. Either simple air or air saturated with the vapor of 
chloroform, iodin, menthol, or turpentine may be used for 
producing the inflation (Formulas 80 to 83). 
In cases where the labyrinth is involved, Politzer's method 
of inflation should be used with extreme gentleness if at all. 
Ordinarily in atrophic cases the Eustachian tubes are widely 
dilated, and the violent use of Politzer's bag causes a most un- 
pleasant sensation to the patient and an immediate decrease in 
the hearing power, which gradually grows worse from repetition 
of the treatment. 
In cases of otosclerosis phosphorus in gr. doses three 
times a day for six months of the year is sometimes beneficial. 
Politzer advises a course of potassium iodid. 
Many cases not too far advanced are greatly benefited 
by a spray of menthol and camphor in fluid albolene (Formula 
127), thrown into the middle ear by means of the Eustachian 
catheter and atomizer. After introducing the catheter and 
applying the auscultation-tube the patulency of the Eustachian 
tube is tested by means of Politzer's bag (Fig. 149). The 
nozzle of an atomizer is then inserted within the proximal 
extremity of the catheter. In cases where the Eustachian tube 
is widely dilated the spray from the atomizer will be heard to 
enter the tympanum; but in most instances it enters the 
Eustachian tube for but a short distance, except during 
the act of swallowing by the patient. After a time a certain 
amount of oil condenses in the catheter and Eustachian tube. 
This should be blown as far up the tube as possible by means 
of Politzer's bag. 
For the same purpose Politzer advises 5 to 8 drops of a solu- 
tion of sodium bicarbonate (10 gr. to 1 dram of water), to 
which has been added 8 drops of glycerin; 5 or 6 drops of a 2 
per cent, solution of pilocarpin has been employed with advan- 
tage. Perspiration and salivation occur while the patient is 
still in the office and the treatment is unadvisable for those 
with weak hearts. 
Thiosinamin, 6 to 10 gr., in divided doses per day, or 12 to DISEASES OF THE MIDDLE EAR 
413 
18 min. of a io per cent, solution three times a week, is said to 
promote absorption of deposits. 
Local treatment should not be continued after improvement 
in the acuteness of hearing ceases. All possible improvement 
can be secured usually in from three to six weeks by local 
treatment every other day. However, if symptoms of relapse 
appear after a time, renewed local treatment will be necessary. 
Stricture of the Eustachian tube may be dilated by care- 
fully passing a Eustachian bougie through the stricture, but 
the use of this instrument requires the utmost care to avoid a 
disastrous or even fatal result from emphysema as the result of 
tearing the tubal mucous membrane. 
The diagnosis of stricture of the tube is made by means of 
the catheter and auscultation-tube. Air is not heard to enter 
the tympanum. This may be due to simple swelling of the 
mucous membrane, transient in character, which can be made 
to yield by blowing a drop or two of a 4 per cent, cocain solution 
from the catheter into the tube, followed in a few moments 
by an oily spray of adrenalin (1 :iooo) through the catheter. 
If after a few moments air is heard to enter the middle ear 
through the catheter, the Eustachian tube may be sprayed 
with menthol-camphor-albolene in the manner previously 
described. 
If, however, these measures fail to secure the entrance of air 
into the middle ear, employment of the Eustachian bougie is a 
justifiable procedure. As long as no stricture is encountered 
the bougie can be passed somewhat readily from the catheter 
along the Eustachian tube. If resistance is felt, it may be due 
to the normal narrowing of the tube at the isthmus. The 
bougie should be marked in millimeters in such a manner that 
it is possible, by referring to these markings, to know the exact 
position of the distal end of the bougie, and when it has entered 
the isthmus or junction of the cartilaginous and bony portions 
of the tube. It is not desirable to push the bougie much be- 
yond this portion of the tube. 
If a stricture is encountered a resistance will be felt to the 414 
DISEASES OF THE NOSE, THROAT, AND EAR 
onward passage of the bougie, which usually can be overcome 
by gentle pressure for a few moments. After the bougie has 
passed beyond the stricture it should be allowed to remain in 
position for a few minutes and then withdrawn. When it is 
impossible to pass a bougie of hard rubber or whalebone, an 
attempt may be made to destroy the stricture by electrolysis. 
Duel has devised gold bougies of three sizes for this purpose, 
one of which is passed through a rubber-covered catheter into 
the tube until the stricture is encountered. The sponge from 
the positive pole of the battery is applied to the patient's neck 
and the negative pole is connected with a bougie. The current 
is then gently turned on to a strength not exceeding 3 to 5 
milliamperes. The bougie is held firmly in contact with the 
stricture and after a moment is felt to pass through it. 
The treatment causes no pain and may be repeated at inter- 
vals of once a week. It is safer not to attempt to inflate the 
middle ear immediately after the passage of a bougie. The 
patient, however, may return the next day to have his ears 
inflated. 
The bougie may be passed into the Eustachian tube after 
the passage has been oiled with the spray from an atomizer 
containing albolene, or a few drops of a 50 per cent, solution of 
argyrol may be dropped into the catheter before passing a hard- 
rubber bougie through it into the tube. 
Massage of the Middle Ear.-Next in importance to inflation 
of the middle ear is systemic massage by means of Siegle's pneu- 
matic speculum (Fig. 23) or some other massage instrument 
by means of which the air within the auditory canal can 
alternately be condensed and rarefied, and motion be thus 
imparted to the membrana tympani and ossicles. This pro- 
cedure is almost invariably followed by an amelioration of 
tinnitus if this be present, and it probably constitutes the most 
satisfactory treatment for this annoying symptom, although 
freezing the tissues over the mastoid process by means of the 
spray from a tube of ethyl chlorid and exhausting the air within DISEASES OF THE MIDDLE EAR 
415 
the auditory canal by a plug of oiled absorbent cotton some- 
times yield good results. 
Systematic massage of the middle ear by means of the 
patient's finger-tips is of the greatest value, for while it is some- 
what dangerous to instruct an individual to inflate his middle 
ear by Valsalva's method, as its frequent use is liable to be 
followed by atrophy of the drum-head and increased deafness, 
automassage with the finger-tips is entirely harmless and may 
be used for the relief of tinnitus whenever it becomes annoying. 
The forefinger should be slightly moistened and slipped into 
the meatus with the nail posterior. With rapid piston-like 
movements of the finger-tip inward and outward a patient 
can easily exercise alternations of pressure and rarefaction of 
the air within the auditory canal, and hence massage the 
intratympanum almost as thoroughly as if a pneumatic 
speculum were used. He may be instructed to employ the 
method several times a day with increasing relief of tinnitus 
in many instances and, generally, improvement of the acute- 
ness of hearing. It is seldom that the method fails to afford 
at least temporary relief from the feeling of fulness or pressure 
within the ear. 
Phonomassage, by means of sounds conveyed to the ear 
through rubber tubes from various musical instruments or 
similar contrivances, has been employed in the treatment of 
catarrhal deafness and tinnitus. If the ears of an individual 
with catarrhal deafness be subjected for a length of time to 
musical tones of about the same pitch as the tinnitus from 
which he suffers, the subjective noiseswill either entirely dis- 
appear or be greatly alleviated, probably as the result of 
fatigue of the portion of the internal ear adapted to the 
perception of sounds of that pitch. This method of treat- 
ment has been largely abandoned in favor of more rational 
methods. 
Pneumomassage with electromagnetic and other machines, 
capable of producing rapid alternate rarefaction and condensa- 
tion of the air in the auditory canal, is undoubtedly of benefit 416 
DISEASES OF THE NOSE, THROAT, AND EAR 
in a large proportion of chronic middle-ear catarrhs, but is 
probably in no way superior to massage with the pneumatic 
speculum or the tip of the forefinger. The same remark also 
applies to direct massage of the chain of ossicles by means of 
Lucca's pressure probe, which is a spring probe, the cup-shaped 
end of which fits over the short process of the malleus to pre- 
vent slipping; and also to the so-called "internal massage," 
where short, sharp puffs of compressed air from an air-receiver 
are, by means of an "automatic cut-off" (Fig. 30) rapidly 
worked with the tip of the thumb, thrown through a catheter 
into the Eustachian tube. 
The wedging of a little ball of absorbent cotton into the space 
above the short process of the malleus where its weight and 
pressure serve constantly to push outward the malleus handle 
and the long process of the incus, thus diminishing pressure on 
the stapes, in a certain number of cases will afford efficient aid 
in the treatment of tinnitus and hardness of hearing. The 
little mass of cotton should be moistened with a suitable anti- 
septic solution, so that it can be molded to the parts when 
inserted above the malleus handle, and may be worn for several 
weeks at a time with benefit in certain cases. It is not readily 
dislodged from its position by massage either with the pneu- 
matic speculum or the finger-tip, and sometimes gives imme- 
diate and ultimately permanent relief from tinnitus. 
Tension of the transmitting apparatus of the middle ear may 
also be decreased by operative procedures, such as repeated 
paracentesis of the drum-head, tenotomy of the tensor tympani 
and stapedius, or removal of the membrana tympani and one or 
more of the ossicles. 
Tinnitus is not always the result of diseases of the ear, but 
rather is a reflex phenomenon due to the irritation of some 
correlated region-the nose, teeth, or, more frequently, the 
digestive tract. Just as acute dyspepsia is ordinarily accom- 
panied by vertigo, so the more chronic ailments of the digestive 
tract sometimes occasion a tinnitus the cause of which is little 
suspected. The manner in which disease of the digestive tract, DISEASES OF THE MIDDLE EAR 
417 
teeth, or nose produces tinnitus is through the nervous connec- 
tion, more or less direct, of those organs with the inferior 
cervical sympathetic ganglion, which supplies the nervi 
vasorum to the occipital artery and its branch, the internal 
auricular. Irritation of the inferior cervical sympathetic 
ganglion would cause tinnitus as the result of dilation of 
the arterioles of the cochlea, which, at first pulsating, would 
afterward become constant in character as the result of trophic 
changes resulting from increased blood-supply. Quinin, the 
salicylates, and certain other drugs are capable of producing 
tinnitus, either as the result of aural hyperemia or by their 
toxic action upon the internal ear. There is also reason to 
suppose that in lithemia the products of indigestion exert a 
similar action in the production of tinnitus. It is, therefore, 
in cases where dyspepsia and lithemia have done their share in 
the production of tinnitus, that acids, including hydrobromic 
acid, are especially useful in controlling this annoying symptom. 
Proper regulation of the diet and regular exercise in the open 
air and sunlight will, in cases where there is neither disease of 
the ear, nose, or teeth to account for tinnitus, generally result 
in a disappearance of the head noises. 
The faint puslating tinnitus due to anemia is diminished by 
the patient's lying down, and in many instances can be per- 
manently cured by hygienic measures and suitable tonics, 
among which the well-known pil. sumbul comp, is especially 
useful. Pulsating tinnitus due to congestion, on the other 
hand, may be alleviated by the bromids, of which, for the reason 
stated above, dilute hydrobromic acid, in doses of from 15 to 60 
drops three times a day, is probably the best. 
The earlier stage of chronic catarrh of the middle ear is ordi- 
narily accompanied by tinnitus, generally constant in character. 
Later on, as deafness becomes profound, tinnitus often dis- 
appears as the result of diminished sensibility of the internal 
ear. Tinnitus due to middle-ear catarrh is sometimes alle- 
viated by large doses of the bromids; but better results can be 
obtained in a limited number of cases by the patient taking 418 
DISEASES OF THE NOSE, THROAT, AND EAR 
after meals, for a few weeks, a pill containing | gr. of nitrate of 
silver, | gr. of extract of hyoscyamus, and gr. of strychnin. 
Otitis Media Suppurativa Acuta.-Acute purulent inflam- 
mation of the middle ear is an acute purulent inflammation of 
the mucous membrane of the tympanum, and usually also of 
that of the Eustachian tube and mastoid cells. 
Pathology.-The tympanic mucous membrane is of a bright 
red color, much swollen, and devoid of its epithelium. There 
is cellular and serous infiltration of its connective-tissue layer 
and much exudation of mucopus or pus from its surface. Per- 
foration of the membrana tympani occurs in the majority of 
cases, the pus being then discharged through the perforation 
into the auditory meatus; occasionally the discharge is tinged 
with blood. 
Etiology.-Generally the disease is the result of a cold or of 
traumatism, or it may occur as a complication during diph- 
theria, scarlatina, small-pox, measles, typhoid fever, syphilis, 
or tuberculosis. Purulent inflammation of the middle ear is 
very common in children. Carious teeth and nasopharyngeal 
disease are predisposing causes of the affection. Suppuration 
presupposes bacterial infection, which probably takes place in 
most instances by way of the pharynx and Eustachian tube. It 
is a general rule that the infection at first at least is monobac- 
terial, but that after the membrane is ruptured, polybacterial 
infection commonly occurs from the canal. Efforts should, of 
course, be directed to prevent if possible this mixed infection. 
The microorganisms most commonly found in otorrheal pus 
are streptococcus pyogenes, pneumococcus, staphylcoccus 
aureus and albus, Friedlander's bacillus, typhoid, and tu- 
bercle bacilli. Of the monobacterial infections, that of the 
streptococcus is most likely to run a severe course, often 
ending in severe mastoid complications. 
Symptoms.-An attack is ushered in by pain in the ear, 
shooting over the side of the head. Sometimes the pain 
originates in a diseased tooth and extends to the ear. Chilly 
sensations and fever are sometimes present, the temperature DISEASES OF THE MIDDLE EAR 
419 
reaching as high as 1020 or 1030 F. The ear feels full and there 
are tinnitus and deafness, the pressure of confined pus upon the 
secondary membrane sometimes interfering with the functions 
of the labyrinth. When perforation takes place there occurs a 
rapid alleviation of the pain and tinnitus. 
The appearance of the drum-head is that of acute myringitis. 
At the end of a few hours to several days or even weeks from 
the beginning of the attack a bulging at some point upon the 
drum-head indicates the position where the pus will burrow its 
way through the membrana. When, however, the attic and 
mastoid antrum contain pus which cannot readily drain into 
the atrium because of swelling of the mucous membrane about 
the ossicles, this pus will sometimes burrow underneath the 
skin of the auditory canal and find an exit either at some point 
within the canal or behind the auricle. Those cases in which 
no perforation occurs run a tedious course and some permanent 
impairment of the hearing usually ensues. The duration of 
the disease from the occurrence of a perforation to its closure 
is very variable. In cases where the perforation occurs early, 
it may remain open only for a few days. Three or four weeks 
are ordinarily required for the closure of a small perforation. 
If the perforation is large it will probably remain open long 
after suppuration has ceased, to finally close by cicatricial 
material destitute of all fibers of the membrana propria, and will 
bulge inward and outward with the varying intratympanic 
pressure. 
Extensive destruction of the structures of the middle ear 
sometimes occurs during acute otitis media. This is especially 
apt to take place when the disease appears as a complication of 
scarlatina, variola, or diphtheria. The whole of the drum- 
membrane and all of the ossicles may come away within a few 
days from the onset of the middle-ear disease as an enormous 
slough. In other cases, ulceration, starting from the perfora- 
tion, proceeds more slowly, but it accomplishes equally 
disastrous results. Inflammation of the mastoid is occasion- 
ally a serious complication of acute otitis media, and the laby- 420 
DISEASES OF THE NOSE, THROAT, AND EAR 
rinth sometimes participates in the purulent inflammation of 
the tympanic cavity, the ultimate result in such cases being 
intracranial complications, often fatal, unless the labyrinth 
is opened and efficient drainage secured. 
Infants affected by acute suppuration cry constantly, 
turning their heads restlessly from side to side, placing the hand 
frequently upon the affected ear. High temperature, reaching 
103° or 104° F., is usually present and convulsions sometimes 
occur. The infant sleeps only when completely exhausted or 
under the influence of opiates. Upon inspection the drum-head 
is often found enormously swollen, projecting into the canal 
like a polypus, for which it has been mistaken. Sleeplessness, 
high temperature, and restlessness quickly disappear after 
evacuation of the pus. 
The prognosis of acute purulent inflammation of the middle 
ear, when it occurs in an otherwise healthy individual, is usually 
favorable, but the severity of the attack depends largely on the 
variety of bacteria causing the infection and their virulence. 
However, the disease frequently assumes the chronic form, 
and in tuberculous individuals this is the usual outcome of the 
affection. 
Treatment.-In the early stages of the disease, leeches, hot 
applications, and the other measures already specified as useful 
for the relief of pain in catarrhal inflammation of the middle ear. 
Paracentesis of the membrane should be done as soon as bulging 
occurs. The cut should be 2 or 3 millimeters long and should 
be made through the point at which the bulging occurs or at 
the so-called point of election in the posterior quadrant of the 
membrana tympani, midway between the malleus handle and 
the periphery (see p. 398). When there is considerable swelling 
of the upper posterior part of the auditory canal, indicating the 
presence of pus beneath the skin of this region, the thrust should 
be through Shrapnell's membrane, and the knife be so with- 
drawn that its point will cut through the swollen tissues at the 
upper posterior portion of the canal to the bone, in order to 
secure free drainage. DISEASES OF THE MIDDLE EAR 
421 
After incision of the drum-membrane or when rupture has 
occurred spontaneously the major part of the pus within the 
auditory canal should daily be removed by means of absorbent 
cotton wrapped about the end of a probe, and the pus within the 
tympanum expelled through the opening in the drum-head by 
the Politzer method of inflation and suction with Siegle's 
pneumatic speculum. After this has been accomplished the 
auditory canal should be cleansed thoroughly by means of a 
cotton-tipped probe wet with a 15-volume solution of hydrogen 
peroxid, the parts thoroughly dried, and covered with powdered 
boric acid by means of a powder-blower. 
Fig. 183.-Blake's polypus snare. 
If exuberant granulations sufficiently large to obstruct free 
drainage from the tympanum occur, they should be removed 
by means of a snare (Fig. 183), by Hartmann's forceps (Fig. 
169), or by touching them with chromic acid fused on the end 
of a probe. Considerable caution is required in the use of 
chromic acid. The granulations or small polypi should be 
first dried thoroughly by means of absorbent cotton, in order 
to prevent the acid dissolving and flowing over adjacent struc- 
tures. No more of the acid should be applied than is neces- 
sary to accomplish the desired result, and any excess remaining 
within the canal should be neutralized by syringing with a warm 
alkaline solution. Small polypi and exuberant granulations are 
most apt to occur and obstruct drainage when the pus has found 
its way through an opening in Shrapnell's membrane at a point 
on the upper and posterior part of the auditory canal. Much 
improvement often results from injecting a 5 per cent, solution 
of argyrol into the tympanum through the perforation every 422 
DISEASES OF THE NOSE, THROAT, ANDEAR 
second or third day. The author has seen the discharge quickly 
cease in a number of cases as the result of one or more such 
intratympanic injections. As the solution frequently remains 
for several hours within the tympanum, its strength should not 
be over 5 per cent., as more concentrated solutions are capable 
of increasing the inflammation; nor should the injections be 
repeated oftener than once in two or three days. 
Brilliant results have been obtained by vaccine therapy. 
Otitis Media Suppurativa Chronica.-Etiology.-'Chronic 
purulent inflammation of the middle ear is 
generally caused by neglect or improper 
treatment of acute purulent disease of the 
middle ear and the failure to secure ade- 
quate drainage. Adenoids, nasopharyn- 
geal disease, and malnutrition prevent 
sometimes a prompt secession of an otor- 
rhea. The affection may, however, de- 
velop primarily as the result of syphilis or 
tuberculosis. Numerous cases are the re- 
sult of scarlatina. 
Symptoms.-There is a mucopurulent or 
purulent discharge, sometimes tinged with blood. The acute- 
ness of hearing varies according to the amount of destruction 
of the structures of the middle ear or to the presence of 
polypi or semi-inspissated secretions blocking the canal or in- 
terfering with the functions of the ossicles. In some instances 
the hearing is nearly normal, while in others deafness is nearly 
absolute. Tinnitus may or may not be present. 
The presence of a discharge in the auditory canal from the 
middle ear presupposes the presence of a perforation of the 
drum-head. The perforation, on the one hand, may be so mi- 
nute as to escape observation by otoscopy, its presence being 
only revealed by a "perforation whistle" during inflation of 
the ear either by Politzer's or Valsalva's method. On the 
other hand, the destruction of the drum-head may be so exten- 
sive as to expose the cavity of the tympanum to view and reveal 
Fig. 184.-Residua 
of middle-ear suppura- 
tion. Nearly total loss 
of the drum-head. 
Handle of hammer 
resting on mucosa of 
promontory (Spalding). DISEASES OF THE MIDDLE EAR 
423 
all of the structures of the inner wall (Fig. 184). In some cases 
the remains of the drum-head may be represented only by a 
narrow ring; in other cases the ossicles may have also disap- 
peared, either from ulceration and sloughing of their ligaments 
or by necrosis of the bones themselves. Necrosis of some por- 
tions of the tympanic walls may also exist. To a considerable 
extent the position and size of the perforation will indicate 
the position and extent of the necrotic process (Fig. 185). 
The appearance of the tympanic mucous membrane varies 
somewhat. In one class of cases it is simply red and swollen, 
while in another class it appears granular and polypi may be 
present, perhaps covering the orifice of a sinus leading to 
exposed bone. 
Fig. 185.-1-5, Simple suppurations of the drum-cavity and the Eustachian 
tube; 6, 8, caries of the incus; 7, caries of the head of the malleus; 9, attic suppura- 
tion with possible caries of both malleus and incus; 10, 11, caries of the head of 
the malleus; 12, caries of the incus and suppuration of the antrum, and, possibly, 
associated cholesteatoma (Leutert). 
Usually there is a destruction of the ciliated epithelium and 
a thickening of the mucous membrane from infiltration of 
round cells with a dilatation and new formation of blood-ves- 
sels. Fungiform excrescences cover the thickened mucous 
membrane, which contains small cysts lined with cylindric 
epithelium containing epithelial cells, leukocytes, and detritus. 
The bacteria of the discharges are staphylococci and sapro- 
phytes. 
Prognosis.-Untreated, some cases, after discharging for a 
year or two, finally cease discharging, the perforation in the 
membrane closes, and the hearing, while not entirely normal, 424 
DISEASES OF THE NOSE, THROAT, AND EAR 
becomes fairly good. This result is most likely to occur in 
cases with perforations similar to those shown in Fig. 185, 1-3. 
In other cases, where there is a large destruction of the mem- 
brane, the discharge ceases for a time only to recur at intervals. 
In this class of cases there is only occasionally an apparent 
discharge, which for long intervals never appears externally. 
A scanty discharge, mixed with dust and other materials, dries 
at the fundus of the canal until it becomes a source of irritation, 
when, perhaps partly as the result of a cold, an abundant otor- 
rhea is set up which sweeps away the old inspissated accumu- 
lations. Gradually this abundant otorrhea subsides until for 
another period no discharge appears externally . This is not an 
infrequent termination in cases where there is a large destruc- 
tion of the membrane, as in Figs. 184 and 185, 4. In cases of 
this character occasional careful cleansing of the ear and in the 
case of a recurrent discharge one or two applications at inter- 
vals of a day of a 10 per cent, solution of argyrol will maintain 
the ear in a fairly satisfactory condition. Often the hearing is 
fairly good. The mucous membrane of the inner wall of the 
tympanum rarely epidermatizes and becomes entirely dry. 
Occasionally, where there is as nearly a complete destruction 
of the drum-head as in Fig. 184, the opening will become closed 
by a huge thin cicatrice, which, ballooning inward and outward 
with every change in intratympanic pressure, is rather a hin- 
drance than an aid to hearing, but serves to exclude cold 
dust, and other irritants. 
Cases where there is a small opening in or just below Shrap- 
nell's membrane leading to carious bone or an accumulation of 
filth (cholesteatomatous material) discharge indefinitely a 
scanty, watery fluid which sometimes dries upon the tym- 
panum, forming an accurate cast of that structure when 
removed. Such so-called "attic cases" (Fig. 185, 6-12) 
are always a source of greater danger in the production of mas- 
toid and intracranial complications than other forms of chronic 
otorrhea, although many attic cases reach a ripe old age with 
no more serious discomfort than partial deafness and a scanty DISEASES OF THE MIDDLE EAR 
425 
discharge. Apparently there are no statistics bearing on the 
subject. 
Treatment.-'Conditions preventing the cessation of a chronic 
discharge from the middle ear are polypi; a pulpy or granular 
condition of the mucous membrane; insufficient drainage, 
because of a small perforation or one unsuitably situated; 
necrosis of one or more of the ossicles or of the tympanic walls; 
cholesteatoma. 
In chronic otorrhea, the result of tuberculous infection, it is 
very difficult to bring about a cure of the suppuration even by 
the most radical operations. However, such cases usually die 
from the concomitant phthisis before the tuberculosis of the 
ear has progressed sufficiently to render a radical mastoid opera- 
tion justifiable. 
The treatment of uncomplicated cases consists in daily thor- 
ough cleansing of the interior of the drum, already described 
as necessary in the treatment of acute purulent inflammation 
of the middle ear. If the perforation through the membrana is 
not sufficiently large to permit of this being readily accom- 
plished, it should be enlarged or a counteropening made, and 
the interior of the drum syringed by means of Blake's middle- 
ear canula (Fig. 28, 2, 3, or 4). When, with large perforation, 
pus is seen to flow downward from the attic into the tympanum, 
the nozzle of the curved canula should be introduced into the 
attic through the perforation so as to thoroughly cleanse this 
cavity. 
After the cavity has been thoroughly cleansed it should be 
dried carefully by means of absorbent cotton wrapped about a 
probe and the parts covered by powdered boric acid. The suc- 
cess of the treatment depends upon the thoroughness with 
which the cleansing is accomplished at each daily visit of the 
patient. 
If the tympanic mucous membrane is granular the routine 
treatment outlined above will not be sufficient to secure a 
speedy cessation of the discharge until the granulations are 
destroyed. Alcohol has the power to cause a shrinking of the 426 
DISEASES OF THE NOSE, THROAT, AND EAR 
granulations because of its dehydrating qualities, and absolute 
alcohol may be applied by means of a cotton-tipped probe at 
each daily visit of the patient after the ear has been thoroughly 
cleansed. The application of absolute alcohol causes some 
pain, and it may augment the discharge for a few days. Al- 
cohol (95 per cent.) may also be prescribed for the patient's 
use at home, 20 drops or more being instilled into the ear sev- 
eral times a day, care being exercised that the patient's head is 
held in such a position each time that the alcohol dropped into 
the ear will be sure to reach the cavity of the tympanum. For 
the first few days it may be necessary to dilute the alcohol 
somewhat because of pain. However, it should be remembered 
that the dehydrating properties of 50 per cent, alcohol are 
practically nothing. A good method of prescribing alcohol is 
to instruct the patient to mix in a 2-dram vial equal parts of 
alcohol and water for the first day's use. If this mixture causes 
only momentary pain, to use the next day 2 parts of alcohol 
and 1 part water, and so on from day to day until 95 per cent, 
alcohol can be used without great distress. When the dis- 
charges are fetid, compound tincture of benzoin should be sub- 
stituted for alcohol until the fetor has disappeared. 
Before dropping alcohol into his ear the patient or one of his 
friends should be instructed to remove all accumulations of pus 
from the ear in the following manner: The auditory canal is 
first straightened by drawing the auricle upward, backward, 
and outward. A cotton-tipped wooden tooth-pick is then in- 
serted gently to the bottom of the canal, and then withdrawn 
and discarded. The procedure is repeated until cotton fails to 
absorb and bring away any discharge. 
In case of a child, where the patient or nurse cleanses the ear, 
the child should be placed in front of a window before the canal 
is straightened, so that the light may be directed into the ear 
and a view of the fundus of the canal obtained. 
Cleansing the ear by some method is absolutely necessary 
before dropping alcohol into it, as otherwise the alcohol will be 
diluted and the tissues protected by a layer of pus so thick in DISEASES OF THE MIDDLE EAR 
427 
most instances that the alcohol will never reach the diseased 
parts. 
If it is deemed wise to order the patient to cleanse his ears 
with a syringe, he should be carefully instructed as to the 
proper method (p. 377), and also how to dry the ear. 
It is well at the first treatment of the patient with chronic 
otorrhea to begin by a thorough cleansing of the canal and tym- 
panum by syringing with sublimate solution. 
The writer has very serious doubts as to the value of home 
syringing, either by the patient or his friends. A girl about 
twelve years of age was brought to the Medico-Chirurgical Ear 
Dispensary some years ago almost totally deaf and with double 
facial paralysis as the result of scarlet fever. The odor from 
the child's ears was indescribably fetid. The mother stated 
that she had syringed the child's ears every day for the past six 
months. From the child's left ear there was quickly syringed a 
fetid mass of pus, the malleus, the incus, and part of the an- 
nulus tympanicus; from the right ear, fetid pus and the malleus. 
In six months of daily syringing the parent had evidently 
failed to remove any of the accumulation at the fundus of the 
auditory canal, but had simply syringed away some of its 
superficial portion. The case illustrates the value of home 
syringing of the ear as ordinarily performed. 
For the patient's use the syringe made of a single piece of 
soft rubber (Fig. 27) is probably the safest and most effective 
instrument. All things considered, a warm saturated solution 
of boric acid is the most convenient detergent ear-wash for 
home use. The patient should be instructed to place 1 or 2 tea- 
spoonfuls of the crystals in a wide-mouthed bottle holding 
about 4 ounces, fill the bottle with warm water, syringe the ear, 
and afterward cork the bottle. At each subsequent syringing a 
sufficient amount of boiling water from the teakettle is added 
to bring the saturated solution of boric acid up to a temperature 
suitable for syringing the ear. As the crystals of boric acid are 
dissolved, more should be added from time to time, in order to 428 
DISEASES OF THE NOSE, THROAT, AND EAR 
maintain a saturated solution of boric acid conveniently ready 
for use. 
However, a certain number of chronic otorrheas, especially 
those with large perforations, do better when syringed with bi- 
chlorid of mercury (1:5000 or 1:10,000) than with boric acid 
solution, and there is a very large proportion of such cases that 
experience little discomfort as long as they syringe their ears 
once a week or even at longer intervals with the bichlorid solu- 
tion. In such cases astringents are much less effective than 
antiseptic solutions. However, most cases of acute and chronic 
suppuration, under ordinary circumstances of ready access 
to the aurist's office or the dispensary, do better without home 
syringing; and when alcohol or other drops are prescribed for 
home use, they are best dropped into the ear after a dry cleans- 
ing with absorbent cotton. 
In a certain proportion of cases of chronic otorrhea the 
discharge continues because the tympanum is constantly rein- 
fected from the Eustachian tube. Yankauer has devised a sec 
of three tubal curettes by means of which the mucous membrane 
can be stripped from the tube at the isthmus thus securing its 
complete closure. The tube is anesthetized with cocain and 
adrenalin and a curette of suitable size to fit somewhat snugly 
is passed through the tympanum into the tube as far as the 
isthmus and the mucous membrane stripped from the bone 
backward toward the atrium. The operation is followed by 
little reaction and in most instances results in at least dimin- 
ution of the discharge. 
Aural Polypi.-In some instances where a large perforation 
exposes swollen or granular mucous membrane upon the 
promontory, rapid cessation of a chronic discharge will be 
brought about by lightly touching the parts once or twice a 
week with a 25 per cent, solution of trichloracetic acid in 
conjunction with the treatment already advised for chronic 
suppuration. When the granulations are isolated they may be 
scraped away with a sharp curette or be removed with the for- 
ceps. Large granulations and polypi are best removed with a DISEASES OF THE MIDDLE EAR 
429 
snare. It should be borne in mind, when removing a polypus 
with a snare, that, although the polypus is absolutely devoid 
of sensation, the wall of the auditory canal, as the result of 
long maceration in pus, is often exquisitely sensitive, and in 
guiding the wire loop of the snare over the polypus it is advis- 
able to avoid, as far as possible, touching the auditory canal. 
If the polypus is large, an effort should be made to locate its 
pedicle by means of a probe. The wire loop of the snare 
should then be worked gradually inward over its surface until, 
if possible, the pedicle of the polypus is encircled. The wire 
loop should then be tightened to cut through the polypus. If 
the operator has not succeeded at the first attempt in removing 
the whole of the polypus, this maneuver may be repeated until 
the desired result has been accomplished. Bleeding may be 
checked at any stage of the operation by means of a tampon 
of absorbent cotton saturated with a i: 1000 solution of adren- 
alin, and by afterward cauterizing the stump of the polypus 
with nitrate of silver fused on the end of a probe. 
Wilde, who was probably the first to design a snare for the 
removal of polypi, generally used his snare, not to cut through 
the polypus, but to firmly grasp it and drag it from its attach- 
ment. The author has frequently used forceps for the same 
purpose; but it should be remembered that when latent diffuse 
labyrinthitis is present, any operation in the middle ear may 
render the latent disease active with resulting septic meningitis 
and death (p. 524). 
Pathology.-Aural polypi (Fig. 186) may be divided into 
four classes. About 50 per cent, of all aural polypi are granu- 
lation tumors, having the same structure as ordinary granula- 
tions, but covered by either squamous or columnar epithelium; 
90 per cent, of aural polypi, other than granulation tumors, are 
mucous papillomata. They are extremely vascular and some- 
times bleed at the slightest touch. Their structure consists 
of capillary loops surrounded by a stroma of somewhat imper- 
fectly developed connective tissue containing cuboidal epithe- 
lial cells. They are covered by a pavement-epithelial layer of 430 
DISEASES OF THE NOSE, THROAT, AND EAR 
varying thickness. Fibroid polypi (fibromata), which are 
somewhat rare, are usually found as large, dense, pale polypi 
developed from the periosteal or deeper layer of the tympanic 
mucous membrane. Fibrous polypi are also covered by 
several layers of pavement epithelium. Myxomatous polypi 
are very rarely found in the human ear. Aural polypi are not 
malignant, the treatment outlined above being sufficient to 
prevent a recurrence of. the growth. It should be borne in 
mind, however, that epitheliomata, sarcomata, and gummata 
sometimes occur in the middle ear 
and present the appearance of polypi, 
but such growths are rare in this 
situation. 
Symptoms. - Long-continued dis- 
charge, often streaked with blood, is 
usually the only subjective symptom. 
Certain reflex symptoms, the result 
of peripheral irritation caused by the 
presence of an aural polypus, have 
been described as occurring in rare 
cases. 
Most aural polypi have their origin 
at the posterior and upper part of the tympanum. They may, 
however, arise from any part of the tympanic cavity or even 
from the dermic layer of the drum-head. Sometimes they 
originate at the mouth of a sinus extending through the skin 
of the auditory canal to carious or necrosed bone. 
Caries and Necrosis.-Caries or necrosis of the temporal 
bone may occur during the course of long-continued suppura- 
tion of the middle ear or as the result of syphilis, tuberculosis, 
trauma, osteomyelitis, and diabetes. The upper and posterior 
part of the auditory canal, the mastoid, and the tegmen of the 
tympanum and antrum are the portions most usually first 
involved. Caries most frequently attacks the cancellous 
bone; necrosis, the compact bone. 
Symptoms- Circumscribed caries may exist within the tym- 
Fig. 186.-Polypi (Steudener). DISEASES OF THE MIDDLE EAR 
431 
panum during chronic purulent disease of the middle ear and 
present no symptoms other than that exposed and roughened 
bone can be detected by means of a probe. Sudden paralysis 
of the facial nerve may occur as the result of necrosis of the 
inner wall of the tympanum involving the facial canal; however, 
a considerable portion of the facial canal may be opened and the 
nerve be bathed in pus for some time before symptoms of Bell's 
palsy occur. The labyrinth may be opened, generally through 
the horizontal semicircular canal, and a circumscribed or 
even a diffuse labyrinthitis with or without ultimate infection 
of the intracranial contents result. The tegmen tympani and 
tegmen mastoideum not infrequently are destroyed as the result 
of necrosis or caries. Under such circumstances there com- 
monly occurs a local pachymeningitis, which prevents the 
spreading of the disease upon the dura mater. Pus may find 
its way into the nasopharynx or beneath the tissues about the 
auricle. 
The necrosed bone in the more chronic cases is usually 
imbedded in exuberant granulations, through which a probe 
detects, by the sensation of a rough surface, necrosed bone. 
If a cotton-tipped probe is used the rough surface catches in 
the fibers of cotton, producing a characteristic sensation. 
Treatment.-The mere presence of localized spots of necrosis 
or caries upon one of the larger ossicles is hardly a sufficient 
reason for its removal. Perfect cleanliness and good drainage 
is ordinarily sufficient to bring about a cure of the condition. 
The rubbing of the parts with a cotton-tipped Allen probe that 
has been dipped in hydrogen peroxid, and proper daily intra- 
tympanic syringing will have a stimulating action upon the 
parts and aid the proliferation of epithelium over the dis- 
eased area. If these measures fail, the malleus and incus should 
be excised to permit freer access to the attic and better drain- 
age, but in cases of suppuration of the antrum (Fig. 187) it is 
probable that a radical mastoid operation will be required to 
bring about a cessation of the discharge. If a sequestrum has 
formed, it should be removed with forceps. Politzer's forceps 432 
DISEASES OE THE NOSE, THROAT, AND EAR 
(Fig. 170) are usually strong enough for this purpose, but 
Sexton's or Hartmann's (Fig. 169) foreign-body forceps can 
often be used to better advantage. If it be found impossible 
to remove the sequestrum through the auditory canal because 
of the granulations and polypi that obstruct the canal, they 
should be removed by means of a snare; after a few days, in 
some instances, the sequestrum will have been pushed outward 
by the granulations behind it into a position where it can 
readily be grasped by forceps and removed. 
In cases of caries or where the necrotic process has not pro- 
gressed to the formation of a sequestrum, the diseased bone 
should be scraped away by means of a sharp curet and the parts 
covered with powdered boric acid. When caries or necrosis 
affects the promontory, only the most superficial curetting is 
justifiable; but the parts should be kept scrupulously clean and 
as dry as possible by means of frequent insufflations of powdered 
boric acid. Cases where necrosed bone can be felt in a portion 
of the tympanum inaccessible to the curette are best treated by 
instillations twice a day of enzymol, a preparation containing 
pepsin. By this means the middle ear is, as it were, converted 
into a stomach capable of digesting the dead bone. Pepsin, 
of course, has no effect on living tissue. The patient should 
then lie down with the diseased ear uppermost and fill the canal 
full of enzymol. The excess of fluid is allowed to escape when 
the patient assumes the erect posture. Several hours are 
required for the pepsin to produce its effect as a digestant, and 
the presence of granulations may prevent its coming into con- 
tact wit dead bone. It is well, therefore, after enzymol has 
been used for a few days to employ instillations of alcohol for a 
day or two. However, when the ear is deaf and there is a 
fistula into the labyrinth, it will be safer to do a radical mastoid 
operation to prevent the possible infection of the meninges. 
The prognosis, of course, varies according to the part of the 
tympanum attacked by necrosis. In individuals otherwise 
healthy the prospects of a favorable result are encouraging, 
even when a large portion of the temporal bone is involved by DISEASES OF THE MIDDLE EAR 
433 
the disease. In tuberculous individuals, however, the disease 
sometimes progresses toward a fatal termination notwith- 
standing all efforts to prevent it. The prognosis is doubtful 
where there are symptoms of intracranial imvolvement, pye- 
mia, or metastatic abscess. Fatal hemorrhage may occur 
from the carotid when its bony canal is involved. The rup- 
ture of the vessel usually occurs at " Hassler's site of predilec- 
tion," that is, at the knee of the carotid in the bony canal, 
where it abruptly changes its course from the vertical to the 
horizontal. 
Aural cholesteatoma is an accumulation within the auditory 
canal and tympanum of a mass consisting of epithelial scales, 
cholesterin crystals, and inspissated pus, derived by desquama- 
tive inflammation from the lining membrane of the tympanum 
or mastoid cells. 
The presence of cholesteatomatous masses usually causes 
impaired hearing and sometimes tinnitus, nausea, and dizziness. 
The bony and soft structures become absorbed as the result of 
the pressure caused by the accumulation, so that choleste- 
atomatous accumulations sometimes occupy large cavities. 
Small collections of cholesteatomatous material are common 
at the upper and posterior portion of the auditory canal in 
cases in which perforation of Shrapnell's membrane has 
occurred. The mass often extends into the attic of the tym- 
panum, sometimes into the mastoid antrum. Cholesteatoma 
are usually not easily detected at the first glance. Sometimes 
a small mass projecting into the meatus will be the only evi- 
dence of the presence of a cholesteatoma of considerable size. 
If, however, the small mass be removed, other masses will be 
found, until in some instances a cavity of considerable size will 
have been emptied of its contents. 
Etiology.-When the membrana tympani is perforated as 
the result of disease or operative interference the opening in the 
drum-head generally promptly closes. If, however, a large 
portion of the drum-head is destroyed as the result of long- 
continued suppuration, the epidermis of the canal proliferates 434 
DISEASES OE THE NOSE, THROAT, AND EAR 
over the margins of the perforation and prevents its being filled 
by granulations; so that the perforation tends to become per- 
manent. Furthermore, under certain conditions the epidermis 
of the canal proliferates over the walls of the cavities of the 
middle ear, and a greater or less extent of surface assumes a 
skin-like character and appearance. The entire tympanum, 
aditus, and antrum may become epidermized, but generally 
the epidermis extends but a short distance into the tympanum. 
When the attic and antrum become epidermized, their lining 
membrane exfoliates as the result of chronic inflammation, and 
Fig. 187.-Vertical sagittal section through a left temporal bone; median surface 
of the lateral portion. The mastoid antrum, aditus, and attic of the tympanum 
are filled by a cholesteatoma. The mastoid process is sclerosed and its pneumatic 
cells are few and small: A, Antrum containing a portion of the cholesteatoma; M, 
auditory meatus. (From a photograph of a specimen in the author's collection.) 
Fig. 188.-Lateral surface of the median portion of the same specimen. A part 
of the auditory meatus has been cut away and the specimen tilted toward the right 
in order to show the membrana tympani in the photograph, which is on a some- 
what larger scale than Fig. 187: A, Aditus containing part of the cholesteatoma, 
which extends into and completely fills the attic; the tegmen of the aditus and 
antrum is extremely thin and discolored about a small perforation that extends 
from the antrum into the middle cranial fossa; MH, malleus handle attached to 
the promontory throughout its entire length in such a manner that the portion of 
the antium anterior to the malleus is the only part of the middle ear communicat- 
ing with the Eustachian tube. The membrana tympani is cicatricial and collapsed. 
There are two large perforations posterior to the malleus handle and one anterior. 
Fig 187. 
Fig. 188. 
epidermic scales accumulate until the entire cavities become 
filled, as shown in Figs. 187 and 188. 
Occasionally the presence of a small collection of cholesteato- 
matous material in the attic will cause a discharge through a 
fistula over the drum-head, and this scanty discharge, drying 
almost as it is secreted, forms closely adherent casts of the 
drum-head that might easily be mistaken for the drum-head DISEASES OF THE MIDDLE EAR 
435 
itself. The removal of such casts from the drum-head is fol- 
lowed by considerable improvement in the hearing. 
When the attic has become epidermized, scales of epidermis 
will be exfoliated from time to time, until a little ball of chol- 
esteatomatous material will have collected in the attic and per- 
haps have extended into the aditus. The disintegration of 
such masses is a common cause of chronic suppuration and the 
growth of polypi. In every case of long-continued suppura- 
tion the presence of cholesteatoma may be suspected. It is 
rare to fail to remove by intratympanic syringing of the attic 
cholesteatomatous scales in cases of long-continued middle-ear 
suppuration in which the discharge originates within this cavity. 
The removal of such little masses, and also the granulation- 
tissue or small polypi that their presence commonly causes, 
will in most instances be all that is necessary to bring about 
cessation for the time being of a chronic discharge that may 
havepersisted for years. However, because cholesteatomatous 
prolongations force their way into the Haversian canals, thus 
forming centers from which it may grow again, even the com- 
pleteremoval by curettement of the lining membrane of a chol- 
esteatomatous cavity does not prevent a recurrence of the 
accumulation. 
In most instances where it is necessary to resort to operative 
procedures for bringing about a cessation of a chronic otorrhea, 
the mere removal of the remains of the two larger ossicles will 
not be sufficient, and it is far preferable to resort to a radical 
mastoid operation which would certainly be necessary to bring 
about a cure of the chronic otorrhea resulting from a condition 
similar to that existing in Figs. 187 and 188, for it will be ob- 
served that the cholesteatomatous mass occupies the mastoid 
antrum as well as the attic, and it would be absolutely im- 
possible to remove such a mass except through a comparatively 
large opening. However, it should be borne in mind that no 
operative procedure, even the removal of the lining membrane 
of the cavity by almost thorough curettement and the establish- 
ing of a large permanent postauricular opening, can be ex- 436 
DISEASES OF THE NOSE, THROAT, AND EAR 
pected to bring about a permanent cure of chronic otorrhea due 
to the presence of cholesteatoma. This is perhaps due to the 
fact that cholesteatomatous prolongations force their way into 
the Haversian canals, thus forming centers from which it grows 
again. Reinhard states that membranes still continued to 
exfoliate in the cases that he had operated upon by establishing 
a large permanent postauricular opening into the antrum, and 
required removal to prevent the recurrence of suppuration; 
" in some more frequently, sometimes but once in three years." 
The same rule applies to all cases of chronic suppuration where 
the middle ear has become epidermized. Whether an opera- 
tion has been performed or not, cholesteatomatous masses 
will form, and their removal from time to time is necessary in 
order to prevent a recurrence of the suppuration. 
Relapses after simple mastoid operations in cases of chronic 
otorrhea were notoriously frequent, and in all such cases the 
necessity for a secondary operation is the accumulation of 
cholesteatomatous masses within the middle ear. In some in- 
stances years may elapse before such masses cause marked aural 
symptoms, but finally suppuration occurs, and the mastoid 
antrum has to be reopened to permit the removal of material 
that fails to find a ready exit through the tympanum and the 
auditory canal. Therefore it is better in cases of mastoiditis 
occurring in the course of chronic suppuration to do a rad- 
ical rather than a simple mastoid operation, except in young 
children. 
In some instances nature does a Stacke operation as the re- 
sult of necrosis of the lateral bony attic wall, or a large perma- 
nent postauricular opening may occur behind the auricle, lead- 
ing directly into the antrum. In either case the middle ear 
becomes completely epidermized; but suppuration tends to 
recur if epidermal scales are not removed from time to time. 
The advantage of such large openings, secured either by nature 
or by the method of Reinhard, is that epidermal scales and other 
debris can readily be removed, and thus a cessation of the 
otorrhea brought about for a time. However, it should never DISEASES OF THE MIDDLE EAR 
437 
be forgotten that a radical mastoid operation in most cases of 
recurrent otorrhea when only the atrium is involved renders the 
patient's condition worse rather than better, because the vast ma- 
jority of such cases go through life with fair hearing and only 
occasional suppuration, readily controlled by a competent aurist. 
That is, with very little if any more attention than many individ- 
uals require after a radical mastoid operation. 
SYSTEMIC DISEASES CAUSING OTIC INFLAMMATION 
The systemic diseases most frequently causing otitis are 
scarlet fever, measles, diphtheria, grip, typhoid fever, pneu- 
monia, syphilis, tuberculosis, and diabetes. 
The appearance of otic inflammation in most of these diseases 
is a very serious complication, and although the subject has 
been already discussed in sections on the etiology and path- 
ology of the various forms of otitis, it seems best to state briefly 
here the peculiarities of the otitis resulting from these systemic 
diseases and the modification of treatment necessary. 
Scarlatina.-The middle ear is frequently involved during 
scarlet fever. In some cases the inflammation seems to be 
simply catarrhal in character, probably due to closure of the 
Eustachian tube rather than the actual presence of the micro- 
organism causing the disease. Such cases run a mild course. 
There may not be perforation of the membrana. The deafness 
resulting in those cases where no perforation has occurred is 
often considerable. 
When the ear complication occurs during the eruptive stage 
of scarlet fever it usually assumes a severe purulent type. The 
membrana and ossicles may come away as a slough in a surpris- 
ingly short space of time, and finally large sequestra of bone. 
The purulent inflammation may involve the labyrinth, with 
resulting total deafness, or the facial nerve, causing facial 
paralysis. 
There is one practical point the practitioner should never 
forget, which is that the contagion sometimes lingers for several 438 
DISEASES OF THE NOSE, THROAT, AND EAR 
months in the discharge from the ear, and that a child with 
scarlatinal otorrhea may be the source of infection to other 
children. 
The treatment of scarlatinal otitis differs in no respect from 
that of otitis from other causes, providing the condition of the 
patient will permit of its being carried out. The nose and 
throat should be cleansed once a day by the medical attendant 
with an atomizer containing Dobell's solution. The nose, if 
stenosed, should then be sprayed with adrenalin solution 
(1:5000) to overcome the stenosis and, finally, the mucous 
membrane covered with the spray of menthol-camphor-albo- 
lene and powdered calomel applied. 
The ears should now be Politzerized and, if discharging, 
gently syringed with a saturated boric acid solution and a piece 
of iodoform gauze placed loosely in the meatus. Every other 
day sublimate solution (1 :2000) may be substituted for the 
boric acid solution should the gravity of the case seem to 
require it. 
In some cases the patient, especially if a child, will be too 
weak or indocile to permit of so lengthy a treatment, and the 
practitioner may have to content himself with simply syring- 
ing with boric acid or sublimate solution. 
Sequestra of necrosed bone, polypi, mastoid complications, 
and intracranial involvement, if the condition of the patient 
permit, should be treated in the manner described in other 
sections. 
Measles.-The ear is usually affected in measles, but with 
less virulence than in scarlatina. The condition is usually that 
of the catarrhal type, acute or subacute. Rarely does per- 
foration occur. 
Treatment is the same as in similar types of otitis from other 
causes. 
Diphtheria.-Otitis media purulenta is not very infrequent 
in diphtheria. When the drum is perforated pseudomembranes 
may extend from the middle ear on to the excoriated skin of 
the canal. In those with otorrhea, diphtheritic pseudomen- DISEASES OF THE MIDDLE EAR 
439 
branous infection may occur in the tympanum if they are 
brought into contact with diphtheritic patients. 
Treatment is similar to otitis from other causes. When the 
membrana has ruptured and a pseudomembrane is visible the 
condition should be treated as described in the section on Diph- 
theria of the Meatus. 
Grip.-Aural complications in epidemics of influenza are very 
frequent. Minute hemorrhages into the drum-head or beneath 
the epidermis of the canal are not infrequently encountered and 
are somewhat characteristic of the disease. 
The aural complications vary from a subacute catarrh, from 
which recovery takes place within a short time, to severe otitis 
media purulenta with intracranial complications. The pos- 
sible gravity of an aural complication in a case of influenza 
should not be underestimated, and such a case should receive 
the most careful attention from its onset. 
The treatment is similar to otitis from other causes. 
Typhoid Fever.-The hebetude and apparent deafness of 
typhoid is due to the effect of the toxins of the disease on the in- 
ternal ear. Occasionally internal-ear impairment of hearing 
is encountered years after recovery from the fever. 
Purulent inflammation of the middle ear is the result of in- 
vasion of the bacterium coliinto the middle ear. Day andjack- 
son, of Pittsburg, describe three types of purulent otitis in ty- 
phoid--the hemorrhagic, the slow, and the fulminating. The 
disease is usually rapid in its onset and characterized by intense 
pain. Day and Jackson state that in io cases no otitis was 
manifest one or two days previous to spontaneous rupture of 
the membrana. 
In the Medico-Chirurgical Hospital during the Spanish War, 
of 268 soldiers sick from typhoid fever 3 had severe otitis media 
purulenta as a complication of the disease. 
The ear complications of typhoid occur usually in the third 
or fourth week. The symptoms vary from those of subacute 
catarrh to the severe form of middle-ear suppuration. Hemor- 
rhagic blebs similar to those encountered in aural influenza 440 
DISEASES OF THE NOSE, THROAT, AND EAR 
have been observed by Day and Jackson previous to rupture of 
the drum-head. 
The treatment is that of otitis elsewhere when the condition 
of the patient will permit. The danger of heart failure from 
sitting up in bed, and nasal hemorrhage as the result of using 
the spray and Politzer's bag, should be borne in mind. In 
some cases, for a few days at least, it is best to be content with 
simply syringing the meatus with boric acid solution twice a 
day and inserting a little iodoform gauze loosely into the concha. 
It is better to avoid inserting gauze into the canal, especially 
if the dressing be entrusted to a nurse, for fear that the gauze 
will become impacted from some cause, possibly the finger of 
the patient. The gauze should be changed as often as it be- 
comes saturated. Pressure-pain with bulging of the drum- 
head will indicate paracentesis. 
Tuberculosis of the middle ear is probably always secondary 
in phthisis. Tuberculous deposits occur in the middle ear, 
which, after a time, break down, causing more or less rapid 
destruction of tissue. The most marked symptom is the pain- 
less character of the otitis media purulenta that results in perfo- 
ration of the membrana. After a considerable destruction of 
the drum-head has occurred the parts not infrequently become 
sensitive, probably as the result of mixed infection. Ordina- 
rily the disease pursues a chronic course, and otorrhea may even 
cease for a time and reappear. 
Sometimes the destruction of tissue is rapid and the disease 
extends to the mastoid, necessitating operation. Caries of the 
bone may involve the facial nerve and cause facial paralysis, or 
the internal ear may be invaded. Pus, in the more severe 
forms of the disease, is abundant and fetid, but tubercle bacilli 
are not usually numerous nor easy to find in the discharges. 
It should be borne in mind in this connection that otitis media 
purulenta may occur in a tuberculous individual without the 
disease being due to tuberculosis. 
Treatment.-The general treatment is of primary inportance 
and consists of a diet largely of milk and raw eggs, outdoor DISEASES OF THE MIDDLE EAR 
441 
life, and tonics. Local treatment is usually not very successful 
in bringing about a cessation of the discharge. The parts, 
however, in the middle-ear suppuration should be kept clean, 
either by the dry method or by syringing with boric acid and 
sublimate solution. It should be borne in mind that the dis- 
charges are contagious and care should be exercised to destroy 
all dressings used about the ear. 
Pneumonia.-As in typhoid, otitis media purulenta generally 
occurs late in the disease, if at all. The pneumococcus is not 
infrequently found in the pus of an otorrhea occurring independ- 
ent of pneumonia. 
The treatment is the same as in otitis occurring from other 
causes. 
Syphilis.-The middle ear is frequently inflamed during the 
period of secondary skin rashes and sore throat. In a case 
observed by the author facial paralysis occurred. The middle 
ear may become the seat of a gumma in the tertiary period 
of the disease. The symptoms at first are those of pressure 
within the middle ear, deafness, tinnitus, and sometimes ver- 
tigo. Sooner or later suppuration with perforation of the mem- 
brane occurs, and the disease assumes the appearance of chronic 
otitis media purulenta. The destruction of tissue is often 
considerable. 
Treatment.-The local treatment is that of otitis; the con- 
stitutional treatment being of greater importance. In cases 
where the diagnosis of gumma is made early, inunctions of 
mercury with iodid of potassium internally may result in 
absorption of the gumma before it breaks down. 
Bright's Disease.-In advanced Bright's disease all opera- 
tions under a general anesthetic about the nose, throat, and ear 
are dangerous because of the possibility of fatal coma. 
Diabetes.-Recurrent furunculosis of the canal may result 
from glycosuria. Mastoid wounds and large wounds about the 
upper respiratory tract do not heal as rapidly in well-marked 
glycosuria as in a normal individual, and otitis media purulenta 
runs a more severe course with greater destruction of tissue. 442 
DISEASES OF THE NOSE, THROAT, AND EAR 
Debility and excessive fatigue or excitement reduce the 
acuteness of hearing very noticeably when it is already defective 
from middle-ear catarrh or as the result of suppuration. The 
same is true of shock resulting from a serious accident, even 
when the individual though present was not seriously injured. 
Under such circumstances the hearing may be seriously 
impaired for many months before it somewhat gradually 
becomes as acute as before the accident. 
OPERATIONS UPON THE MIDDLE EAR 
Operations are performed upon the middle ear for the 
improvement of hearing, the relief of tinnitus aurium or vertigo, 
and to bring about the cure of a persistent discharge from the 
middle ear. 
The operations that have been performed from time to time 
are quite numerous, the following being a partial list: Paracen- 
tesis, single or multiple; excision, or destruction by caustics of 
a portion of the membrana tympani for the purpose of estab- 
lishing a permanent opening; plicotomy or division of the pos- 
terior fold; section of the anterior ligament of the malleus; 
tenotomy of the tensor tympani or stapedius muscle, or both; 
division of adhesions between the membrana and promontory 
or between the ossicles, etc.; excision of a portion of the mem- 
brana; disarticulation of the incudostapedial articulation or 
division of the descending process of the incus and mobilization 
of the stapes; plastic operations for uniting either the incus or 
stapes with the membrana tympani; and removal of one or more 
of the ossicles. 
Severing the Incudostapedial Articulation and Mobilizing 
or Extracting the Stapes.-A general anesthetic may be ad- 
ministered, but it is preferable to operate under cocain anes- 
thesia in order to secure the co-operation of the patient and to 
test his hearing from time to time during the different stages of 
the operation. The field of operation is prepared, upon the 
preceding day, by carefully cleansing the auditory canal with a OPERATIONS UPON THE MIDDLE EAR 
443 
solution of hydrogen peroxid and syringing with a 1:2000 
solution of corrosive sublimate, after which the auditory canal 
is stopped with a plug of iodoform gauze. All instruments, 
the absorbent cotton, and the solutions of cocain are sterilized 
in the usual manner by heat. Anesthesia is secured by the 
method of Ballin, which consists in subcutaneous injection into 
the roof of the canal of a mixture of equal quantities of a 1 per 
cent, solution of cocain and a 1:1000 solution of adrenalin 
(Formula 11). 
Fig. 189.-Pocket case instruments for minor surgery of the auditory canal 
and tympanum. 
Technic.-Commencing rather below the middle of the pos- 
terior periphery of the drum-head, an incision is made and pro- 
longed upward with the probe-pointed knife (Fig. 189) through 
the clear portion of the drum-head close to the annulus, beneath 
the posterior fold, and for a short distance downward along the 
malleus handle (Fig. 190). Little more than a fraction of a 
drop of blood ordinarily follows the incision, but the flap should 
be turned forward, and a pledget of absorbent cotton wrapped 
about the end of an Allen probe and saturated with a solution 
of adrenalin should be held in contact with the cut surfaces and 444 
DISEASES OF THE NOSE, THROAT, AND EAR 
the tympanic mucous membrane until all bleeding has ceased. 
Before proceeding further with the operation it is well to test 
the patient's hearing with both voice and the watch, in order to 
ascertain if any improvement in the hearing has resulted from 
the artificial opening in the drum-head. This is rarely the case. 
Generally when the flap is turned forward it remains in that 
position, and a good view of the interior of the drum is obtained. 
If this is not the case, the incision should be continued down- 
ward along the posterior border of the malleus handle until 
the flap does not tend to close the wound and 
obstruct the view. The region of the round 
window should be carefully inspected and any 
abnormality noted and remedied, if possible, 
at a subsequent stage of the operation. If 
the incudostapedial articulation is not visible, 
it is brought into view by inclining the pa- 
tient's head strongly toward his opposite 
shoulder, so that it is possible to see up- 
ward beneath the posterior fold. The 
incus-hook (Fig. 189) should now be passed around the de- 
scending process of the incus close to the stapes and an effort 
made to mobilize the ossicles by gentle traction in anterior, 
posterior, and lateral directions, and any improvement in the 
patient's hearing noted. If none occurs, the tendon of the 
stapedius muscle should next be divided with the point of the 
sharp-pointed knife (Fig. 189) by a downward stroke close 
behind the incudostapedial articulation. Sometimes the ten- 
don gives way with an audible snap and immediate improve- 
ment in the patient's hearing follows. If, however, the hearing 
is not improved, the incudostapedial articulation should be 
severed by means of an angular knife, which is made to cut 
downward through the joint either from in front of or behind the 
incus-shank, which it hugs closely while the downward stroke 
or strokes are being made. If the knife cannot readily be 
passed beyond the incus-shank, either in front of or behind it, 
the joint may be severed from below with the point of the knife. 
Fig. 190.-Dia- 
gram of the left 
membrana t y m - 
pani; B, Incision 
through the drum- 
head. OPERATIONS UPON THE MIDDLE EAR 
445 
After the incudostapedial articulation has been severed the 
incus-shank is pushed forward and upward in order to diminish 
the possibility of its tip reuniting with the stapes. After 
severing the incudostapedial joint, if the patient's hearing still 
remains unimproved, the point of the sharp-pointed knife may 
be cautiously carried about the head of the stapes, within the 
pelvis of the oval window, and an attempt made to mobilize 
the stapes by means of an Allen probe about the end of which 
a few fibers of cotton have been wrapped. The head of the 
stapes should be gently pressed upward, then backward, then 
forward, care being exercised that sufficient force is not em- 
ployed to endanger fracturing the crura of the stapes, which, as 
the result of atrophic changes, are sometimes very fragile. 
If, in spite of these manipulations, the bonelet remains firmly 
fixed and the patient's hearing unimproved, an attempt may 
be made to remove the ossicle by traction with a hook. If bony 
ankylosis exists between the foot-plate of the stapes, Politzer 
has shown by experiments on the cadaver that the effort will 
not succeed, but that the crura will be fractured in the effort 
to remove the stapes. A portion of the foot-plate may, how- 
ever, be removed with the fragment of the crura of the stapes 
and the patient's hearing improved, at least for a time. 
After the completion of the operation the edges of the wound 
in the drum-head are brought together and supported by a 
small amount of boric acid or iodoform insufflated by the 
powder-blower. Ordinarily the edges of the wound quickly 
unite, but suppuration has been reported as following the opera- 
tion in a few instances. 
Prognosis.-In all intratympanic operations the prognosis 
is uncertain. The prognosis as regards diminishing tinnitus 
is much better than that of improving the hearing to a useful 
degree. The author performed this operation a considerable 
number of times some years ago. In many cases there was 
permanent improvement as regards tinnitus and temporary 
improvement of hearing. (See former editions of this manual 
for details.) 446 
DISEASES OE THE NOSE, THROAT, AND EAR 
Operations for the relief of deafness and tinnitus resulting 
from chronic suppuration of the middle ear are division or 
divulsion of false membranes and adhesions binding the ossicles 
together or to the tympanic walls in such a manner as to inter- 
fere with the vibration of the stapes; mobilization or removal of 
the stapes; removal of the remains of the drum-head and the 
two larger ossicles. 
In most instances the first ossicle 
to become carious or necrosed as the 
result of chronic intratympanic sup- 
puration is the incus, because of its 
imperfect blood-supply as compared 
with that of the other intratympanic 
structures. The entire bonelet may 
disappear as the result of a few weeks 
of intratympanic suppuration. Ordi- 
narily the descending process is the first 
portion of the incus to disappear, thus 
freeing the stapes. The comparatively 
good hearing of the patients with large 
dry perforations of the membrana is due 
in many instances to the fact that the 
stapes is thus freed at an early stage of 
the suppurative process, and does not 
become involved by subsequent con- 
tractions and adhesions. In some in- 
stances, however, this fortunate result 
does not occur, and the detached stapes may be completely 
buried in a mass of cicatricial tissue which holds it immov- 
able in the pelvis of the oval window. When not detached 
from the incus the movements of the stapes may be inter- 
fered with by bands of tissue binding the two larger ossicles 
together or to the tympanic wall. The most common of such 
bands is one extending from the long process of the incus to the 
tympanic wall and the malleus handle (Fig. 191). 
Division or divulsion of such bands is, in some instances. 
Fig. 191.-A, Band of 
connective tissue extending 
from the long process of the 
incus, C, to the malleus 
handle, B, which was adher- 
ent to the promontory. 
Hearing for the watch in- 
creased from 2 inches to 2 
feet as result of divulsing 
this band by gentle traction 
with an Allen probe, the 
point of which was bent 
nearly at a right angle and 
inserted underneath the 
band. The improvement 
lasted for nearly three years, 
when the operation was re- 
peated with equally satis- 
factory results. OPERATIONS UPON THE MIDDLE EAR 
447 
followed by the most astonishing improvement in the hearing 
power and the complete relief of tinnitus. In suitable cases 
more permanent results are secured by divulsion or stretching 
of the bands than by cutting them. In some cases the vibra- 
tions of the ossicular chain are interfered with by an adhesion 
of the remains of the drum-head to the promontory in such a 
manner as to bind down the malleus handle. Under such 
circumstances division of the adhesion is followed by improved 
hearing and decreased tinnitus. In most instances divulsion 
of intratympanic bands and adhesions will have to be repeated 
from time to time in order to secure permanent results; but 
as the operations are by no means formidable, when required 
they may be done during an ordinary office visit. In the divul- 
sion of bands and adhesions care should be exercised that suffi- 
cient force is not employed to endanger dislocation of one of the 
ossicles, more especially the stapes. After division of synechiae 
and surgical mobilizing of the stapes the hearing power can 
sometimes be increased by the use of an artificial drum-mem- 
brane; for this purpose a membrane made of paper, as first 
employed by Blake, answers an admirable purpose, and is 
sometimes followed by so much permanent improvement of 
the hearing that its use can finally be dispensed with. The 
permanent improvement is doubtless due to 11 automobiliza- 
tion" of the stapes during hearing as the result of wearing the 
disk. 
The removal of the two larger ossicles, or what remains of 
them, is admissable as a means of improving the hearing or 
diminishing tinnitus; but cases are hardly conceivable in which 
all the improvement possible, as regards both tinnitus and 
hearing, cannot be secured by the division of adhesions, dis- 
articulation of the incudostapedial joint, or mobilization of 
the stapes. 
Operation for the Removal of the Remains of the Drum- 
head, Malleus, and Incus in Suppurative Cases.-The opera- 
tion is better done under cocain anesthesia by the transfusion 
method of Ballin (Formula n) or a general anesthetic may be 448 
DISEASES OF THE NOSE, THROAT, AND EAR 
employed. However, when a large amount of the intratym- 
panic mucous membrane is exposed as the result of disease, 
except in nervous patients, simply the application of a io per 
cent, solution of cocain yields fairly satisfactory anesthesia. 
If the incudostapedial articulation is intact and visible, it 
is well to begin the operation by severing the joint, to avoid 
possible injury to the stapes while removing the incus. If the 
membrana flaccida is intact, a sharp-pointed knife is thrust 
through it behind the short process, as close as possible to the 
margin of the annulus, and the incision continued backward 
and downward for a sufficient distance to completely sever 
the posterior attachments of the malleus. Without removing 
the knife from the wound its edge is turned in the opposite 
direction, its point is slightly withdrawn so as to ride over the 
malleus above the short process, and the anterior attachments 
of the malleus are rapidly severed. The neck of the malleus 
is seized with foreign-body forceps and an effort made to dis- 
lodge the head of the malleus from the scute or shelf of bone on 
which it lies on the lateral portion of the attic, by gentle pres- 
sure inward and downward with the forceps. Should gentle 
manipulation not succeed, it is probable that the malleus is 
held in position by adhesions to the tympanic walls. Any 
adhesions that can be reached should be severed by means of 
angular knives (Fig. 189-24 and 25). By means of one of these 
knives or the incus-hook (Fig. 189-29) traction directly out- 
ward should be made upon the tip of the malleus handle until 
the head of the bonelet is dislodged inward. If now the bone- 
let be seized in the neighborhood of the short process with the 
foreign-body forceps it will readily be removed by traction- 
at first inward and downward and then outward. 
The malleus when withdrawn from the ear should be inspected 
to determine whether or not the incus is adherent to it. In 
not a few instance the bonelets will be found firmly bound to- 
gether by bony ankylosis or strong fibrous bands, so that both 
bonelets will be removed together. If this does not occur, and 
the presence of the incus has been determined previous to the OPERATIONS UPON THE MIDDLE EAR 
449 
operation by the use of an Allen probe, the tip of which has 
been bent upward andguarded by a few fibers of cotton wrapped 
about it, a diligent search should be made for the incus by means 
of incus-hooks. (Fig. 189-10, 14, 15.) The incus will prob- 
ably be found behind the annulus, dislocated downward and 
outward as the result of the withdrawal of the malleus. The 
tip of its long process will probably be found close behind the 
annulus posteriorly and somewhat below the middle of the 
tympanum. If the incushook be introduced into the lower 
part of the tympanum, with its concave surface upward and 
the tip of the hook behind the annulus, by lifting the hook 
slightly upward and at the same time rotating it the long 
process of the incus will probably be pushed anteriorly into 
view from behind the annulus. In executing this maneuver 
it is necessary that the tip of the hook be held somewhat closely 
in contact with the median surface of the annulus. The ota- 
tion of the hook may have to be repeated several times be- 
fore the incus-shank is brought into view. The ossicle will 
probably be found lying somewhat lower down in the tym- 
panum than would naturally be expected, but if careful mani- 
pulation of the hook fails to locate it in this region, the 
ossicle should be searched for higher up, and if necessary 
the other hook may be inserted with its concavity down- 
ward and its tip behind the scute, and rotated in such a 
manner as to dislocate the ossicle downward. This maneuver 
should be executed with great care and gentleness, as there is 
danger of pushing the ossicle backward into the antrum. 
After the incus is brought into view it should be seized with the 
forceps manipulated in such a manner as to free it from the 
annulus and withdrawn. 
It should be borne in mind that the first portion of the ossicle 
destroyed By caries is the long process, and that it sometimes 
requires but a short period of suppuration to cause the entire 
destruction of this ossicle. Too prolonged search for the incus 
after the removal of the malleus is not advisable, unless it is 
certain from previous examinations that the incus is certainly 
present. 450 
DISEASES OF THE NOSE, THROAT, AND EAR 
After the withdrawal of the incus, the edge of the annulus 
and the tympanic vault should be carefully searched by means 
of a cotton-tipped probe for exposed bone or areas of granula- 
tions. If such spots be found, they should carefully be curetted 
by means of a bent curette (Fig. 189). The success of the opera- 
tion in bringing about a cessation of persistent or recurrent 
suppuration will often depend upon the thoroughness and care 
Fig. 192.-Vertical frontal section through the middle of the external meatus: 
A, Anterior, P, posterior portion of the specimen; 5, scute or external bony wall 
of attic; C, carotid artery; J, internal jugular vein. The carotid is separated 
from the anterior median wall of the tympanum by an extremely thin septum of 
bone, which in numerous instances is entirely lacking, so that the vessel might be 
wounded by the knife of a heedless operator during an intratympanic operation. 
The bulb of the jugular vein is separated from the cavity of the tympanum by the 
mucous membrane and a thin septum of bone that is sometimes lacking. The 
bulb of the. jugular vein has been wounded during the operation of paracentesis. 
In the specimen the drum-head, malleus, and incus have disappeared as the result, 
probably, of chronic suppuration. (Author's specimen.) 
with which this is done. Any remaining portions of the mem- 
brana should also be removed with the probe-pointed knife or 
with a curette. 
In operating upon the anterior or inferior portion of the tym- 
panum the position of the carotid artery and the bulb of the 
jugular vein should be borne in mind (Fig. 192, 210, 217). OPERATIONS UPON THE MIDDLE EAR 
451 
Ordinarily the jugular vein is covered by bone of sufficient 
thickness to prevent injury to the vessel, but sometimes this 
bone is lacking and the vein lies just below the tympanic 
mucous membrane. Several cases of injury to the jugular 
vein during intratympanic operations have occurred, but with- 
out fatal results. Although no cases of injury to the carotid 
artery during operations upon the middle ear are known, yet 
Fig. 193.-Adult temporal bone, with the upper and part of the posterior wall 
of the meatus chiseled away so as to form one large cavity of the meatus, tympa- 
num,. and antrum: A, Hard ridge of bone surrounding the Fallopian canal. 
Within the tympanum the oval and round windows are plainly shown. It should 
be dome in mind that the facial nerve arches backward above the oval window 
and then descends vertically (Figs. 137, 138, 213, and 214). .The inner end of the 
ridge of bone between the auditory canal and mastoid near A is, therefore, not far 
distant from this nerve, and considerable caution should be used in smoothing 
down this portion of the ridge, the outer portion of which can be removed quickly 
with rongeur forceps without pain or difficulty. In a complete Kiister operation 
healing will be facilitated and a better final result obtained by removing not only 
the ridge, between the canal and the operative cavity in the mastoid but also the 
overhanging edge of bone about this cavity, both above and behind, to render the 
operative cavity as flat, smooth, and shallow as possible. The root of the zygo- 
matic process and the tip of the mastoid contain cells, and in most instances it is 
desirable to open these cells thoroughly. The ridge between the canal and the 
operative cavity and overhanging edges have been allowed to remain in order to 
better show the topography. (Author's specimen.) 
the artery lies dangerously near anteriorly, and it is well to 
use a probe-pointed kinfe when operating in this locality. 
Hemorrhage from this portion of the artery as the result of 
necrosis has almost invariably terminated fatally, even after 
ligation of the internal carotid artery. 
After the removal of the malleus and incus, if it be deemed 452 
DISEASES OF THE NOSE, THROAT, AND EAR 
necessary in order to gain better access to the attic for after- 
treatment, the lateral wall of the attic may be removed by 
means of a small chisel or curette (Fig. 208). 
The after-treatment of the operation consists in daily cleans- 
ing of the parts with absorbent cotton and the insufflation of 
powdered boric acid. 
Fig. 194.-Vertical frontal section through the external auditory canals of a 
fetus stillborn at the end of the seventh month, anterior portion of the head. The 
external auditory canal slopes somewhat downward and the membrana tympani 
are nearly horizontal. The lower wall of each canal is in contact with the upper 
except for the presence of a small quantity of the same cheesy material {vernix 
caseosa) that covered the rest of the skin of the fetus. The tympanum is completely 
filled by the ossicles and its own mucous membrane, which is much thicker than 
that of the adult. The malleus is in position in the right ear, but has been removed 
by the saw from the left: B, Brain; M.H, head of the malleus; C, cochlea of the 
left ear. (Author's specimen.) 
Mastoiditis. The External and Middle Ear of a Newborn 
Child.-At birth the external meatus is essentially a closed 
canal. The drum-head lies nearly in the same plane with 
the upper wall of the meatus (Fig. 194), and forms such an 
extremely acute angle with the lower wall that the upper and 
lower walls are practically in contact except for the vernix 
caseosa, which, covering the entire body of the child at birth, 
also extends into the auditory canal, completely blocking it up 
so that no air can enter. The drum-head is covered by OPERATIONS UPON THE MIDDLE EAR 
453 
extremely thick epidermis, while the cavity of the tympanum is 
usually completely filled with its own mucous membrane, which, 
Fig. 195.-Left half of the skull of a stillborn infant, showing the inferior sur- 
face of the petrous bone, the annulus tympanicus, the ossicles, the tympanum, and 
the mastoid process. The ossicles, the tympanum, and the mastoid antrum are 
nearly as large as those of an adult: M, Mastoid process. The end of the line 
is at the stylomastoid foramen. Hence, at birth the facial nerve emerges not, 
as in the adult, on the inferior, but on the lateral, surface of the temporal bone. 
Therefore it readily may be wounded during a mastoid operation by a careless 
operator or injured by too tightly packing or bandaging the mastoid wound; S.P, 
short process of the malleus; P.T, posterior tubercle of the annulus tympanicus. 
(Author's specimen.) 
Fig. 196.-Same specimen as Fig. 19s, but with the mastoid antrum exposed, 
showing its normal position at birth immediately above the posterior tubercle of 
the annulus, in most instances it has assumed the position of adult life when the 
child is two years old. 
enormously hypertrophied at all parts of the tympanum, is 
thickest upon the inner wall, where it is markedly hyperemic 454 
DISEASES OF THE NOSE, THROAT, AND EAR 
and jelly-like in appearance, in marked contrast to that of adult 
life, which upon the promontory is thin and nearly bloodless in 
appearance. 
Hence, the offspring of the human race, like that of many of 
the lower animals, is born into the world almost completely 
deaf. Almost from birth the eyes of the infant follow the 
movements of individuals about the room, but it is not until 
the eighth or tenth day after birth that an infant shows any 
Fig. 197.-The temporal bone of a newborn child separated into its three com- 
ponent parts: the squamous and petrous portions and the annulus tympanicus or 
processus auditorius (Gray). 
evidence of hearing the sound of a tuning-fork held close to its 
ear. At birth or soon afterward the tympanum becomes a 
cavity containing air. The thick epidermis of the outer layer 
of the drum-head is exfoliated and the mucous cushions within 
the tympanum disappear. 
The temporal bone ossifies from eight centers. These have 
coalesced at the end of the fifth month but even at birth, the 
bone readily separates into three parts, Fig. 197. The osseous ORERATIONS UPON THE MIDDLE EAR 
455 
canal of the adult is represented in infants by the annulus 
tympanicus or processus auditorius (Figs. 195, 197), which forms 
by gradual development the vaginal process of the auditory 
meatus of the adult. The rest of the canal is composed largely 
of embryonic tissues covered by skin, and measures from the 
tragus to the umbo usually about 30 mm., while that of the 
adult measures from 31 to 35 mm. between the same struc- 
tures. Because of the nearly horizontal position of the drum- 
head, Shrapnell's membrane (Fig. 135) lies so near the orifice 
of the canal that when greatly swollen it almost protrudes, re- 
sembling a polypus somewhat in appearance; indeed, it has 
been mistaken for a polypus and removed, together with the 
malleus and incus. 
To examine the drum-head of young children it is necessary 
to draw the lobule downward in order to detach the lower from 
the upper wall of the meatus. The ossicles, tympanum, and 
mastoid antrum are nearly as large as those of an adult, but are 
superficially situated, and in opening a mastoid abscess in an 
infant, therefore, it is not unusual for the probe to pass through 
the antrum into the attic for a distance of nearly 1 inch. The 
mastoid antrum of young infants is situated immediately above 
the posterior tubercle of the annulus (Fig. 195), and this ele- 
vation should be searched for as a landmark when operating 
upon the temporal bone of infants. It should also be borne in 
mind that the mastoid-squamous suture (Fig. 195) is not ossi- 
fied at birth, and frequently presents large dehiscences during 
childhood, so that when making the primary incision for a 
mastoid operation upon a young child the point of the knife 
should not be pressed with force against the bone or it may enter 
one of these dehiscences and penetrate the cranial cavity. 
The incision should be made with due deliberation until the 
bone is exposed in the whole length of the incision, and the 
periosteum pushed forward with great care and gentleness. 
It should be borne in mind also that at birth the facial nerve 
emerges not on the inferior surface, but on the external (lateral) 
surface of the temporal bone, at a point close to the annulus 456 
DISEASES OF THE NOSE, THROAT, AND EAR 
and somewhat above its inferior border (Fig. 195). Unneces- 
sary curetting within the mastoid antrum and attic should also 
be avoided, as the petrosquamous suture, where the horizontal 
plate of the squamous portion of the temporal bone unites with 
the petrous portion to form the tegmen or roof of the tympanum 
and antrum, remains open for some time after birth, and a 
process from the dura not infrequently extends downward 
to unite with the mucous membrane of the middle ear. 
The Adult Mastoid Process.-At birth the mastoid process 
consists of a small flattened tuberosity containing but one cell, 
Figs. 198 and 199.-Large-Celled pneumatic processes: the tip of the one to the left 
diploetic. (Author's specimens.) 
the mastoid antrum. At the age of eight years the child's 
mastoid generally contains numerous other pneumatic spaces 
radiating from the antrum. At puberty the mastoid has be- 
come a distinct prominence, conic in shape, with its apex 
downward. It may or may not contain pneumatic cells in 
addition to the antrum. 
Types oj Mastoid Structure.-There are four distinct types of 
mastoid structure: 
1. The pneumatic, in which the whole mastoid process is 
composed of pneumatic spaces communicating with each other 
and with the antrum, and lined with a continuation of the mu- 
cous membrane of the middle ear. The pneumatic spaces 
may be large (Figs. 198 and 199) or small (Figs. 200 and 201). OPERATIONS UPON THE MIDDLE EAR 
457 
If the pneumatic spaces are small, one comparatively large cell 
is generally found at the mastoid tip. 
2. The diploetic, the entire bone containing no air-spaces, 
but composed of diploetic tissue. 
3. The pneumodiploetic, in which pneumatic spaces and 
diploetic tissue are both found (Figs. 198 and 199). 
4. The sclerosed, in which the entire bone is composed of 
compact bone often as hard as a tooth (Fig. 202). 
Pathologic Importance of Types.-Pathologically and sur- 
gically the structure of the mastoid process is of the utmost 
Figs. 200 and 201.-Frontal section through the spina of a mastoid process 
consisting almost entirely of small pneumatic cells: Fig. 200, Anterior, Fig. 201, 
posterior portion of the specimen; A, antrum; C, large cell at the tip of the process; 
the semicircular canals and the aquaeductus Fallopii have been laid open after the 
section was made. (Author's specimen.) 
Fig. 200. 
Fig. 201. 
importance. In the pneumatic type of mastoid with large 
cells, pus from the antrum readily finds its way to the lateral 
surface, but in the diploetic, and more especially in the sclerosed 
type, there is greater danger of pus burrowing its way into the 
cranial cavity. The difficulties of the mastoid operation are 
also greatly increased by the compactness and hardness of the 
bone. Where a large cell is present at the mastoid tip with a 
thin median wall, pus is more likely to find its way into the 
digastric fossae than to penetrate the thicker external cortex. 
Long narrow or dolichocephalic skulls have pneumatic processes 458 
DISEASES OF THE NOSE, THROAT, AND EAR 
oftener than brachycephalic or round skulls. In round skulls 
the external canal is proportionately longer, that is, the ear 
lies deeper. Often there are no cells, so that the sinus and 
dura are very close to the external meatus and the middle ear 
(Fig. 210). 
Etiology.-Primary inflammation of the mastoid rarely oc- 
curs except as the result of syphilis, tuberculosis, or traumatism, 
especially in individuals with chronic 
suppuration of the tympanum and attic. 
The symptoms are those of acute peri- 
ostitis, pain, heat, and swelling behind 
the ear. Within a few days the perios- 
titis subsides or the deeper structures 
become involved. In such cases should 
caries occur, the abscess-cavity does not 
usually communicate with the mastoid 
antrum, but is generally superficially 
situated beneath the cortex of the bone. 
However, the disease in almost every 
instance is the result of an extension, by 
continuity of structure, of inflammation 
from the tympanum. Mastoiditis, then, 
is generally the sequence of acute in- 
flammation of the tympanum or of 
chronic suppuration of the middle ear. 
In rare instances suppurative inflamma- 
tion of the deeper portion of the audi- 
tory canal may extend under the periosteum until pus ap- 
pears upon the external surface of the mastoid beneath the 
periosteum (Fig. 203); or infection may be transmitted by 
means of the veins which traverse canals from the meatus 
into the mastoid cells. 
Pathology.-Koerner divides the suppurative processes 
within the mastoid into: 1. empyema; 2. softening and 
dissolution of the bony substance, and 3. necrosis. Empyema 
is restricted to suppuration within the cell spaces without in- 
Fig. 202.-Vertical 
sagittal section through 
a sclerosed mastoid proc- 
ess, the cellular structure 
of which, with the excep- 
tion of an exceedingly 
small antrum, has been 
entirely replaced bjr dense 
eburnated bone. 
(Author's specimen.) OPERATIONS UPON THE MIDDLE EAR 
459 
volvement of their bony walls. This condition frequently 
occurs on the third or fourth day of acute otitis and recovery 
usually results without destruction of bone if there is free 
drainage through the tympanum. Dissolutions of bony sub- 
stance is brought about by swelling of the inflamed mucous 
membrane and periosteum lining the cells which finally com- 
pletely fills them. A further increase takes place at the ex- 
pense of the bony septa which soften and disintegrate, and a 
large amount of pus is usually poured out by granulation-like 
tissue which escapes through the tympanum. This process 
may invade the diploea or break through the mastoid cortex. 
Fig. 203.-Periostitis and necrosis of the petrous portion of the temporal bone 
after otitis media, in a boy three years of age. The presence of pus beneath the 
perioteum produces the characteristic appearance of the ear being pushed outward 
from the side of the head (Friihwald). 
Necrosis resulting from acute purulent otitis media is more 
frequent in young children than adults, in whom it is not 
unusual to find a sequestrum during a mastoid operation. 
However, necrosis is much rarer than the former condition 
which is sometimes, even at present, called caries. Necrosis is 
a slower and usually less painful process than caries. It 
may follow scarlet fever; hereditary syphilis and tuberculosis 
are said to be predisposing causes. The symptoms are at 
first similar to caries but perforation of the cortex occurs 
earlier when the parts assume the appearance shown in Fig. 460 
DISEASES OF THE NOSE, THROAT, AND EAR 
2i4 as the result of pus beneath the periostium. In tubercular 
adults the process often runs a chronic course, months or even 
years being required for the sequestrum to become separated. 
If operated upon before this occurs the air cells will be found 
empty or partly filled with a thin foetid pus, and mucous 
membrane and bone are pale and bloodless. It is important 
in operating on such cases to produce a bone wound that 
bleeds from its entire surface. Otherwise it is probable that 
it has not extended beyond the necrotic area and that a 
sequestrum will form and require removal, before the wound 
will heal. 
In most chronic cases the mastoid antrum becomes filled with 
cholesteatomatous masses, thus isolating the mastoid cells from 
the tympanic cavity. Active mastoid complications during 
chronic suppuration of the middle ear frequently manifest 
themselves during an acute exacerbation of the middle-ear 
disease, with the result of producing an acute inflammation of 
a limited area of bone in the center of a sclerosed mastoid. 
Caries or necrosis of the mastoid may extend inward and 
involve the lateral sinus, producing phlebitis, thrombosis, 
embolus, and their consequences. The middle fossa of the 
skull may also be penetrated and an abscess produced beneath 
the dura mater, a local pachymeningitis preventing further 
extension of the disease; or meningitis, both at the base and 
convexity of the brain, or brain-abscess may occur. 
Symptoms.-In acute cases the first symptom is intense pain, 
involving the mastoid and often the whole side of the head. 
The patient's face assumes the expression of abject woe. He 
eats little and sleeps less. There are tenderness on pressure over 
the mastoid, fever, and in most cases swelling and congestion 
of the upper posterior part of the meatus. In the more chronic 
form of the disease the patient is sometimes remarkably free 
from pain, almost the first symptom to which the surgeon's 
attention is called being congestion of Shrapnell's membrane, 
with swelling at the inner upper posterior part of the meatus, 
over the mastoid, or of the neck below the ear. Especially in OPERATIONS UPON THE MIDDLE EAR 
461 
children, the external cortex of the mastoid may be penetrated 
early in the disease and the pus find its way underneath the 
periosteum. Under such circumstances the whole auricle, 
when seen from the rear, appears as if pushed out from the side 
of the head (Fig. 203). 
A symptom of considerable diagnostic importance is sudden 
cessation of discharge from the meatus in the course of an acute 
otorrhea. It is probably caused by lack of sufficient drainage 
from the attic and antrum. If the discharge is not re-estab- 
lished within a few days, mastoid symptoms requiring opera- 
tive interference generally manifest themselves. Granulations 
protruding through a perforation should be removed to secure 
better drainage. If pus exudes through a tit-like mass of 
swollen tissue on Shrapnell's membrane, the mass should be 
snared or cruetted away, as very often these procedures are 
sufficient to secure rapid subsidence of mastoid symptoms. 
In cases requiring operation the temperature is not a very re- 
liable guide. In some cases it .may be very little if any above 
normal. Pain on pressure over the antrum or at the mastoid 
tip may disappear. However, when in conjunction with ten- 
derness on pressure over the antrum, which has been present 
for some days, there is swelling of the posterior wall of the 
meatus close up to the drum-head, so that a portion of Shrap- 
nell's membrane is hidden, an operation should not longer be 
delayed, as such cases rarely or never recover without it. How- 
ever, when the large cells at the tip of the mastoid are princi- 
pally involved there will be no bulging of the canal, but never- 
theless an operation is imperative. In making pressure over 
the antrum the observer should insert his finger at a level with 
the superior border of the meatus into the angle made by the 
junction of the auricle with the mastoid and press upon the 
bone in a direction backward and inward, being careful to 
move the auricle as little as possible, so as not to mistake the 
the pain commonly caused in acute suppuration of the middle 
ear by movements of the auricle for bone tenderness over the 
antrum. 462 
DISEASES OF THE NOSE, THROAT, AND EAR 
A small lymphatic gland is found upon the surface of the 
mastoid about | inch posterior to the meatus. Tenderness of 
this gland should not be mistaken for the bone tenderness of 
mastoiditis. Should this gland become infected and break 
down as the result of furunculosis of the canal or other causes, 
the pus will be beneath the skin and not beneath the periosteum, 
and consequently the auricle will not, when seen from the 
rear, appear pushed out from the side of the head. Such 
superficial abscesses simply require opening and not a mas- 
toid operation. 
Persistent tenderness of the mastoid tip and swelling of the 
tissues of the neck behind and below the mastoid indicate the 
presence of pus in the digastric fossae as the result of suppura- 
tion of the large cell at the tip of the mastoid. Usually the 
median bony wall of this cell is thinner than the external cortex 
and breaks down more readily. In such cases the entire tip of 
the mastoid should be removed at the mastoid operation and 
the abscess cavity in the tissues of the neck laid freely open. 
If a bacteriologic examination of the discharge from the 
meatus shows the presence of streptococcus, Friedlander's 
bacillus, or the encapsulated streptococcus, it is wise to operate 
earlier than if staphylococci only were present. A blood- 
count should be made, but only in a few doubtful cases will 
an increase in the polynuclear neutrophiles prove a safe 
guide when suppurative lesions of other parts of the body 
can be excluded. A negative blood-count should not deter 
the surgeon from opening the mastoid should the symptoms 
manifestly require it. 
Atypical cases are those where the disease progresses with- 
out well-marked symptoms-the so-called "latent mastoiditis." 
The onset, corresponding to the invasion of the middle-ear, 
may be so slight as not to be perceived by the patient, or 
there may be a tonsilitis of a day or two's duration, followed 
by dull pains in the ear, and imparied hearing. The pain soon 
subsides, and the patient forgets that he has had any trouble 
until after a time, varying from two or three weeks to several OPERATIONS UPON THE MIDDLE EAR 
463 
months, when he is suddenly seized with severe pain, in the 
mastoid. Examination at that time will show pronounced 
mastoid tenderness on pressure, usually at the tip. The 
subjective pain, however, may radiate over the entire side of 
the head. The drum-membrane will appear normal in color, 
or there may be a slight lack of luster, and possibly injection 
of the malleus handle. In the majority of cases there is 
impaired hearing; which is only incidentally the case in 
hysterical mastoiditis, mastoid neuralgia, or in the pain 
referred to the mastoid in sclerosis, Fig. 202. The appearance 
of the drum-head is often normal or nearly normal both in 
latent mastoiditis and mastoidalgia but tenderness on pressure 
is persistently present either over the antrum or the tip in 
latent mastoiditis. In some cases comparison of the per- 
cussion note of each mastoid, transillumination or the x-ray 
yield valuable information. In doubtful cases there should 
be no hesitancy in opening the mastoid cells. The drum-head 
does not break down because of the mild virulence of the bac- 
teria present in these cases or the possibility that the drum 
was thick and abnormally resistant. The fact that mastoid 
abscess with intracranial complications may occur months 
or even years after a suppurating ear has apparently healed 
is probably due to some infective focus of pus in the mastoid cells 
which remains latent. Especially in diabetes, but also in 
influenza, pnuemonia, typhoid and the exanthemata rapidly 
extending suppuration and softening of the bone may occur 
without pain, fever, or other marked symptoms. Such cases 
are most common in diploic mastoids with a cortex sufficiently 
thick to prevent great tenderness on pressure over the dis- 
eased area and the process may extend to a general osteomy- 
elitis beyond the limits of the temporal bone or meningitis 
or sinus thrombosis. 
Treatment.-'When there is congestion of the posterior 
portion of Shrapnell's membrane and swelling of the neighboring 
tissues of the meatus, a free incision through Shrapnell's 
membrane and the swollen tissue will sometimes abort the 464 
DISEASES OF THE NOSE, THROAT, AND EAR 
attack (see p. 420). The mastoid process should be thickly 
covered with an ointment of 20 per cent, ichthyol in lanolin. 
The parts should then be covered with waxed paper and 
bandaged in order to prevent soiling the patient's clothing 
or bed-linen. 
Pain is best combated by the application of dry heat by 
means of a hot-water bag. If absolutely necessary, an anodyne 
should be administered. Pain often can be relieved entirely for 
days by the application of cold to the mastoid process, either 
in the form of an ice-bag or Leiter's coil. However, this 
method is becoming less popular, as cold does not control 
the suppurative process, but simply masks its symptoms. 
The application of heat is the better treatment. 
With the object of promoting the reaction of inflammation, 
1:5000 hot bichlorid irrigations every hour have been made; 
and for the same purpose, Bier's treatment by constriction 
of the neck with an Esmarch elastic band applied only sufficient 
ly tight to produce slight constriction of the neck, but no 
pain or discomfort, has been used. The bandage is applied 
four times in twenty-four hours with intervals of two hours 
between the applications, and the foot of the bed is slightly 
raised. 
Painting the mastoid process with iodin or cantharidal col- 
lodion renders the skin so sore that it is difficult to determine 
whether tenderness on pressure is the result of the counterirri- 
tant or inflammation of the bone. Although a favorite 
method of treatment with the aurists of half a century ago, it 
is doubtful if counterirritation over the mastoid ever accom- 
plished an appreciable amount of good. The writer has been 
called in consultation to see 2 cases of erysipelas apparently 
resulting from the application of cantharidal collodion over 
the mastoid. One of these cases, an old man with advanced 
chronic Bright's disease, proved fatal. 
If, notwithstanding the application of ichthyol over the 
mastoid, dry heat, and the systematic treatment of the tym- 
panic suppuration, the tenderness over the mastoid is not OPERATIONS UPON THE MIDDLE EAR 
465 
relieved, and pain, sleeplessness, and loss of appetite increase, 
it is necessary to operate. 
The prognosis in uncomplicated mastoiditis is favorable. 
The major portion of cases recover with or without operation. 
The mastoid tenderness occurring in a large proportion of 
cases of acute suppuration of the middle ear within a few days 
of the onset of the disease commonly disappears within a short 
time as the result of treatment. The more severe forms of the 
disease occurring later, providing there is no swelling of the 
tissues at the inner upper portion of the canal, frequently re- 
cover without operation if properly treated, if the infection is 
not due to the presence of streptococci or the result of grip. 
The prognosis in scarlatina, tuberculosis, diphtheria, etc., 
is, of course, more uncertain with or without operation. 
However, an early mastoid operation subjects the patient to 
practically no risk, and when in doubt as to the advisability of 
operating the patient's interests, both as regards the risk of 
life and the integrity of the organ of hearing will be conserved 
by giving the benefit of the doubt in favor of the operation. 
Even if the surgeon has the mortification at the operation to 
chisel through absolutely normal bone to an antrum but 
slightly inflamed, there is usually a rapid cure of the otorrhea, 
and such procedures may be considered as similar to the explora- 
tory incisions of the general surgeon. 
Technic.-The instruments required for the performance of 
the mastoid operation are scalpels, 6 hemostats, 2 Jansen's 
dilators (Fig. 207), 3 bone-gnawing foceps (Figs. 205, 206), 3 
bone gouges (Fig 209), a mallet, bone curettes (Figs. 204, 208), 
periosteal elevator, grooved director, and a probe. 
While opening the mastoid is generally performed for 
liberating the contents of a septic cavity, it should be done 
under antiseptic precautions. The instruments should be 
sterilized by boiling them in a 2 per cent, soda solution and the 
hands of the operator and those of his assistants disinfected in 
the usual manner. The patient's hair should be shaved off 
for a distance of about 2| inches above and behind the ear to 466 
DISEASES OF THE NOSE, THROAT, AND EAR 
be operated upon. The skin covering the field of operation 
should be disinfected in the usual manner and the auditory 
Fig. 204.-Whiting's mastoid curette. There are several sizes of this instru- 
ment manufactured. The medium size is the most useful; but during an operation 
the largest and smallest sizes should be on the instrument table, as they are oc- 
tasionally required. 
canal syringed with warm bichlorid solution. These prepara- 
tions of the patient for operation are better made previous to 
Figs. 205 and 206.-Hartmann's curved rongeur forceps. Four or more sizes and 
kinds of rongeur forceps are convenient for mastoid operations and opening the 
cranial cavity. A fairly practical outfit consists of Hartmann's curved, half- 
curved, and angular mastoid rongeur forceps, Jansen's small double curved forceps 
and Keen's craniotomy forceps. 
giving the ether. If the patient's hair is long it should be 
covered by a towel wet in bichlorid solution or a rubber cap 
If the drum-head has not been perforated during the cours. OPERATIONS UPON THE MIDDLE EAR 
467 
of the disease, it is best to preface the operation by an incision 
around the posterior periphery. 
An incision is made through the skin to the bone from the 
tip of the mastoid to a point above the helix. The incision 
should be close to the insertion of the auricle. In children this 
incision should be made somewhat deliberately, with the edge 
of the knife rather than its point, so that there will be no danger 
of thrusting the knife-point deeply into a dehiscence of the 
bone. In infants the incision should be far enough back to 
avoid injuring the facial nerve (Figs. 195, 196). In adults the 
tip of the mastoid should be located with the end of the index- 
finger of the left hand and the point of the knife thrust at 
once through skin and periosteum into the bone. Maintaining 
firm pressure with the knife-point against the bone, the incision 
is continued upward around the auricle to stop at a point just 
short of the temporal artery, the exact position of which has 
previously been located with a finger-tip of the left hand. If 
the incision is made in this manner it will cut through the peri- 
osteum the entire length of the cut. 
After the incision has been made several little spurting arter- 
ies will require clamping with hemostats by the operator or his 
assistant, and if the parts are brawny and swollen there will 
probably be a somewhat profuse venous hemorrhage from all 
parts of the wound, which will be lessened if the head of the 
operating table is slightly elevated. It can be controlled by 
the application of hot water or may be disregarded until the 
periosteum is separated from the bone, as it will cease after 
Jansen's dilator has been applied. If the mastoid process is 
large it may be desirable to secure additional space by making 
an incision about 1 inch in length at right angles to the original 
incision from the center of the auditory meatus toward the 
occipital protuberance. The presence of this second incision 
not only secures additional space, but has the advantage that 
the two posterior triangular flaps fall away from the bone and 
do not require the use of a dilator to hold the wound open. 
The periosteum should be separated from the bone with 468 
DISEASES OF THE NOSE, THROAT, AND EAR 
every precaution to avoid tearing it. It peals off from the bone 
very readily except where the bone is rough, at the tips of the 
mastoid, where the strenocleidomastoid muscle is attached. 
Here some patience and skill are necessary to avoid tearing; 
the best instrument for the purpose being the hoe-shaped 
periosteum elevator of Langenbeck or 
one of its modifications. 
As soon as the periosteum has been 
separated from the bone, Jansen's dilator 
(Fig. 207) is inserted in the wound. As 
the instrument is opened by means of the 
thumb-screw the wound becomes widely 
dilated and the pressure on the soft 
parts is sufficient to cause all hemorr- 
hage to cease. Two of these instru- 
ments should be used, one at each extre- 
mity of the wound. The hooks of the in- 
struments should be kept closely in con- 
tact with the bone as the blades are 
opened in order to grasp all of the tissues 
efficiently. 
When the surface of the mastoid has been uncovered by the 
separation of its periosteum, it should be inspected carefully 
with a probe for the presence of any sinus or soft spot leading to 
an abscess-cavity. If such a sinus is found it should be 
explored with a probe passed in the direction of the antrum and 
Fig. 207.-Jansen's 
dilator. 
Fig. 208.-Gleason's double-end bone-curette with curved tip. 
the softened cortex of the mastoid removed with a curette 
(Fig. 204) or bone forceps (Figs. 205, 206), used in such a man- 
ner as not to endanger the lateral sinus (Figs. 210, 211). 
When the cortex has been sufficiently removed it may be 
found that the entire mastoid is a cavity filled with pus and 
pulpy granulations, every trace of cellular structure having OPERATIONS UPON THE MIDDLE EAR 
469 
disappeared. This condition of affairs is most likely to occur 
in large-celled pneumatic mastoids. The pulpy granulations 
Fig. 209.-Alexander's mastoid gouges. These instruments are marked accord- 
ing to their width in millimeters, 14, 10, 8, 4 are the most useful sizes, similar chisels 
are made, but are not as useful as the gouges. 
and debris should be scraped away with the curette until firm 
normal bone is encountered. However, the curette should be 
Fig. 210.-Horizontal section through a right temporal bone below the spina, 
showing an extreme anterior and superficial position of the sigmoid sulcus, thus 
bringing the lateral sinus within 1.5 mm. of the bony surface at the operating point 
and rendering the ordinary mastoid operation impossible. At a position some- 
what above the operating point the sulcus is less than J mm. from the bony sur- 
face: V, Upper, L, lower portion of the specimen; S.C, sigmoid sulcus; T, tym- 
panum; At, attic; A, small antrum; S.S.M, spina suprameatum. (Author's 
specimen.) 
used with gentleness and judgment in positions where the lat- 
eral sinus is likely to be encountered, so as not unnecessarily 470 
DISEASES OF THE NOSE, THROAT, AND EAR 
and unexpectedly to expose or wound this important vessel. 
The position of the mastoid antrum should also be located, 
and when working toward it with the curette the position of the 
aqueductus Fallopii (Figs. 137, 138, 193, 213) should be 
borne in mind, so as to avoid danger of curetting away a part 
of the facial nerve. 
Fig. 211.-Right temporal bone, showing: I, Opening the antrum after Schwartze; 
2, point where the chisel is first inserted in removing the posterior wall of the meatus 
after Wolf; in the radical mastoid operation-in this space is the spina supra- 
meatus; 3, the same after Stacke; 4, portion of mastoid process removed in 
same operation; 5, exposing the sinus and cerebellum; 6, exposing the cerebrum 
(temporal lobe); 7, spur; sometimes mistaken for the spina suprameatum; 8, middle 
meningeal artery; 9, second temporal fissure; 10, first temporal fissure; II, fissure of 
Sylvius; 12, mastoid foramen. (Bruhl and Politzer.) 
The floor of the mastoid antrum lies just behind and below 
the spina suprameatum (Fig. 211), in a direction parallel to the 
bony meatus. If the operator is in doubt as to the direction of 
the bony meatus, it is permissible to insert a probe between the 
bony and membranous meatus so as to be absolutely sure as to 
the proper direction in which to continue the use of the curette OPERATIONS UPON THE MIDDLE EAR 
471 
or the chisel. Not infrequently after the abscess-cavity in the 
mastoid has been cleansed there will be found a small opening 
into the antrum, if, indeed, any exist large enough to permit 
the passage of a probe. The bone in this locality is usually 
soft enough to permit it being readily scraped away with the 
curette, but if not, a gouge should be used in the following 
manner: The edge of an 8 mm. gouge with its convexity 
forward is placed upon the bone about 2 mm. posterior to the 
superior suprameatus and struck one or more sharp blows 
with the mallet in such a manner that it penetrates the bone 
to a considerable distance parallel to the canal. The gouge 
is then placed just beneath the linea temporalis slightly poste- 
rior to the meatus and struck with the mallet so that the 
chisel penetrates the bone in a direction toward the antrum; 
that is slightly downward, inward and forward. The triangular 
space of bone thus outlined corresponds with the upper por- 
tion of Macewen's triangle and is removed layer by layer with 
the gouge from behind forward until the antrum is opened. 
The operator can assure himself that it is certainly the antrum 
that is opened by passing a probe forward and inward through 
it into the attic. Fluid syringed into the antrum should appear 
in the meatus unless the aditus or attic is filled with granula- 
tions or the drum-head is not perforated. Should this be the 
case, they should be removed by means of a small curette (Fig. 
189), being careful not to dislocate the incus during the 
procedure. However, should it prove impossible to syringe 
from the attic into the meatus, no especial harm need be 
apprehended. 
Formerly, when the main abscess-cavity had been thoroughly 
cleansed and a free communication established between the 
mastoid antrum and the external wound, the operation was 
considered complete. The larger proportion of cases operated 
on in this manner make an uneventful recovery and the result- 
ing scar or deformity is inconspicuous. However, there are 
often a few cellular spaces above the meatus in the root of the 
zygomatic process, so that in cases where the operation results 472 
DISEASES OF THE NOSE, THROAT, AND EAR 
in the formation of a discharging sinus, the fistula frequently 
leads to one of the cell-spaces that was not thoroughly opened 
at the time of the operation. Hence the disposition has been 
to make the bone wound larger than formerly by chiseling 
away the overhanging edge of bone above and behind the 
meatus at the root of the zygoma. Not only are all cell- 
spaces, if present in this locality, by this method of operating 
removed, but the mastoid antrum is thoroughly exposed and 
becomes the bottom of a shallow cup-shaped cavity from which 
exuberant granulations can readily and thoroughly be scraped 
away. All cellular structures should be removed by a curette 
rotated on its long axis until every portion of the bone wound is 
firm and hard to the touch of a probe which should be fre- 
quently applied during the curettage to be certain that the 
cranium has not been opened inadvertently and the dura ex- 
posed. As the cells overlying and posterior to the compact 
bone of the sulcus of the sigmoid sinus are removed the convex 
outer surface appears bulging into the bone cavity. 
The wall of the bony external meatus should not be interfered 
with or collapse of the cartilaginous portion will occur when 
healing is complete. 
In the tip of most mastoid processes there usually is a large 
cell even when the bone is of the small-celled diploetic type 
(Fig. 198, 199, 200, 201). It is best in all cases, therefore, to 
remove the cortex of the mastoid tip and thoroughly expose 
this large cell, if present, to inspection. If it be filled with 
pulpy granulations, these should be scraped away until the 
normal bone beneath has been thoroughly cleansed and 
exposed. In a small percentage of cases abscess of the large 
cell in the tip of the mastoid results in perforation through 
the median wall and the gravitation of pus into the digastric 
fossa and beneath the sternocleidomastoid muscle into the 
deeper tissues of the neck. Under these circumstances it is 
necessary to removed the entire tip of the mastoid and 
thoroughly expose the abscess-cavity. The incision through 
the skin should be lengthened along the anterior border of the OPERATIONS UPON THE MIDDLE EAR 
473 
sternocleidomastoid muscle, and the attachment of the 
muscle to the end and median surface of the tip severed with 
scissors held as close to the bone as possible, after which the 
tip is very readily removed with the rongeur forceps (Figs. 
205, 206). Newmann removes the tip with a bone gouge which 
is placed vertically on the mastoid at the lower border of the 
meatus and struck a sharp blow with the mallet. This process 
is repeated at the posterior border of the tip and its fracture 
is complete. The tip is then seized with forceps and subluxed 
outward, the muscle fibers being cut away with scissors. 
Instances where the median surface of the large cell at the tip 
of the mastoid is perforated, with the result of the gravitation 
of pus into the digastric fossa and the deeper tissues of the 
neck, were first described by Bezold, and are hence frequently 
referred to as Bezold cases. They are characterized by a 
brawny swelling below and behind the mastoid, and movements 
of the neck are extremely painful to the patient. Not only is 
it necessary to remove the entire tip of the mastoid in such 
cases, but the abscess-cavity in the tissues of the neck should 
be thoroughly laid open by a free incision through the skin. 
The sternocleidomastoid is attached not only to the tip of the 
mastoid process, but to the base of the skull posteriorly, and 
severing its attachment to the mastoid does not apparently 
impair its functions. However, except in Bezold's cases, it is 
manifestly not absolutely necessary as a mere matter of routine 
to remove the entire tip of the mastoid and expose the diagas- 
tric fossa. 
If no softened spot or sinus is found upon the surface of the 
mastoid bone after denuding it of its epithelium, it will be 
necessary to make an opening by means of the mallet and 
chisel. For this purpose the spina suprameatum or spine of 
Henle should be carefully located and preserved during the 
subsequent procedures of the operation to serve as a land- 
mark. Some portion of the mastoid antrum will be found at a 
depth of from 12 to 22 mm. in a direction parallel to the 
meatus, immediately behind the spina suprameatum, in a 474 
DISEASES OF THE NOSE, THROAT, AND EAR 
space called the mastoid fossa, the suprameatal triangle, or 
triangle of Macewen, which is bounded above by the linea 
temporalis, in front by the posterior wall of the meatus, and 
behind by the remains of the squamomastoid fissure of infants 
(Figs. 195, 197). If the latter landmark is not readily dis- 
cernible an imaginary line drawn from the parietal notch to 
the tip of the mastoid will answer the purpose. This line 
represents the course of the sigmoid sinus and in most temporal 
bones there is a decided bulging of the mastoid surface over it. 
If at a depth of 15 mm. or about y inch when chiseling through 
dense bone the antrum is not opened, the operator should pro- 
ceed with great caution to avoid injuring the facial canal or 
entering the cranial cavity, as the antrum may be small 
Fig. 212.-Stacke's protector. 
and easily overlooked. In some instances (Fig. 210) the lateral 
sinus is much further forward than usual, and to avoid injuring 
it the operator must keep as close to the meatus as possible. 
Where the drum-head and ossicles are partially destroyed, 
Stacke's protector (Fig. 212) or a silver probe with its tip 
bent at a right angle may be carried through the canal into 
the vault of the tympanum and held in such a position as to 
serve as a guide. If the chiseling and curetting be continued 
in the right direction within the triangle of Macewen, that 
is, from behind forward and from below upward, parallel to 
the canal and linea temporalis, there is little danger of wound- 
ing any important structure before the probe is encountered. 
When chiseling through sclerosed bones (Fig. 202), even 
though no cell structure or pus, but only softened bone in OPERATIONS UPON THE MIDDLE EAR 
475 
the region of the antrum is encountered, the relief of all mas- 
toid symptoms usually follows the operation. 
After-technic.-After the operation is completed, the wound 
and auditory meatus should be irrigated with warm sterile 
water and thoroughly cleaned. The wound may be allowed 
to fill with blood-clot or may be dressed by the open method. 
The former has the advantage of securing healing in ten days 
instead of the six weeks required by the other method, but is 
only applicable in cases where the operator is certain that he 
has secured an absolutely clean wound. The bone wound is 
allowed to fill with blood-clot. The upper and lower angles 
of the skin wound, including the periosteum, are carefully 
brought together with one or two sutures. A very small 
cigarette drain, made by inserting sterile gauze into a piece of 
catheter rubber which has been slit spirally, is then inserted 
superficially and held in place by a suture through the skin. 
Sterile gauze, cotton, and a roller bandage complete the dress- 
ing, which is not disturbed until the third or fourth day should 
the temperature remain normal. The cigarette drain is then 
removed and the dressing reapplied. Should the blood-clot 
become infected and break down, the sutures are removed, the 
wound cleansed with sublimate solution, and treated by the 
open method, which in a considerable proportion of cases is 
the preferable one from the start. 
After the mastoid wound and meatus have been cleansed as 
described above, they are filled with i : 2000 sublimate solu- 
tion and the wound packed loosely with iodoform gauze, one 
or two sutures being inserted at each angle of the wound if 
required and a roller bandage applied over sterilized gauze 
and cotton. 
If the temperature remains normal and the patient com- 
fortable after the operation the dressing should not be removed 
from the wound until the third day, after which the wound 
should be dressed every day or every other day. The parts 
should then be douched with a 1:5000 bichlorid solution, the 
wound again packed lightly with iodoform gauze, and sterilized 476 
DISEASES OF THE NOSE, THROAT, AND EAR 
gauze, cotton, and roller bandage applied, especially in infants. 
If the wound be packed too firmly during the first few days 
following the operation there is danger of injuring the facial 
nerve, with resulting transient paralysis of some of the facial 
muscles; later on the wound may with advantage be packed 
more firmly. In some cases the wound does better if, after 
thoroughly cleansing, it be dusted with boric acid and packed 
either with sublimate or sterilized gauze. This is more es- 
pecially the case if the lips of the wound appear sluggish and 
the exposed bone does not quickly cover itself with granula- 
tions. The presence of edema in the superficial tissues about 
the wound may render advisable the use of a wet sublimate 
dressing for from twenty-four to forty-eight hours. Some- 
times exuberant granulations on the superficial edges of the 
wound will require removal with the curette or scissors, as the 
wound requires to be kept open until firmly healed from the 
bottom, a result that usually requires from three to six weeks. 
Usually recovery from a mastoid operation is uneventful. 
Pain and sleeplessness on the night following the operation 
may require the use of a small dose of chloral and bromid of 
sodium or even an opiate. Usually the temperature is 
practically normal and the patient entirely comfortable on 
the morning following the operation. If the evening tempera- 
ture for the first three or four days reaches ioo° or even ioi° 
F., it need occasion no anxiety. When the temperature re- 
mains normal for one or two days the patient may be allowed 
to sit up and move about in his room. 
Persistent pain and sleeplessness with high temperature 
following the operation may be due to a slight attack of 
local periostitis or to the fact that all the foci of inflammation 
in the mastoid bone have not been reached by the chisel. 
The former requires that the dressings be kept moist with a 
i: 3000 bichlorid solution for three or four days, the latter may 
necessitate a secondary operation. 
Accidents Occurring During the Mastoid Operation.-The 
middle cranial fossa or the posterior cranial fossa may be OPERATIONS UPON THE MIDDLE EAR 
477 
opened, and the lateral sinus exposed or wounded. One of 
the semicircular canals may be penetrated. The facial nerve 
may be wounded or divided. 
Occasionally the middle cranial fossa extends downward to 
a level scarcely more than | inch above the meatus. It is 
better, therefore, not to do any deep chiseling in this locality 
until the mastoid antrum has been located. After this has 
been accomplished and the cavity thoroughly exposed, it is 
easy to locate the exact position of the floor of the middle 
cranial fossa by means of a probe. After the antrum has been 
explored with the probe, it is easy, without the slightest danger 
of entering the middle cranial fossa, to remove the superficial 
bone, including the spina suprameatum above and behind the 
meatus, in order to secure a flat wound. Any considerable 
portion of the bony meatus itself should not be removed, as it 
is followed by collapse of the cartilaginous meatus after 
healing. However, if the middle cranial fossa be opened and 
the dura exposed, it is not a serious accident, as the dura 
granulates like the other portions of the wound. It is perfectly 
justifiable when softened bone is found in the vicinity of the 
tegmen to thoroughly remove the diseased bone even if by so 
doing the dura is exposed, as by this procedure a small ex- 
tradural abscess may be opened whose presence otherwise 
would not be suspected. Should pus be located between the 
skull and the dura, the opening in the bone should be made 
sufficiently large to secure ample drainage, but exploration with 
the probe between the bone and the dura should be under- 
taken with extreme caution and gentleness, because the dura 
ordinarily attaches itself about such an abscess-cavity to the 
skull, thus isolating the suppuration from the rest of the dural 
surface and preventing a general infection. If the dura is 
punctured, the opening should be enlarged with scissors to the 
extent of | inch to afford drainage and diminish the possibility 
of infection. 
Opening the Posterior Cranial Fossa and Wounding the Lateral 
Sinus During the Mastoid Operation.-In diploetic and small 478 
DISEASES OF THE NOSE, THROAT, AND EAR 
compact mastoid bones the lateral sinus often occupies a 
position more anterior and superficial than is normally the 
case. In the bone shown in Fig. 210 a careless operator might 
readily expose and open the lateral sinus with the chisel. In 
very rare instances the sinus is not covered by bone at all, but 
lies immediately beneath the skin and might be freely opened 
by the first stroke of the knife. However, even in extreme 
cases of anterior position of the lateral sinus, there is usually 
a sufficient space of comparatively soft bone between the hard 
bone covering the sinus and that of the meatus for a careful 
operator to work through safely to the antrum with a curette or 
gouge. The position of the lateral sinus is often apparent 
after the cellular tissue has been curetted away, a distinct oval 
elevation of hard bone gradually shaping itself into view. This 
elevation is the hard bony wall of the sigmoid fossa in which 
the lateral sinus lies. Should the bone be carious and soft 
it should be scraped away with the curette and the sinus exposed, 
because extradural abscess is common in this locality. When 
the lateral sinus is torn or cut during a mastoid operation it 
does not spurt like an artery, but a gush of blood wells out from 
the wound, pulsating with each heart-beat as it flows. The 
lightest pressure of the finger upon the bleeding sinus causes 
the hemorrhage to cease. 
When the lateral sinus is accidentally wounded during a 
mastoid operation a small piece of iodoform gauze should be 
placed on the sinus and held in position by the finger of an 
assistant and, if possible, the operation completed. The 
wound should then be firmly packed with iodoform gauze in 
such a manner as to control the hemorrhage and a firm roller 
bandage applied. The dressing should not be disturbed unless 
absolutely necessary before the third or fourth day. At 
this time, if the packing over the sinus is slowly and gently 
removed, in all probability the hemorrhage will not reappear. 
Cases in which the lateral sinus has been accidentally wounded 
generally do well an make an uneventful recovery. However, 
it is wise during the first few days to keep such cases under OPERATIONS UPON THE MIDDLE EAR 
479 
careful observation lest the bandage be displaced and a 
hemorrhage recur. 
Opening the Horizontal Semicircular Canal and Wounding 
the Facial Nerve.-The position of the horizontal semicircular 
canal and the facial nerve is shown in Figs. 137, 138, 213, and 
216. The aural portion of the facial nerve may be divided into 
a horizontal and vertical portion (Figs. 137, 138). The hori- 
zontal portion is embedded in a ridge of bone just above the 
oval window. The horizontal semicircular canal lies just 
above posteriorly. Both of these structures are embedded 
in ridges of extremely hard bone. These ridges can frequently 
be seen in the radical mastoid operation as soon as the attic 
is well exposed, and hence the exact position of the nerve 
located. The simple mastoid operation, even when it is suffi- 
ciently complete to convert the antrum into a shallow cup in 
the bottom of the bone wound, does not expose the bony 
ridges containing the horizontal semicircular canal and the 
horizontal portion of the facial nerve. However, these struc- 
tures lie so high up and so far forward that there is little 
danger of injuring them, except by a careless operator. Ordi- 
narily the ridges of bone containing the horizontal semicircular 
canal and the horizontal portion of the facial nerve are suffi- 
ciently hard and thick to offer great resistance to an instru- 
ment, but occasionally the bone is very thin over the horizontal 
part of the facial nerve or may in part be lacking, so that the 
nerve lies just beneath the mucous membrane. Hence, if 
at the close of a simple mastoid operation the aditus and attic 
are found to be full of exuberant granulations and the small 
curette (Fig. 189) is used to remove them, it should be em- 
ployed with great gentleness when scraping the inner median 
wall of the aditus. 
However, it is the vertical portion of the nerve that is 
most liable to injury during a mastoid operation. Because of 
the oblique position of the membrana tympani the annulus 
approaches in some instances as close to the nerve as | mm. at 
a position opposite the malleus tip. The operator should 480 
DISEASES OF THE NOSE, THROAT, AND EAR 
observe considerable caution in removing much bone in this 
locality. 
When the bone forming the facial canal is necrosed it is 
difficult to avoid injuring the nerve during its removal, and 
hence, if the nerve is partially paralyzed before an operation, 
it is well to caution the patient that the operation may fail 
to relieve this condition or even make it worse. A simple 
bruising of the nerve during a mastoid operation is followed by 
transient paralysis of the muscles of one side of the face. 
The paralysis is usually worse in the muscles of the lower 
portion of the face because that part of the face is supplied by 
the more superficial fibers of the nerve. Cases of this kind 
and paralysis resulting from too tight packing of the mastoid 
wound end in complete recovery. If is stated that the nerve 
may be completely severed without causing permanent facial 
paralysis. The nerve also may be wounded at its exit from the 
stylomastoid canal which is at the anterior extremity of the 
digastric groove, posterior to the root of the styloid process, 
and immediately beneath the inner posterior wall of the ex- 
ternal meatus. If these facts are borne in mind, the position 
of the nerve at its exit from the skull is readily located with 
the finger after the removal of the mastoid tip. 
Radical Mastoid Operation, Exenteration of the Middle 
Ear.-So termed in contradistinction to the simple and 
complete mastoid operation also tympano-mastoid in con- 
tradistinction to the meato-mastoid or Heath operation. The 
object of the procedure is to convert the middle ear into a skin- 
lined cavity, all parts of which are visible and easily accessible 
for the removal of accumulations. 
After opening the antrum as in the simple mastoid operation 
the cartilaginous canal and as much of the periosteum as 
possible are separated from the bony canal by means of a 
small elevator. An incision is made through the loosened 
tissues as close to the drum-head as possible, and by traction 
forward upon the auricle the funnel-shaped mass is pulled 
out of the bony canal, exposing the tympanic structures OPERATIONS UPON THE MIDDLE EAR 
481 
clearly to view. A narrow strip of gauze is now passed 
through the cartilaginous canal from without inward and the 
ends tied together and handed to an assistant. The strip of 
gauze forms an efficient retractor for holding the canal and 
auricle forward out of the operator's way. The bone inter- 
vening between the meatus and the artificial opening is now 
chiseled away down to the annulus tympanicus. It should 
be borne in mind that the facial nerve approaches the annulus 
somewhat closely posteriorly on a level with the tip of the 
malleus handle, and the annulus should not be chiseled 
away below the level of the external semicircular canal. 
There yet remains the bony outer wall of the attic and aditus. 
This is weakened by chiseling with a narrow gouge the upper 
wall of the meatus until finally it is easily removed with a 
curette, the author's curette (Fig. 208) being convenient for this 
purpose. Its curved tip is introduced into the tympanum 
beneath the overhanging bone, which is rapidly cut away, not 
by drawing the instrument outward, but by rotating it in 
such a manner that the bone is cut alternately by the sharp 
anterior and posterior edges of the cup, the curved tip of the 
curette in the meanwhile preventing the instrument from 
becoming displaced. In order to afford a rirm grasp upon the 
instrument while executing this maneuver, the handle of the 
instrument between the cups is made very broad and rough- 
ened. The tendon of the stapedius muscle and the incudo- 
stapedial articulation are now severed and the malleus and 
incus removed. The curetting of the outer wall of the antrum 
and attic is continued until there is no overhanging wall of 
bone to prevent a clear view of the tegmen. It is important 
that no ridges of bone remain between the floor of the meatus 
and the mastoid wound. Such a ridge is conveniently chiseled 
away from behind forward with a gouge held at right angles to 
the axis of the canal; but the region of the facial nerve should 
not be incroached upon. The " hypotympanic space," or that 
portion of the tympanum below the level of the external bony 
meatus, is obliterated by cutting down the floor of the meatus 482 
DISEASES OF THE NOSE, THROAT, AND EAR 
with a 4 mm .gouge. The tip of Stacke's protector .(Fig. 212) 
is f rst inserted into the hypotympanic space and held by an 
assistant. The operator then chisels away the bone toward the 
instrument being careful not to encroach on the posterior wall of 
the meatus and injure the facial nerve. The mucous membrane 
at the mouth of the Eustachian tube is also carefully rasped, 
or curetted away to secure obliteration of the tube mouth, 
which is accomplished by the growth of granulations during 
healing. However no amount of curetting which would be 
safe in the Eustachian tube will obliterate the tubal cells 
which are frequently present leading off into the bone. The 
position of the carotid canal should be borne in mind, as the 
use of cutting instruments at the tympanic tube mouth in a 
backward and downward direction is dangerous. The bony 
wound is flushed with cold bichlorid solution and firmly packed 
with iodoform gauze during the preparation of skin-flaps to 
check all oozing and permit of a thorough inspection of the 
tegmen and inner wall of the tympanum is search for necrosed 
bone or a fistulous opening leading into the cranial cavity or the 
labyrinth. 
Having exenterated the middle ear, a method is adopted for 
lining as much as possible of the large bone cavity with skin- 
flaps cut from the meatus and concha, to secure rapid epi- 
dermization and an enlarged meatus, to permit the free en- 
trance of air, and facilitate the drying and removal of debris 
after healing. It should be remembered that these flaps must 
consist only of skin, and, before cutting them, tissue and 
cartilage must be dissected from the posterior and upper part 
of the meatus down to the skin. An assistant inserts a 
hemostat into the cartilaginous meatus, which, when opened, 
stretches the meatus. The flesh and cartilage is then some- 
what easily removed with forceps and curved scissors. The 
skin of the meatus is now slit, by Pause's method, along its 
posterior surface to the concha, whence two right-angled in- 
cisions are made, one upward and the other downward, thus 
forming two quadrilateral flaps which are stitched to the OPERATIONS UPON THE MIDDLE EAR 
483 
periosteum and subcutaneous tissues with catgut in such a 
manner as to form a partial dermic lining for the middle-ear 
cavity and enlarge the meatus. Passow's modification of the 
Panse flaps is to make the incision >- shaped, so as to secure 
a short anterior flap which is bent sharply back and stretched 
into place after the meatus has been dilated by the operator's 
little finger. The uncovered space between these flaps may be 
allowed to heal by granulations or may be grafted at the time 
of the operation or ten days afterward by Thiersch's method. 
The wound behind the auricle is brought together by sutures 
through the periosteum and skin. A small cigarette drain is 
then placed loosely in the enlarged meatus and the parts 
protected by a dressing of gauze, absorbent cotton, and a roller 
bandage, in the same manner as after a simple mastoid opera- 
tion. If the temperature remain normal, the wound is not 
dressed for three or four days, after which daily dressings per- 
haps will be required. At each dressing the meatus is either 
syringed lightly with a x: 5000 bichlorid solution or simply 
mopped dry and a fresh cigarette drain inserted. Should the 
skin-flaps fail to grow or the wound becomes infected, exuber- 
ant granulations may require removal with scissors or snare 
and the instillation of alcohol. Epidermation is greatly 
hastened by applications of a 10 per cent, ointment of scarlet 
red. 
Kbrner's flap is made by two incisions, one at the postero- 
superior and the other at the postero-inferior border of the 
meatus, from its median aspect out to the concha; the resulting 
large quadrilateral flap is then reflected backward into the 
bone-cavity, partially lining it. 
Ballance's flaps are made by means of an incision which ex- 
tends from the median aspect of the meatus to the concha and 
then around the concha in the form of a shepherd's crook. 
The upper and lower flaps are secured by means of anchor 
sutures, two for the upper and one for the lower. 
Causes of Failure after the Radical Operation.-Failure may 
be due to the anomalous structure of the temporal bone where 484 
DISEASES OF THE NOSE, THROAT, AND EAR 
the cellular structure leads to depths from which it is impru- 
dent to remove it; in some instances into the sphenoid and 
occipital. 2. Incomplete operation: generally failure to re- 
move the outer wall of the attic and antrum and completely 
open all cells. Epidermis grows with difficulty if at all over 
sharp edges of bone or into small cells with overhanging edges. 
3. Failure to completely close the Eustachian tube: so that with 
each cold-muco-pressure is either blown or flows into the 
middle ear. 4. Retained secretions occasionally form choles- 
teatomatous masses which if long retained set up infection. 
5. Neglect to watch the process of granulation and epider- 
mization; so that strictures of the canal result from thin walls 
of epidermis or pockets result from the bridging over of spaces 
by epidermis. 6. Insufficient space to permit free access to 
the mastoid cavity from the canal as the result of a faulty 
management of the skin flaps. 
The last word has probably not been said as regards the 
value of complete exenteration of the middle ear as a treat- 
ment of chronic otorrhea and the prevention of intracranial 
complications. It is urged that such complications do not 
occur except in a very small percentage of cases, and that 
chronic otorrhea not infrequently exists from early childhood 
during the entire life of the individual without greatly impair- 
ing his hearing or requiring more attention than somewhat 
frequent cleaning. That, on the other hand, besides the risk 
of complete exenteration, the patient's hearing, if good 
before the operation, will almost certainly be impaired to the 
extent of inability to hear the whispered voice at a greater 
distance than 1 meter, and may be practically entirely lost, 
and in a majority of cases, if epithelium and other debris are 
not removed every few months, there will be recurrent otorrhea. 
Therefore, it would seem wise, where there is a large perfora- 
tion of the drum-head and only the atrium affected, not to 
advise a radical operation, and in attic cases not until cleansing 
treatment faithfully carried out has failed to bring about a cure 
of the otorrhea. The operation is rarely justifiable in young 485 
OPERATIONS UPON THE MIDDLE EAR 
Fig. 213.-Vertical frontal section through the skull, anterior portion of the 
specimen seen from behind. The saw has passed through the spina on the right 
side and laid open the aquaeductus Fallopii through its entire vertical portion, 
showing the facial nerve, under which a pin has been passed. It should be ob- 
served that the nerve lies nearly vertical in this part of its course, while above and 
external to it is an opening into the most external portion of the horizontal semi- 
circular canal. The anterior part of the antrum, A, has been opened, and also 
the vestibule, V, and the superior semicircular canal. On the left side the saw 
has passed through the posterior portion of the external and internal meatus, 
removing the posterior edge of the drum-head and the incus. . The stapes still 
retains its position in the oval window._ Below the tympanum is the bulb of the 
jugular vein. In comparing Fig. 213 with Fig. 214, note that the saw has passed 
slightly more anteriorly through the left ear of the specimen. (Author's specimen.) 486 
DISEASES OF THE NOSE, THROAT, AND EAR 
children or on the ear of an adult upon which he mainly depends 
for hearing. 
Fig. 214.-Vertical section through the skull, posterior portion of the same 
specimen as Fig. 213. On the left side the saw has passed just anterior to the 
aquaeductus Fallopii, and.a pin has been passed under the facial nerve, N, at its 
exit from the stylomastoid foramen. Above is seen an opening made into the 
commencement of the vertical portion of the facial canal. Still higher up is a 
portion of the horizontal semicircular canal (H) laid open and occupying a posi- 
tion somewhat lateral to the facial nerve and median to the aditus (A). On the 
right side the section has passed through the anterior part of the antrum and is 
posterior to the facial canal, and has opened the horizontal semicircular canal 
at its most external part. (Author's specimen.) 
In order to overcome the disadvantages of exenteration, 
Heath has advised a semiradical operation similar to the 
ordinary operation, including the employment of skin-flaps OPERATIONS URON THE MIDDLE EAR 
487 
from the meatus and concha, which does not disturb the 
tympanic contents; on the thory that in most instances the 
Eustachian tube is able to drain the discharges of the attic 
and tympanum, but not also those from the mastoid cells. At 
the time of the operation the attic is thoroughly cleansed 
through the aditus by means of syringing and currents of air 
from the syringe, so that cholesteatomatous scales of epithelium 
Fig. 2is.-Vertical sagittal section through the tympanum; median aspect of 
the lateral portion of the specimen. The lower part of the membrana tympani is 
cut away by the saw and above the drum-head inclines outward at an angle of 
140 degrees with the upper wall of the meatus. The malleus handle and the 
malleo-incudal articulation, as well as the descending process of the incus, are 
visible. The section passes through the canal for the tensor tympani muscle, so 
that the trochlea and tendon are shown. Above the tympanum portions of each 
of the semicircular canals are visible, (Author's specimen.) 
and even small pedunculated polypi are blown from the attic 
and appear in the canal, whence they are easily removed. 
Ultimately the aditus is closed posteriorly by cicatricial tissue 
after cessation of the otorrhea, without the impairment of 
hearing so common after a complete exenteration. In some 
cases regeneration of the drum-head occurs either wholly or 
partly. s 
When chiseling away the posterosuperior wall of the meatus 
and opening the attic, the topographic relation of the posterior 
wall of the meatus to the descending portion of the facial nerve 488 
DISEASES OF THE NOSE, THROAT, AND EAR 
should be borne in mind. The student should study the 
topographic relation of the structures involved in operations 
upon the middle ear by preparing a large number of frontal, 
sagittal, and horizontal sections of the ear. Such sections 
should be made, not through a separated temporal bone, 
but while the bone is still in position in the skull. Injected 
heads, sawn in half through the sagittal structure and mummi- 
fied by exposure upon the roof of a house for a few months, 
Fig. 2 i6.-Posterior surface of the portion of the ear removed by the two ver- 
tical frontal saw-cuts seen in Fig. 215. The external bony meatus has been laid 
open only at its most external position. Above, the saw has passed through the 
aditus and posterior to the facial canal: A, Aditus, with its bony tocf partly re- 
moved; H, horizontal semicircular canal; M, meatus; N, facial nerve. 
are very suitable for making such sections. After the sections 
are made the parts should be freed from fat by repeated soak- 
ings in gasoline or benzine. By careful attention to this 
detail the specimens may be rendered almost devoid of smell, 
as the foul odor originates principally in the fat of the tissues. 
The specimens may be further cleansed and bleached by 
placing them in the sun and spraying them frcm time to 
time with an atomizer containing hydrogen peroxid rendered 
slightly alkaline by the addition of liquor potassae. After OPERATIONS UPON THE MIDDLE EAR 
489 
subsequent drying the soft parts should be preserved by ap- 
plying to them several coats of bleached shellac varnish, which 
may be made to assume any color required to render the 
structure more natural in appearance by the addition of one 
of the aniline dyes. Each coat of varnish is allowed to soak 
well into the soft tissues in order to preserve them. However, 
Fig. 217.-Horizontal section through the roof of the external meatus: I, Infe- 
rior portion; S, superior portion of the specimen; M, external auditory meatus: T, 
tympanum; M. A. mastoid antrum; A, carotid artery; L.S, lateral sinus; B, bulb 
of the jugular vein; N, facial nerve. In the lower half of the specimen is the handle 
and short process of the malleus, the saw having passed through the neck of the 
bonelet. The membrane slopes obliquely forward at an angle of 55 degrees with 
the axis of the meatus, and outward at an angle of 140 degrees with the roof of 
the meatus. The section passes through the oval window, so that the cavity of 
the vestibule (V), as well as the cochlea (C), is shown in the upper half of the 
specimen. _ Here also is to be seen the malleus head, the incus, the attic, and 
the mastoid antrum. The stapes has been removed by the saw. The bulb (B) 
of the jugular vein extends further upward than in most specimens. (Author's 
specimen.) 
specimens of a large section of the head prepared in this manner 
are rather too realistic to show indiscriminately to office 
patients, as by the skilful use of the aniline dyes they are made 
to look as if still bleeding and freshly severed from the body. 
Therefore, if it is found convenient to have a few specimens 
like Fig. 71, for example, to aid in the explanation to patients 490 
DISEASES OE THE NOSE, THROAT, AND EAR 
a proposed operation, it is better to coat such specimens with 
aluminum or bronze paint. The most useful sections for 
purposes of study are a vertical, frontal section through the 
spina suprameatum (Fig. 216), a vertical sagittal section 
through the floor of the tympanum (Fig. 215), a horizontal 
section through the roof of the meatus (Fig. 217), and a 
section parallel to the inner wall of the tympanum (Figs. 
136, 137, 138). Besides making the sections through the 
middle ear, the student would do well to operate many times 
upon the cadaver before attempting any serious operation 
upon the ear of a patient. 
INTRACRANIAL COMPLICATIONS OF OTIC DISEASE 
Intracranial complications of otic disease from acute sup- 
puration frequently are rapid and virulent. The infection may 
advance along the lymph-sheaths of vessels or nerves, in the 
blood-current, or from one of four points. The labyrinth, by 
way of the internal meatus, duct, or aqueduct, probably the 
most common route in septic leptomeningitis, or by infection 
through the thinnest layers of bone about the middle ear. 
These are the tegmen of the attic and antrum, the wall of the 
cells overlying the lateral sinus, and the floor of the tympanum. 
Extradural abscess, abscess of the temporal lobe, and men- 
ingitis originate by way of the tegmen. Extradural abscess, 
cerebellar abscess, sinus phlebitis, and meningitis by way of 
the cells about the lateral sinus; and infection of the jugular 
bulb through the tympanic floor. Intracranial complications 
occur in the following order of frequency: extradural abscess, 
sinus thrombosis, brain abscess, septic meningitis. Three- 
fourths of the infections occur in the posterior fossa and only 
one-fourth in the middle fossa. Theoretically the existence 
of an uncomplicated intracranial disease produces well-defined 
symptoms, but practically it is rare to have one portion of 
the intracranial contents infected without complicating others 
and rendering exact diagnosis as to the principal lesion often OPERATIONS UPON THE MIDDLE EAR 
491 
impossible. No single symptom is characteristic. Optic 
neuritis frequently occurs early in leptomeningitis and later 
in sinus thrombosis but may occur in purulent middle ear 
disease without obvious signs of an intracranial complication, 
and in this condition, vascular changes are so frequent as to 
amount to at least 25 per cent. There may be convulsions 
or exaggerated reflexes, as shown by Babinski's sign, which 
consists in extension of the great toe on touching the sole of 
the foot. Kernig's sign is probably the most constant, and 
stiffening of the muscles of the neck occurs in all inflamma- 
tions of the contents of the posterior fossa. Sensory symp- 
toms, photophobia, and hyperesthesia; sympathetic vaso- 
motor disturbances, the tache cerebrale, and finally symp- 
toms due to the death of nerve-cells, paralysis, anesthesia, 
and coma, may all be present in meningitis. The degree of 
purulence and the kind of bacteria in the cerebrospinal fluid 
obtained by lumbar puncture furnishes valuable informa- 
tion as to the extent and virulency of meningitis. When clear 
and sterile, only circumscribed inflammation is probable. 
Great purulency and streptococci or a mixed infection indicate 
a virulent diffuse meningitis, where operation would probably 
be useless, but slight turbidity and few bacteria do not indicate 
a hopeless condition. 
Lumbar puncture is performed as follows: The patient 
either sits up or lies upon the side, with the back arched and 
the knees flexed against the abdomen. The spine of the fourth 
lumbar vertebra should be located (a line drawn from one 
posterosuperior spine of the ilium to the other passes across 
it) and the puncture made | inch to one side, at the level of its 
lower end. The needle should be inclined at an angle of about 
45 degrees to the surface of the skin, and should be thrust in a 
distance of from 2| to 3 inches. The most scrupulous asepsis 
must be observed. The spinal fluid flows readily, either in a 
stream when the pressure is high, or drop by drop if it is normal. 
In purulent meningitis it is cloudy and contains pus-cells; in 
tuberculous meningitis it is usually clear; in cerebral hemor- 492 
DISEASES OF THE NOSE, THROAT, AND EAR 
rhage it may be bloody, but as admixed blood may be due to 
the injury of a vessel by a needle, the diagnosis should be made 
with caution. The quantity obtained varies from 2 to 3 to 
80 or 90 ccm.-i. e., from a few drops to 3 fluidounces. 
Pressure symptoms, of which the most common is pain 
located in the frontal or occipital region, do not indicate the 
seat of the lesion. Vomiting in the initial stage is from septic 
absorption, but in the later stages results from pressure and is 
most common in cerebellar abscess. Restlessness, drowsiness, 
apathy, or moroseness, and in children intolerance of light are 
common. Pressure produces a slow pulse, and hence both in 
meningitis and abscess the pulse is rapid only in the initial 
stages. Localized symptoms, such as impairment of speech, 
muscular atony, and cerebellar ataxia occur when certain areas 
are involved and may be the result of pressure, inflammation, 
or actual destruction of the part. 
Kemig's Sign.-In 1884 Kernig announced the impossibility 
of producing complete extension of the leg on the thigh, with 
the patient sitting and the thigh flexed at right angles to the 
trunk, when there is irritation of the meninges of the lower 
portion of the cord. In bedfast patients the thigh should be 
flexed on the abdomen, and if meningitis be present, complete 
extension of the leg will be prevented by contraction of the 
flexor muscles. Kernig's sign may be present in any form 
of meningitis, but its absence does not exclude localized 
meningitis. 
Examination of the blood in intracranial complications of 
mastoiditis may render valuable assistance. The blood is 
composed of fluid and corpuscular portions. The fluid 
portion is called the liquor sanguinis or plasma and yields on 
evaporation about 10 per cent, of solid matter, consisting of 
fibrinogen, serum, albumin, serum albumin, serum globin, and 
salts, mostly sodium chlorid. The corpuscular elements con- 
sists of red cells or erythrocytes, white cells or leukocytes, 
blood-plaques, and hemoconia or blood dust. 
The chief function of the red corpuscles is to carry oxygen OPERATIONS UPON THE MIDDLE EAR 
493 
from the lungs to the tissues. In health their number varies 
from 4,500,000 to 5,000,000 to the cubic millimeter, and the 
percentage of their chief component, hemoglobin, from 85 
to 95 per cent. A decided diminution in the number of red 
cells or in the percentage of hemoglobin in sepsis is propor- 
tionate to the virulence and duration of the infection. In 
simple anemia, where the proportion of hemoglobin is below 
50 per cent., it is better to delay operations when possible until 
systemic treatment has corrected the deficiency. 
The normal coagulation time of blood, as tested by the glass 
slide or Wright's coagulatometer, is from two to five minutes. 
In patients suffering from jaundice, hemophilia, or purpura, if 
coagulation does not occur in ten or fifteen minutes, it is 
best to avoid operations when possible until systemic treat- 
ment has brought about the normal coagulability of the blood 
in order to avoid troublesome hemorrhage. This can be 
accomplished in most instances by the administration of 5 gr. 
of calcium chlorid (Formula 47) every three hours for one or 
two days, or the injection of horse serum. 
Blood-plaques are small spheric bodies whose function is but 
imperfectly understood, but they are supposed to play an 
important part in the formation of a clot. In health they 
number from 108,000 to 500,000 to the cubic millimeter. 
Hemoconise are small highly refractive bodies constantly 
present, about whose origin and function nothing definite is 
known. 
Bacteriemia, or the presence of specific bacteria in the blood, 
is conclusive evidence of the nature of an infection, and it is 
possible to secure sometimes a nearly pure culture of the 
offending organism. According to some authorities the pres- 
ence in the blood of the staphylococcus pyogenes albus does 
not affect the prognosis, but the prognosis is grave when any 
other pyogenic bacteria are present. Positive results from 
blood culture tests are said to be only found in otic cases 
when complicated by meningitis or sinus thrombosis, and the 
method is especially valuable when there is doubt as to the 494 
DISEASES OF THE NOSE, THROAT, AND EAR 
existence of a sinus thrombosis after a mastoid operation when 
the temperature remains high. 
Leukocytes are of three groups depending upon the stain- 
ing qualities of the granules within the cystoplasm: eosinophiles 
stain best with acid aniline dyes; basophiles with basic 
dyes and neutrophiles with neutral dyes. There are two 
varieties of leukocytes: I. Lymphocytes large and small with- 
out granules in the cell and without ameboid movements; 
II. leukocytes with granular cytoplasm and ameboid move- 
ments. There are mononuclear leukocytes, a transition form 
between lymphocytes and polymorphonuclear leukocytes, 
polymorphonuclear leukocytes and eosinophiles. 
Leukocytes, by their bactericidal or phagocytic action, pro- 
tect the system from infection and assist the elimination of the 
products of inflammation, irritation, and tissue metamorphosis. 
In health their number varies from 5000 to 10,000 to the cubic 
millimeter. DaCosta states the proportion of the different 
leukocytes as follows: 
Variety 
Per Cent. 
Number per 
Cubic Millimeter 
Small lymphocytes 
20-30 
1000-3000 
Large lymphocytes and transitional forms 
4-8 
200- 800 
Polynuclear neutrophiles 
60-75 
3000-7500 
Eosinop hiles 
o.5-5 
25- 500 
Basophiles 
0.5 
25 
85-118 
4250-11800 
Leukocytosis is an increase in the proportion of white cells, 
generally as the result of an increase in the number of poly- 
nuclear neutrophiles. Pus may be suspected when the per- 
centage is over 75 per cent., but a lower percentage does not 
contraindicate a mastoid operation when clinical symptoms 
are present because the percentage indicates only the amount 
of toxins being absorbed. Sometimes all the varieties of 
leukocytes are increased in number. In health various causes 
may produce a temporary leukocytosis up to 10,000. Leu- 
kocytosis is said to be mild when the number of leukocytes is OPERATIONS UPON THE MIDDLE EAR 
495 
not above 16,000, and well marked when their number reaches 
20,000 or 25,000. The grade of leukocytosis indicates the vigor 
of resistance to infection. Generally a mild infection with 
good resistance results in moderate leukocytosis and a virulent 
infection in well-marked leukocytosis; but if the infection is 
so severe as to overwhelm the patient's powers of resistance, 
there will be a decrease (leukopenial) in the percentage of 
white cells. 
These facts have an important bearing on the prognosis in 
the intracranial complications of mastoiditis, because if there 
is a decided leukocytosis present, it indicates that the resist- 
ance of the patient to the bacteria causing the infection is 
active, while a decided leukopenia indicates feeble resistance 
and an unfavorable operative prognosis. However, it should 
be borne in mind that bacterial infection does not produce 
leukocytosis unless the toxins resulting enter the blood in 
sufficient amount to exert a chemotactic action on the leu- 
kocytes, and the blood-count is usually negative in chronic 
pus cavities. Hence, in uncomplicated tuberculosis of the 
ear or upper respiratory tract, there usually is no leukocytosis 
present. For the same reason, in malignant disease there 
may be no leukocytosis, or it may be present to the extent of 
30,000 or even 40,000, but in septicemia from any cause the 
leukocytosis is not usually above 20,000. In leptomeningitis 
and sinus thrombosis there is usually either high leukocytosis 
or leukopenia. 
Serous leptomeningitis begins as a general hyperemia of 
the pia and arachnoid, followed by a serous exudation. The 
dura and ventricles become distended by the exudate with 
resulting pressure symptoms. 
Slight cerebral irritation, especially in children, probably 
meningitis, frequently accompanies acute inflammation of the 
middle ear. The symptoms are localized headache referred 
to the temporal or occipital region, which may be tender on 
palpation. Morning and evening fever is sometimes present 
and, in infants, convulsions. These symptoms may disappear 496 
DISEASES OF THE NOSE, THROAT, AND EAR 
within a short time as the result of purgation with calomel, 
the use of bromid of potash, and an ice-cap, or the pulse may 
become rapid, the temperature rise, the pupils cease to react 
to light, and hebetude with loss of consciousness occur. 
Under such circumstances immediate relief frequently follows 
lumbar puncture. An ounce or more of cerebrospinal fluid some- 
times quickly flows from the cannula and pressure symptoms 
subside. Especially in children grave intracranial symptoms 
sometimes disappear within a few hours after the evacuation 
of pus from the mastoid antrum. Lumbar puncture may be 
repeated as often as necessary to afford relief, and the cerebro- 
spinal fluid can, if clear and apparently normal, be carefully 
examined for the presence of bacteria. Sometimes a latent 
tubercular meningitis is fanned into fierce activity by the 
irritation of a simple acute otitis media. 
Subdural or Extradural Abscess.-It is an inflammation of 
the dura mater, also called external meningitis and perimen- 
ingitis. Generally it is the result of infection from caries. 
Fortunately, under such circumstances the dura generally 
forms adhesions around the carious area of bone and thus 
prevents the spread of the infection. The disease then 
becomes a subdural abscess. The infection may remain 
quiescent or the dura may be penetrated with resulting lepto- 
meningitis or inflammation of the pia and arachnoid. Here 
again adhesions may prevent the spread of the infection with a 
resulting localized meningitis, involving also perhaps a super- 
ficial portion of the brain, or sooner or later the white matter 
of the brain, and the formation of one or more abscesses. 
The usual sites of subdural abscess following aural suppura- 
tion are the groove for the lateral sinus and the superior surface 
of the petrous bone. Such collections of pus can sometimes 
be located and evacuated by surgical intervention. Cases 
of spontaneous evacuation through the middle ear have been 
reported. 
It is not very unusual during a mastoid operation to open 
such an abscess when removing carious bone with a curette. OPERATIONS UPON THE MIDDLE EAR 
497 
When the dura is thus exposed a probe should be used with 
great gentleness in order not to break up any adhesions that 
have formed between the dura and bone about the abscess- 
cavity. At the same time the amount of bone removed 
should be sufficient to permit ample drainage from the infected 
dural surface, which is usually covered by granulations and 
Fig. 218.-Left temporal bone, showing dura mater of cerebrum and cere- 
bellum, the lateral sinus, the tympanic membrane, and the interior of the mastoid 
antrum. The anterior wall of the auditory meatus has been removed: I, Dura 
mater; 2, middle meningeal artery; 3, lateral sinus; 4, mastoid emissary. (Bruhl 
and Politzer.) See Fig. 211. 
which should not be disturbed, as they prevent the spreading 
infection. 
Abscesses of the cerebrum or cerebellum following otitis are 
probably invariably located on the affected side. They may 
be single or multiple, frequently small and connected by tiny 
canals. It is the white substance that is generally involved 498 
DISEASES OF THE NOSE, THROAT, AND EAR 
and there can be a considerable thickness of sound tissue 
between the abscess and the cortex. The bacteria found in 
the pus are various, generally those found in the discharges of 
the ear that has been the cause of the infection. 
The disease is generally the result of chronic purulent otitis. 
The entire brain may be inflamed (diffuse encephalitis) or the 
inflammation may be localized about the abscess (localized en- 
cephalitis). A labile pupil and paralysis of the third nerve on 
the same side as the abscess, is of diagnostic importance. 
Symptoms.-'Cerebral abscess may present no symptoms 
for many months, but at any moment acute meningitis may 
occur or increased intracranial pressure result in coma and 
death. If the abscess is acute, absorption is sufficient to 
produce a high polynuclear count, but if long standing and 
encapsulated there may be no leukocytosis and the symptoms 
so ill defined that the abscess is only found accidentally during 
a mastoid operation as the result of a telltale fistulous opening. 
The dura when exposed should be examined for discolora- 
tions and lack of pulsation, which, however, may not be 
present if the abscess is small and deep seated. When symp- 
toms of abscess are not marked it is customary to await the 
result of a mastoid operation before exploring the brain. 
When the abscess is large, pressure symptoms appear, with, 
possibly, optic neuritis and papillary phenomena. There is 
headache, mental depression and loss of weight and vomiting 
as a late symptom. 
When the left temporal lobe is involved, either by the 
pressure or inflammation, there may be disturbances of 
speech; when motor areas are affected, muscular symptoms; 
and when the abscess is located in the cerebellum, cerebellar 
ataxia with weakness of the hand grasp and rigidity of the 
muscles of the neck. In chronic cases there may suddenly 
occur a chill followed by a septic temperature, high leukocyto- 
sis, and polymorphonuclear percentage and a cerebrospinal 
fluid free from pus. The pulse becomes slow, there is cachexia 
and increasing mental dulness, ending in coma and death. OPERATIONS UPON THE MIDDLE EAR 
499 
The symptoms of cerebellar abscess are more obscure even 
than in cerebral abscess and the diagnosis extremely difficult. 
Subjects of cerebellar abscess may present absolutely no 
symptoms, and yet suddenly die as the result of the rupture of 
the abscess into the fourth ventricle. 
Nystagmus is present in cerebellar abscess and suppuration 
of the labyrinth (p. 520). It becomes more apparent as the 
disease progresses in cerebellar abscess; weaker in progressive 
suppuration of the labyrinth. 
Treatment.-Surgical intervention in all cases of intracranial 
suppuration is the only adequate remedy. As a general rule 
the cranial cavity should only be entered after removing 
diseased structures from the middle ear. After the antrum and 
attic have been cleansed, the original skin-wound is enlarged 
to a sufficient degree by an incision directly backward toward 
the occipital protuberance if the posterior fossa is to be ex- 
plored, or directly upward from the anterior point of the mas- 
toid wound if the middle fossa of the skull is to be opened. If 
the symptoms indicate the posterior fossa as the probable seat 
of the lesion, the groove for the lateral sinus is then opened 
and the sinus examined carefully for thrombus. If it is 
normal in appearance or covered by healthy granulations, 
more dura is exposed medianly by the removal of the mastoid 
bone from "Troutman's triangle," which is a space with its 
anterior angle at the prominence containing the labyrinth, 
bounded behind by the lateral sinus and above by the linea 
temporalis. At the upper posterior angle of this triangle, 
when the bone is removed, the superior petrosal sinus (Fig. 217) 
will be encountered and should be examined carefully for 
thrombus, which sometimes occludes this vessel without 
extending into the lateral sinus. While proceeding with the 
operation it is possible that an extradural abscess may be 
opened. Under such circumstances free drainage should be 
secured and the wound dressed. If no such collection of pus 
is discovered while enlarging the cranial opening, a flexible 
grooved director should be passed in different directions 500 
DISEASES OF THE NOSE, THROAT, AND EAR 
between the dura and the skull in search of pus, and finally the 
tegmen of the antrum and attic removed, as an extradural 
abscess is not infrequently located upon this thin plate of bone. 
If an abscess of considerable size be present near the dura, 
it will bulge without pulsation into the wound. The dura 
should be incised for a distance of about i inch, and a brain 
explorer forceps with separable arms inserted carefully into 
the brain. Should pus escape or the instrument yield a fetid 
odor when withdrawn, the wound should be carefully enlarged 
sufficiently to allow the pus to escape and the abscess-cav- 
ity gently washed out with a sterilized saturated boric acid 
solution. A strip of gauze is then inserted and the wound 
dressed. It is probably safer to wash out the abscess-cavity 
each day with boric acid solution. Whiting has devised an 
instrument which he calls an encephaloscope, through which the 
interior of the abscess-cavity can be inspected, irrigated, and 
a drain inserted without bruising the normal brain tissue. 
If no pus follow the insertion of the brain explorer into the 
brain, it may be inserted at another place or in another direc- 
tion, with due regard for the anatomy of the parts. When 
searching for an abscess in the temporal lobe the explorer 
cannot be inserted for a distance over 4 cm. (r-| inches) without 
endangering the lateral ventricles. 
While most operators find the mallet and chisel and heavy 
forceps like those of Keen sufficient for removal of bone for 
the exploration of the anterior and posterior fossa, yet a tre- 
phine can sometimes be used to advantage. One of at least 
f inch should be employed. For epidural abscess the center 
pin of the trephine should be placed upon the skull 1 inch 
above the center of the meatus. The resulting opening in the 
skull, if sufficiently enlarged with the rongeur forceps, will 
enable the operator to explore the surface of the tegmen of the 
atrium and tympanum. The posterior cranial cavity may be 
explored by a trephine opening if the center pin of the instru- 
ment be placed i| inches behind the center of the meatus and 
| inch below Reid's base line. Both the middle and the OPERATIONS UPON THE MIDDLE EAR 
501 
posterior cranial cavities can be explored by means of a 
trephine opening if the center pin of the instrument be placed 
ij inches behind the center of the meatus and i| inches above 
Reid's base line. As the skull in this position is compara- 
tively thin, it is easy from such a trephine opening with the 
rongeur forceps to tear away the skull either downward into 
the posterior fossa or forward into the middle fossa. 
Purulent Leptomeningitis.-In purulent meningitis the 
exudate becomes cloudy and mucopurulent in appearance 
from the presence of leukocytes. The bacteria present vary 
and are usually those found in the otorrhea that has caused the 
condition. 
Pathology.-The vessels of the pia and arachnoid are in- 
fected and the membranes become cloudy. A serofibrinous 
or purulent exudate distends the dura or may exist only in 
patches. The cerebral membranes may be involved either as 
a whole or in part. In severe cases those of the spine are 
affected as well. The brain or cord may be softened in 
places or, as Anders states, no gross lesions, either of meninges, 
brain, or cord, even microscopic, are found postmortem in 
many cases presenting the clinical picture of meningitis. 
Symptoms.-The temperature is usually from ioi° to 1050 F., 
and exhibits but slight variation during the day and night. 
There are severe headache, photophobia, vomiting, and 
localized or general convulsions. Delirium is common in 
young subjects, but in adults the patient is at first wakeful, 
but slowly passes into a condition of fatal coma. Paralysis 
of the pupil, strabismus, and ptosis are the most frequent 
forms of paralysis present. 
There is often retraction and fixation of the head. Reflexes 
are at first increased and later diminished or absent. There is 
hyperesthesia of the skin. The pulse, at first full and rapid, 
later in the disease is slow, but becomes again rapid in the last 
stage. Koenig's and Babinski's signs are usually both present, 
and a finger drawn across the skin produces a red mark which 
persists for a time ("tache cerebrate"). The pupils finally 502 
DISEASES OF THE NOSE, THROAT, AND EAR 
become dilated. There is general paralysis and death, occur- 
ring as early as two or three days or postponed for some 
weeks. 
Diagnosis.-True leptomeningitis differs from serous menin- 
gitis with symptoms of "meningeal irritation" or meningismus 
in that it generally starts with great suddenness a considerable 
time after the onset of the aural suppuration that produced it, 
and may exist without symptoms of mastoiditis and runs its 
course with increasing rapidity of symptoms, and is somewhat 
rare in infants among whom meningeal irritation and serous 
meningitis is far more common. 
Treatment.-Where the symptoms are simply those of cere- 
bral irritation, perfect rest in bed, large doses of the bromids, 
purgation with small, frequently repeated doses of calomel, 
and salines are sometimes sufficient to check the attack. An 
ice-bag should be applied to the head. 
In some cases urotropin (Formula 93) undoubtedly does good 
and may be administered in five-grain doses every two to three 
hours by the mouth; with colonic irrigation by the Murphy 
method with warm normal salt solution. 
Where lumbar puncture gives relief, it should be repeated 
as often as necessary. The procedure is of value not only as 
a method of treatment, but as a matter of diagnosis. The 
amount of fluid flowing freely through the needle indicates the 
degree of pressure, and the microscope will disclose the presence 
of pus and the bacteria causing the infection. Great cloudi- 
ness from pus and numerous virulent bacteria indicate an 
almost inevitable fatal termination by any known treatment. 
For this reason surgical measures, to be of value, must be 
instituted before general infection of the meninges has occurred. 
A mastoid operation should be done before or at least as soon as 
intracranial symptoms appear. This may be sufficient, 
especially in children, to cause a speedy subsidence of menin- 
geal symptoms. Should this not occur, the cranial cavity 
should be opened in search of abscess or sinus phlebitis, and if 
neither are present, the dura should be incised in one or more OPERATIONS UPON THE MIDDLE EAR 
503 
places to permit leakage of cerebrospinal fluid. Opening of 
the cisterna magna through a trephine opening at the base of 
skull allows of continuous drainage of cerebrospinal fluid and 
relief of pressure symptoms. In addition, 30 to 60 gr. of 
urotropin a day may be given or the injection of antistrep- 
tococcus serum tried. 
Sinus Thrombosis.-The lateral sinus may be infected by 
way of the superior petrosal sinus as the result of attic suppura- 
tion or, especially in children, the bulb of the jugular vein may 
be infected through the floor of the tympanum. Usually, 
however, the infection proceeds from the mastoid cells by the 
numerous small veins that reach the sinus through the bone. 
An early stage of the process is the occlusion of the sinus by a 
firm fibrinous clot which may extend backward as far as the 
torcular Herophili or downward into the internal jugular vein. 
The development of septic bacteria within the clot leads to 
general septic infection; and if the patient survives long enough, 
secondary abscesses appear in various organs of the body, septic 
pneumonia being the most common complication; but it should 
not be forgotten that sinus thrombosis may produce secondary 
sinus thrombosis and brain abscess on the opposite side. 
Occasionally sinus phlebitis occurs as the result of the contact 
of necrosed bone, so that the sinus is easily torn during the 
mastoid operation, with resulting severe hemorrhage. 
The process begins as a phlebitis with swelling of the sinus 
walls sufficient to cause slowing of the blood current and the 
formation of an adherent clot which, however, never extends 
further than the inflammation of the vessel walls. At any part 
of the thickened and inflamed sinus the swelling may be so 
great as to completely obliterate its lumen, and if at an 
operation the walls of the jugular are found collapsed a clot 
may exist lower down toward the heart, but if the vessel walls 
are healthy no such clot can exist and it is useless to look for it. 
Ballenger states that, at the beginning the thrombus is not 
infected. It is only after the wall of the membranous sinus has 
undergone marked deterioration that the infective micro- 504 
DISEASES OF THE NOSE, THROAT, AND EAR 
organisms penetrate it and lodge in the thrombus. That is, 
if the condition were diagnosticated before infection, it 
would be prevented by the removal of the diseased bone 
without opening the sinus. 
Symptoms.-In typic cases the temperature abruptly rises to 
1040 or even 1060 F., and as quickly falls to normal or even 
subnormal. There may be only one rise in temperature during 
twenty-four hours, or several, depending upon the rapidity 
and quantity of toxin entering the system. In about 50 per 
cent, of cases the sudden rise in temperature is preceded by 
profuse sweating. The pulse corresponds with the tempera- 
ture and may reach 150; but where the phlebitis is complicated 
by meningitis, usually it is much slower. During the period 
of high temperature the respirations may reach 40 or 50 a 
minute, especially in children. Nausea and vomiting are 
usually present at some stage of the disease. Patients are 
frequently drowsy, but when aroused answer questions 
rationally, and usually there are no symptoms of impaired 
cerebration in the earlier stages of the disease. 
The face is anxious, the skin is dry, and in the later stages of a 
yellowish hue, denoting sepsis. There is loss of appetite,afoul 
tongue, and fetid breath. There may be edema of the mastoid 
in the region of its vein and marked stiffness of the muscles of 
the neck, the face being drawn toward the affected side. In 
the later stages the inflamed jugular may sometimes be felt as 
a cord-like swelling at the anterior border of the sternocleido- 
mastoid muscle. Optic neuritis occurs in less than one-third 
of the cases and is not followed by atrophy. 
Atypic cases are those following a mastoid operation when the 
patient does well only for a few days. The tongue becomes 
coated and there is a gradual rise in the temperature to 1030 
or even 1050 F., remaining so for several days without sudden 
elevations and depressions. There is intense headache and 
inability to sleep, and if surgical measures are not adopted, 
pyemic symptoms develop. 
On inspection, the mastoid wound will be found granulating OPERATIONS UPON THE MIDDLE EAR 
505 
normally except at a point over the sinus, where the bone will 
appear darker than when exposed during the operation. If 
the sinus was uncovered at the operation, it will be seen devoid 
of granulations, gray, and easily compressible. 
When the bulb of the jugular vein is primarily affected from 
the tympanic cavity in the early stages of acute purulent otitis, 
the symptoms are those of that disease in an aggravated form. 
There is, however, sudden rise in temperature to 1040 F. or 
above, and sudden remissions to 990 or ioo° F. In doubtful 
Posterior belly of digas- 
tric muscle 
Spinal accessory nerve 
Occipital artery 
Stylohyoid muscle 
Facial vein 
Hypoglossal nerve 
Descendens hypoglossi 
nerve 
Lingual vein 
Sternocleidomastoid mus- 
cle 
Superior thyroid vein 
Anterior belly of omo- 
hyoid muscle 
Communicantes hypo- 
glossi nerves 
Sternothyroid muscle 
Common carotid artery 
Phrenic nerve 
Sternohyoid muscle 
Middle thyroid vein 
Fig. 219.-Exposure of the internal jugular vein, etc.; the vein is about ready for 
removal (Allport). 
cases a blood-culture, showing the presence of streptococci, and 
a high or low leukocytosis and high polymorphonuclear per- 
centage, renders the diagnosis more than probable. During 
the temperature remissions the patients, who are usually young 
children, feel remarkably well and ask to sit up and play with 
their toys, so that the uninitiated may be led to think that 
there is a decided improvement in the patient's condition 
until another sudden rise in temperature dipels any doubt as to 
the nature of the infection. 506 
DISEASES OF THE NOSE, THROAT, AND EAR 
Prognosis.-A certain number of cases of primary thrombosis 
recover spontaneously, although it is impossible to state how 
many die subsequently of secondary cerebral abscess and other 
sequelae of the disease. Without operation sinus phlebitis is 
usually fatal. 
The diagnosis is usually easy in a typic case. When during 
the mastoid operation the sinus is uncovered as the result of 
the removal of carious bone, there is usually an epidural 
collection of pus. When this is removed the sinus wall may 
appear thicker than normal and darker in color. It may be 
lusterless and of a dirty white or covered with an exudate or 
granulations. The sinus may be flatter than normal and when 
pressed upon does not quickly refill as soon as the pressure is 
released. However, without the characteristic temperature 
chart, these appearances are not sufficient to warrant opening 
the sinus. 
In io cases of thrombosis in the Mt. Sinai Hospital, New 
York, cultures of blood from the median vein were positive in 
7 cases; in 5 cases streptococcus pyogenes, one case strepto- 
coccus mucosa, one case Bacillus proteus. A differential blood- 
count showing a polynuclear percentage of over 80 indicates an 
nfective process that almost certainly demands surgical in- 
tervention. The amount of leukocytosis indicates the pati- 
ent's resistance to the disease. 
Treatment.-Early operation if the diagnosis is certain. 
The only therapeutic measures of value are those which combat 
the asthenia. Nutritious food, two or three grains of quinin 
every three hours with one or two ounces of whiskey and 
colonic irrigation with normal salt solution by the drop method. 
More than one-half pint of whiskey or ten or twelve grains of 
quinin per day usually causes so much gastric irritation that 
larger doses are unadvisable. 
When the mastoid antrum has been previously opened, the 
original opening should be enlarged backward and down- 
ward, and the sinus exposed from a point above its downward 
bend or "knee" to a point as near the jugular bulb as possible, OPERATIONS UPON THE MIDDLE EAR 
507 
but too much bone should not be removed so as to uncover a 
large dural area over the cerebellum, as hernias are more liable 
to occur at this point than in other regions of the brain. The 
partial notch is over the knee of the sinus which at this point 
receives the blood from the superior petrosal sinus (Figs. 
218-220) at the most posterior lateral corner of the floor of 
the middle fossa of the skull. A line from the parietal notch 
to the tip of the mastoid will indicate the course of the sigmoid 
portion of the sinus from the knee to the jugular bulb, and a line 
from the notch to the occipital protuberance, the course of 
the sinus toward the torcular Herophili. 
After the sinus has been uncovered, a small piece of iodoform 
gauze should be rolled up and inserted between the sinus and 
the bone at the upper angle of the wound, in such a manner as 
to cut off the circulation in the vessel should it be present. A 
similar piece of gauze should also be inserted at the lower angle 
of the wound between the bone and sinus. The head of the 
operating table should be lowered, the wound filled with sterile 
water and the sinus between the pledgets of gauze laid freely 
open and the contents of the vessel evacuated. If, after re- 
moving the upper piece of gauze, blood does not freely flow 
from the distal end of the sinus, the vessel should be further 
exposed toward the torcular by the removal of the overlying 
bone and laid open to the torcular unless a free hemorrhage 
is encountered before that point has been reached, as it is 
important that the septic clot should be removed from this 
region to prevent a further spread of the infection. 
When the pledget of iodoform gauze is removed from the 
lower portion of the wound, a free hemorrhage through the 
sinus from the bulb is sometimes encountered. It is impos- 
sible to determine whether this comes from the internal jugu- 
lar or from the inferior petrosal; but it is customary under 
such circumstances, if the clot removed from the sinus was 
firm, to desist from further operative procedures, pack the 
sinus with gauze, and await developments. However, if 
instead of a firm clot the sinus contents consist of disintegrated 508 
DISEASES OF THE NOSE, THROAT, AND EAR 
Fig. 220.-Base of skull; left labyrinth exposed on the right side; the grooves 
in the base of the skull are shown; the sinuses of the dura mater are marked in 
black (two-thirds life size): I, Crista frontalis (on the left, beginning of the supe- 
rior longitudinal sinus); 2, foramen cecum (emissarium Santorini); 3, crista galli; 
4, lamina cribrosa (olfactory nerve); 5, lesser wing of sphenoid; 6, optic foramen 
(optic nerve, ophthalmic artery); 7, anterior clinoid process; 8, sella turcica, 
flanked by the median clinoid process; 9, dorsum ephippii, with posterior clinoid 
process; 10, foramen rotundum (second division of fifth nerve); 11, foramen 
ovale (third division of fifth nerve); 12, foramen spinosum (middle meningeal 
artery and. recurrent branch of fifth nerve); 13, carotid canal and foramen lace- 
rum anterius (great and lesser superficial petrosal nerves, Eustachian tube, and 
tensor tympani muscles); 14, anterosuperior surface of pyramid; 15, cochlea; 
16, semicircular canals; 17, tegmen tympani and roof of antrum laid open; 18, 
anterior. condyloid foramen (twelfth nerve); 19, posterior condyloid foramen 
(emissarium_ Santorini); 20, foramen magnum; 21, superior petrosal sinus; 22, 
transverse sinus (descending portion); 23, transverse sinus (horizontal portion); 
24, superior longitudinal sinus and torcular Herophili (confluence of the sinuses); 
25, occipital sinus; 26, occipital sinus; 27, vein of aqueduct us vestibuli (emerging 
at the external aperture of aquasductus vestibuli); 28, internal auditory vein 
emerging in the internal auditory meatus); 29, vein of aquaeductus cochleae 
(emerging at the external aperture of aquaeductus cochleae); 30, inferior petrosal 
sinus emptying into the cavernous sinus; 31, circular sinus (Ridley); 32, groove 
traversing anterior fossa of skull; 33, sinus of lesser wing of sphenoid; 34, groove 
for meningeal artery; 35, transverse groove through middle fossa of the skull; 
36, longitudinal groove through petrous portion of temporal bone (tegmen tym- 
pani); 37, groove through apex of pyramid; 38, transverse fissure (between pos- 
terior condyloid foramen and foramen magnum); 39, longitudinal groove through 
posterior fossa of skull; 40, impressio carotica (corresponding to the bend in the 
internal carotid artery); 41, juga cerebralia and impressiones digitatae (Bruhl and 
Politzer), OPERATIONS UPON THE MIDDLE EAR 
509 
clot and pus, further manipulation should be suspended until 
the internal jugular has been ligated as low down in the neck 
as possible. The line of the internal jugular vein is from the 
tip of the mastoid to the intraclavicular notch. The patient 
is placed in the tracheotomy position with a sand-pillow under 
the shoulders and the face turned toward the opposite side. 
An incision is made along the anterior border of the sterno- 
cleidomastoid muscle and the vein exposed by dry dissection. 
The wound should not be held open as in Fig. 219, because 
this procedure interferes greatly with easily finding the vein, 
which lies immediately beneath the anterior border of the 
muscle to the outer side of the carotid with the pneumogastric 
nerve behind both vessels. A double ligature is applied to the 
vein as low down as possible and the vein severed between the 
ligatures. The vein should then be resected upward to its exit 
from the skull. All diseased lymphatics encountered during 
this procedure should be removed, and tributary branches 
ligated as far away from the vein as possible. These consist 
of the middle and superior thyroid, the lingual and facial 
veins and all enter the jugular at its median border. After 
this has been done the contents of the sinus above should be 
evacuated. Under these circumstances there will be a free 
hemorrhage through the bulb from the inferior petrosal sinus. 
Should this not occur, as fortunately is rarely the case, it 
indicates that the inferior petrosal sinus is obstructed, and 
should the patient's condition permit, this sinus and the 
superior, if necessary, should be exposed and emptied of their 
contents. The wound in the neck may be treated by the 
open method, the skin subsequently being drawn together by 
adhesive strips, or a cigarette drain may be inserted and the 
skin sutured. 
Facial paralysis, or Bell's palsy, is a paralysis or paresis of 
some or all of the muscles supplied by the facial nerve. In 
the graver form of the disease there is complete immobility of 
the muscles of expression of the affected side of the face, slight 
deafness from involvement of the stapedius muscle, unilateral 510 
DISEASES OF THE NOSE, THROAT, AND EAR 
paralysis of the uvula and the palate, and unilateral impair- 
ment of the sense of taste at the anterior two-thirds of the 
tongue, through involvement of the chorda tympani nerve. 
Etiology.-The disease may be central, as the result of basilar 
meningitis, tumors or exostoses at the base of the brain, 
syphilitic lesions in this situation, or aneurysm of the vessels 
at the base of the brain. Not a few cases are apparently rheu- 
matic and result from exposing one side of the face to a draft, 
sitting in a damp room, or suddenly chilling the body when 
overheated. This disease is of interest to the aurist chiefly 
from the fact that it may occur as a complication in a large 
variety of middle-ear affections, or as a result of the nerve 
being bruised or wounded during the course of an operation 
upon the middle ear, or from packing the wound too tightly 
after the operation. It should be borne in mind that the facial 
canal arches backward over the oval window and then descends 
almost perpendicularly through the temporal bone. As the 
result of the oblique position of the drum-head the facial canal 
approaches in some skulls to within i millimeter of the annulus, 
at a position about midway between the floor and the roof of 
the canal. The pressure of a polypus or an accumulation of 
epithelium or cerumen on the nerve through the thin bone 
of this region is sufficient in some cases to produce paralysis 
of the facial nerve, usually remediable by the removal of 
the offending body. Generally, however, the facial nerve in 
its passage through the middle ear is defended by compara- 
tively thick and hard bone. In some instances, however, the 
bone covering the nerve above the oval window is as thin as 
tissue-paper, and congenital dehiscence of the bone of this 
region are by no means uncommon, so that the nerve in such 
cases lies almost immediately under the mucous membrane. 
Such a congenital lack of bone in this position explains the 
occasional occurrence of facial paralysis as the result of simple 
non-suppurative catarrh of the middle ear. Suppuration of 
the middle ear is a common cause of facial paralysis, some- 
times so slight that the lack of mobility of the affected side of OPERATIONS UPON THE MIDDLE EAR 
511 
the face can be detected only by the closest scrutiny; at other 
times the paralysis is complete and involves all the muscles 
supplied by the facial nerve on the affected side of the face. 
Such cases are doubtless the result of pressure on the nerve 
caused by spreading of the inflammation from the mucous 
membrane to the bony wall of the facial canal and the sheath 
of the nerve, and are the more favorable instances of the 
disease; for after the subsidence of the inflammation and the 
absorption of the exudation the facial paralysis disappears 
spontaneously. F acial paralysis occurs during caries and 
necrosis of the temporal bone if the inflammation and destruc- 
tion extend to the nerve; but caries of the facial canal is not 
always accompanied by paralysis, for the nerve has been 
exposed and bathed in pus for months without the occurrence 
of facial paralysis. Facial paralysis in more than one instance 
has followed the simple removal of the drum-head and larger 
ossicles, and is not uncommon as the result of the mastoid 
operation. Most of these cases ultimately completely recover, 
sometimes even when there was reason to suppose that the 
nerve had been completely severed. When working in the 
neighborhood of the facial nerve some operators direct their 
assistant to watch for slight twitching of the muscles of the 
face, and desist immediately should this occur. 
Symptoms.-Double facial paralysis is somewhat rare. 
When it does occur and is complete, the face is absolutely ex- 
pressionless and as immobile as that of a graven image. 
Facial paralysis sometimes appears quite suddenly, but in 
many instances there are premonitory symptoms of pain in 
the side of the head and twitching of the muscles of the side 
of the face. A patient suffering from complete facial paralysis 
is unable to wrinkle the brow or close the eyes, although the 
upper eyelid often descends somewhat during the effort. On 
account of the paralysis of the orbicularis the punctum lacri- 
malia drop away from the globe and the eye is constantly 
suffused with tears, and, being no longer protected from dust 
and cold by the motionless lips, soon becomes inflamed. 512 
DISEASES OF THE NOSE, THROAT, AND EAR 
The ala nasi on the affected side cannot be distended during 
inspiration, and hence nasal respiration and the sense of smell 
are impaired on the affected side. The angle of the mouth 
drops a little and is drawn somewhat toward the unaffected 
side. While drinking, some of the fluid dribbles from the cor- 
ner of the mouth, and the food collects between the cheek and 
the teeth, so that it is necessary while eating to remove it 
from time to time with the finger. If the cheeks are distended 
air escapes at the corner of the mouth, and because of the 
paralysis of the palate-muscles it is usually necessary to employ 
the Eustachian catheter if the ears require inflation. The 
hearing is usually somewhat impaired as the result of paralysis 
of the stapedius muscle, but sometimes becomes still worse, if 
care is not exercised, from Eustachian salpingitis resulting 
from the paralysis of the tubopalatine muscles. When an 
attempt is made to smile the entire lower part of the patient's 
face seems to move toward the unaffected side. If recovery 
does not occur the affected muscles sometimes undergo atrophy, 
so that the affected side of the face looks smaller than the other. 
Contractures and spasms of the affected muscles in some cases 
finally occur, the spasms being clonic in character and not 
painful. As the result of contracture the angle of the mouth is 
sometimes drawn upward and the nasolabial fold deepened 
until at the first glance it would appear as if the unaffected 
side of the face were the paralyzed one. 
In many instances the paralysis of the facial muscles is not 
complete, the muscles of the lower portion of the face being the 
ones most affected. However, the muscles of the lower 
portion of the face and those of the forehead as well may be 
almost completely paralyzed, while the eye can still be com- 
pletely shut, although with considerable effort. As this form 
of paralysis is the most ommon after middle-ear operations, 
it would appear that the fibers of the nerve supplying the 
muscles of the lower part of the face and the forehead occupied 
a more superficial position within the facial canal than those 
supplied to the orbicularis palpebrarum. OPERATIONS UPON THE MIDDLE EAR 
513 
Diagnosis.-In the variety of the disease due to a central 
lesion the paralysis usually occurs after an apoplectic seizure, 
and other muscles are generally affected besides those of the 
face. Generally in such cases the muscles of the forehead and 
the orbicularis palpebrarum are affected to a considerable less 
degree than those of the other parts of the face, and the electric 
contractility of the affected muscles is not affected in the 
slightest degree, no matter how profound the paralysis may be. 
In a certain proportion of cases the unilateral paralysis of the 
palate, impairment of the fuction of taste at the anterior 
two-thirds of the tongue, and the presence of a disease of the 
middle ear that is capable of causing a lesion of the seventh 
nerve are points that will help to clear up the diagnosis. In 
peripheral facial paralysis it is sometimes possible to determine 
with a certain amount of accuracy the portion of the seventh 
nerve in which the lesion has occurred. If the lesion is above 
the geniculate ganglion there will be paralysis of all the facial 
muscles and those of the palate and uvula, with disturbance 
of hearing, but the sense of taste will be unimpaired because the 
chorda tympani nerve enters the facial at the geniculate 
ganglion. If the lesion is between the geniculate ganglion 
and the point at which the nerve to the stapedius muscle is 
given off there will be paralysis of the facial muscles, disturb- 
ance of hearing, and impairment of the sense of taste, but the 
movements of the soft palate will remain unimpaired because 
its motor fibers are supplied from the geniculate ganglion. If 
the lesion is situated between the point where the stapedius 
nerve is given off and the point where the chorda tympani 
leaves the nerve, the former symptoms will be present, with the 
exception that there will be no disturbance of hearing; and if 
the lesion is below the point where the chorda leaves the facial 
nerve there will simply be paralysis of the muscles of one side 
of the face. In order that the above should be practical for 
purposes of diagnosis it is necessary that the lesion should be 
sufficiently great to involve all the fibers of the nerve, which, of 
course, is not always the case. 514 
DISEASES OF THE NOSE, THROAT, ANp EAR 
The prognosis depends upon the nature of the lesion produc- 
ing the facial paralysis. When a portion of the nerve has 
sloughed away as the result of caries of the temporal bone re- 
covery from facial paralysis is not to be expected, and where 
the nerve has been completely divided during a middle-ear 
operation complete recovery rarely occurs. Cases of paresis 
of the facial nerve and cases where only a part of the muscles 
of the face are involved usually result in complete recovery. 
The development of contractures and spasms is a most 
unfortunate event, as no cases where this occurs recover 
from the facial paralysis; and considerable deformity of the 
face is usually the result of the contractures and spasms. 
When the electric excitability of the nerve and muscles remains 
unchanged spontaneous recovery in from three to eight weeks 
may be expected, providing the middle-ear disease that pro- 
duced the lesion of the nerve ceases to be an active factor in 
the case. In many cases the excitability of the nerve and 
muscles to the Faradaic and galvanic currents begins to diminish 
within a few days of the onset of the paralysis, and is entirely 
lost at the end of a week or ten days; and this extinction of 
electric excitability continues until the patient begins to 
recover. Usually, in such cases, the patient is able to produce 
voluntary movements of the paralyzed muscles before the 
nerve begins to react to electric stimuli. The case should not 
be regarded as hopeless when electric excitability of the 
affected muscles is entirely lost for a short period; but such 
cases recover slowly, from six to nine months usually elapsing 
before a cure of the paralysis occurs. 
Treatment.-If diseased, the middle ear should, of course, 
receive appropriate local treatment. In rheumatic cases and 
those resulting from disease of the middle ear it is well to place 
the patient upon full doses of iodid of potassium and an 
ointment composed of equal parts of mercurial, iodin, and bella- 
donna ointments should be rubbed into the skin over the mas- 
toid and below the ear sufficiently often to keep the parts 
slightly sore to the touch. After from one to three weeks have OPERATIONS UPON THE MIDDLE EAR 
515 
elapsed and reaction has set in, it is well to begin the use of 
electricity, preferably the Faradaic current to the affected 
muscles, but in some cases better results are obtained from the 
employment of the galvanic current. A weak galvanic current 
may be sent along the affected nerve-trunk by placing a medium- 
sized electrode over each ear (the negative on the affected side), 
and passing a current between them. The Faradaic current 
may be applied to the affected muscles by placing a small 
electrode over them in turn; or the electrode may be passed 
along a line in front of the auricle in order to reach the fibers 
of the pes anserinus where they cross the side of the face. 
The current should be of sufficient strength to produce contrac- 
tions of the affected muscles, and the sittings should last not 
longer than ten minutes every day or every other day. Dur- 
ing an operation if the nerve is cut, the ends should be approx- 
imated in the hope that whey will unite. If it is impossible 
to suture, some fine fibers of catgut should be passed along 
side the nerve and the part protected from the dressing by a 
strip of rubber tissue. 
In cases where a considerable section of the facial nerve has 
been removed during a mastoid operation and in some other 
cases successful neuroplastic operations have been reported. 
The facial nerve is located at the posterior border of the 
parotid gland and dissected back to the stylomastoid foramen, 
where it is cut off as high up as possible. The cut end of the 
nerve is then implanted into the trunk of the spinal accessory, 
glossopharyngeal, or, preferably, the hypoglossal. 
DISEASES OF THE PERCEPTIVE APPARATUS 
Diagnosis Between Middle-ear Deafness and that Result- 
ing from Disease of the Internal Ear.-The diagnosis is made 
from the history of the case and by means of tuning-forks. 
It must not be supposed that tests with the tuning-fork are 
infallible, for example, in cases in which the capsular ligament 
around the stapediovestibular joint has become stiff as the 
result of disease, it is easy to understand how the stapes can 516 
DISEASES OF THE NOSE, THROAT, AND EAR 
become fixed in the oval window as the result of a blow on 
the side of the head or the concussion produced by the unex- 
pected discharge of firearms. Under such circumstances 
suspension of the function of hearing will result from increased 
intralabyrinthine pressure. The symptoms under such cir- 
cumstances would all point toward disease of the labyrinth, 
and yet the hearing may become nearly normal as the result 
of vigorous inflation of the middle ear by Politzer's method. 
It is evident that in a case of this kind there was no actual 
disease of the labyrinth. 
Anemia of the labyrinth may be part of a general anemia 
or due to some local cause affecting the blood-supply, such as 
tumors of the brain, endocarditis, osteosclerosis, or embolism 
of the auditory artery. 
Symptoms.-After profuse hemorrhage from any cause there 
is tinnitus, vertigo, and nausea as the result of anemia of the 
labyrinth. These symptoms are made worse by sitting or 
standing and are ameliorated by lying down. The same is 
true of anemia of the labyrinth from other causes than hemor- 
rhage. In anemia of the labyrinth the acuteness of hearing is 
impaired, both for aerial and bone-conduction. 
Hyperemia of the labyrinth may result from most of the 
acute infectious diseases, middle-ear inflammation, some intra- 
cranial diseases, valvular disease of the heart, the menopause, 
plethora, gout, alcoholism, quinin, amyl nitrite, salicylic acid 
compounds, calcium chlorid, the irritation resulting from long 
use of the telephone receiver, loud noises, vasomotor disturb- 
ances, etc. 
The symptoms are similar to those of anemia, except that 
they are intensified by the horizontal position. The auricle, 
auditory canal, and drum-head may visibly participate in the 
hyperemia. Occasionally individuals are encountered in whom 
a few grains of quinin or salicylate of sodium will produce 
visible hyperemia of the auricle, canal, and drum-head; also 
tinnitus, presumably from hyperemia of the labyrinth. 
The treatment is systemic. The symptoms are made worse OPERATIONS UPON THE MIDDLE EAR 
517 
by inflation and massage. Relief of tinnitus may be obtained 
from hydrobromic acid or the bromids, but comparatively 
large doses (20 to 30 gr. three times a day) are required. 
Significance of a Discharge of Blood from the Internal 
Ear.-Occurring after traumatism a discharge of blood from 
the internal ear through the tympanum and external auditory 
canal may indicate fracture of the base of the skull. Cerebro- 
spinal fluid may escape from the ear either as the result of frac- 
ture of the base of the skull or injury of the structures of the 
oval or round windows or the aquaeductus Fallopii. 
Concussion of the Labyrinth.-The symptoms are sudden 
deafness following concussion or a blow, without visible local 
injury. Tinnitus is usually present. The prognosis is 
unfavorable, but to | gr. of pilocarpin should be injected 
subcutaneously each day until symptoms of weakness of the 
patient occur or it is manifest that the treatment is unavailing. 
Hysteric deafness is a somewhat rare symptom occurring 
in hysteric women. The deafness may be complete, lasting 
for several hours or days. Treatment is the same as for other 
hysteric conditions. 
Syphilis of the Internal Ear.-Plastic exudations may occur 
within the labyrinth similar to those occurring in plastic iritis. 
The disease is ushered in by loud subjective noises, deafness 
soon following. There is usually a noticeable disturbance of 
the patient's gait and he complains of constant dizziness. The 
prognosis is not altogether unfavorable if vigorous antisyphilitic 
treatment is begun early. In congenital cases, ear symptoms 
usually occur between the ages of ten and fourteen years; in 
many instances following interstitial keratitis. A course of 
pilocarpin sometimes quickly, but often only transiently, 
benefits such cases and should not be allowed to interfere 
with antisyphilitic treatment. However, salvarsan should be 
used with caution as it is sometimes followed by Meniereform 
polyneuritis appearing some weeks after an injection at a 
time when the Wassermann reaction has become negative and 
there is every reason to attribute the disaster to the remedy. 518 
DISEASES OF THE NOSE, THROAT, AND EAR 
Metastasis may occur in parotitis or mumps to the laby- 
rinth, with an exudation of a plastic material, the symptoms 
being deafness, tinnitus, and vertigo. If the affection is 
treated early, before the organization of the plastic material, 
with hypodermic injections of pilocarpin, the prognosis is not 
altogether unfavorable. 
"Meniere's disease" is a name given to a group of symp- 
toms which may be caused by various affections of the laby- 
rinth, the acoustic nerve, or the central nervous system, usually 
apoplectiform in character. There are sudden loss of hearing, 
tinnitus, and vertigo often to such a degree that the patient is 
unable to maintain his balance and falls to the ground (see 
p. 408). 
Hemorrhage into the labyrinth may occur as the result of 
degeneration of the blood-vessels, traumatism, hyperemia, con- 
cussion from explosions, etc. 
The symptoms are sudden deafness, nausea, syncope, vertigo, 
with a tendency to fall toward the affected side and patho- 
logical nystagmus spontaneous or induced by the turning, 
caloric or galvanic tests, by which it is possible often to 
differentiate at least approximately the portion of labyrinth 
in solved. 
Prognosis.-If the hemorrhage is small it may be completely 
absorbed, with a restoration of the normal functions of the ear, 
but should the extravasation undergo fibrous degeneration the 
partial deafness will be permanent. Tinnitus, vertigo, and 
nausea, however, will disappear. 
Treatment consists in free catharsis and abolute rest in bed. 
Pilocarpin hydrochlorate may be given in ro-gr. doses once or 
even twice a day with the usual precautions for five or six days 
or longer if it produces a decided improvement in the aural 
symptoms. lodid of potassium should be given in conjunction 
with or after the use of pilocarpin, in 10- or 15-gr. doses three 
times a day, or, if there is a history of syphilis, the dose should 
be further increased. After the lapse of some months quinin 
may be given slightly above the tonic dose to increase the OPERATIONS UPON THE MIDDLE EAR 
519 
supply of blood to the labyrinth and promote absorption if 
deafness and tinnitus still persist. 
Diseases of the Static Labyrinth or Vestibular Appara- 
tus.-The faculty of equilibrium depends upon three sets of 
sensations, derived respectively from the eyes, labyrinths, and 
muscles. If one set of functions is completely destroyed, 
vertigo does not result because the remaining two are sufficient 
to maintain equilibrium. Hence the destruction of both 
vestibules with their semicircular canals does not cause dizzi- 
ness because sight and muscular sense are still sufficient to 
maintain equilibrium; but if, in addition to paralysis of the 
labyrinths, either sight or muscular sensations are destroyed, 
vertigo results. 
Infants gradually learn to maintain equilibrium by the 
correlation of these three sets of sensations; but if a child is 
born with a labyrinthine lesion, he becomes accustomed to the 
false impressions derived through it and has no vertigo. If 
an adult, accustomed all his life to normal sensations from his 
organs of equilibrium, acquires a labyrinthine disease, he will 
be subjected to conflicting sensations with resulting vertigo, 
which persists until he becomes accustomed to these conflict- 
ing sensations. If the labyrinthine disease is progressive, he 
may never become accustomed to the resulting conflicting 
sensations, and hence never entirely recover from his vertigo. 
For example, in Meniere's disease, when the entire vestibular 
apparatus of one ear is paralyzed or destroyed as the result of 
hemorrhage, the consequent vertigo remains until the patient 
becomes accustomed to the loss of sensations from the de- 
stroyed vestibule. In cases where there is a succession of 
small hemorrhages, the patient must become accustomed to 
sensations varying with each new lesion, and consequently has 
recurrent vertigo. Even when free from vertigo, such patients 
should be cautioned about ascending ladders or going on scaf- 
folding, etc.; but when there is complete destruction of the 
semicircular canals after recovery from the transient vertigo it 
has caused, this precaution is not necessary. 520 
DISEASES OF THE NOSE, THROAT, AND EAR 
Hbgge's Law.-•Cortical nuclei of each side enervate the 
adductor muscles of the corresponding eye and the abductors 
of the other eye. When such a center is stimulated, there 
is a slow movement of the eyes away from the nucleus fol- 
lowed by a quick toward it (Fig. 221). 
Ewald's Law.-Ewald, as the result of experiments upon 
the semicircular canals of pigeons, demonstrated that nystag- 
Fig. 221.-Diagram illustrating the action of Hogge's law. Stimulation of the 
lelt nuclues produces contraction of the adductor muscles of the left eye and abductor 
muscles of the right eye, and hence a slow movement to the right followed by a 
quick movement to the left. 
mus resulting from endolymph currents in a semicircular canal 
is in a direction parallel with the plane of that canal and opposite 
to the current. 
Vestibular nystagmus may be horizontal, vertical, oblique, 
or rotary. It results from stimulation of the vestibular 
apparatus and cortical nuclei. The former produces a slow 
movement and the latter a quick movement. Because the 
quick movement is more readily observed it is the one generally 
referred to as "nystagmus." Hence, "horizontal nystagmus 
to the right " means the quick movement of the eyes to the right. 
However, this quick movement ordinarily disappears under 
general anesthesia, while the slow movement does not. 
Nystagmus of vestibular origin consists of (i) a quick move- 
ment of the eyes (cortex) and a slow return movement in the OPERATIONS UPON THE MIDDLE EAR 
521 
opposite direction (vestibule). (2) It increases in length of 
excursions and rapidity when the eyes are turned voluntarily 
towardt he direction of the quick movement, and (3) it weakens 
or disappears when the eyes are turned in the direction of the 
slow movement. 
Neither nystagmus resulting from ocular lesions nor nystag- 
mus of cerebellar origin has these characteristics. Cerebellar 
nystagmus gets worse as the disease progresses; vestibular 
nystagmus decreases with time, whether the vestibular disease 
gets well or progresses to complete destruction of the labyrinth. 
Fig. 222.-Semcircle resulting from joining the indifferent ends of (a) horizontal 
and (&) vertical semicircular canals, brought into the horizontal plane by bending the 
head forward at a right angle. The arrows represent the endolymph current at the 
end of the turning to the right; the + and - signs, the direction of the consequent 
motor impulses._ In the horizontal canals the motor impulse derived from the am- 
pulla whose hair cells are bent towai d the utricle is about twice as strong as that 
derived from the other ampulla. In the vertical canals the motor impulse is twice 
as great from the ampulla whose hair cells are bent away from the utricle. 
Spontaneous vestibular nystagmus may be apparent even 
when the eyes are directed forward, or only seen when the eyes 
are turned in the direction of the nystagmus. In some cases 
of vestibular disease, nystagmus only occurs as the result of 
the application of turning, caloric, or galvanic tests, which also 
develop nystagmus in normal individuals. 
For purposes of study the semicircular canals can be divided 
into an ampulla end, containing the sensitive hair-cells, and an 
indifferent end. If, for example, the indifferent ends of the 
horizontal semicircular canals could be joined together, a 522 
DISEASES OF THE NOSE, THROAT, AND EAR 
semicircle would result with an ampulla at each end, and these 
ampullae according to Ewald's law, work together, increasing 
nystagmus. If the arrows (Fig. 222 a, lower figure) repre- 
sent the direction of the endolymph current, the resulting 
nystagmus (quick movement, upper figure) is in the opposite 
direction as the result of impulses derived from each am- 
pulla. However, in the horizontal canals the stimulation 
derived from the ampulla whose hair cells are bent toward the 
utricle is twice that of the other ampulla. Hence the con- 
venient but not strictly correct formula "Turning to the right 
determines the condition of the left vestibular apparatus; 
turning to the left that of the right vestibular apparatus." 
Functional Tests.-Turning. 
To produce nystagmus by turning, the semicircular canal to 
be tested must be in the same plane as the turning. To ex- 
amine the condition of the horizontal semicircular canals the 
patient is seated in a chair that is revolved somewhat rapidly 
ten times. Because of the inertia of the endolymph, at the 
beginning of the turning, if it be to the right, the cilia in the 
right ampulla are bent toward the utricle and away in the left 
ampulla; but at the end of the turning, because of this same 
inertia, the current of endolymph continues to flow in the 
direction of the turning, and, according to Ewald's law, there 
will be horizontal nystagmus toward the left (Fig. 222). In 
normal individuals after-turning nystagmus lasts about 24 
seconds if the eyes look straight ahead. The length of time 
after-turning nystagmus lasts is increased if one or both laby- 
rinths are inflamed. If one labyrinth is destroyed, the after- 
turning nystagmus will result only from impulses from the 
remaining normal labyrinth. Its duration will be diminished 
to a different extent according as the turning is to the right or 
left. For example if the right labyrinth is destroyed, after- 
turning nystagmus to the right is reduced to 24" -16 " - 
8"-this 8 seconds of nystagmus representing the reaction 
from the left or well ear. After-turning nystagmus to the left 
on the other hand is 24" - 8" = 16". This 16 seconds of nys- OPERATIONS UPON THE MIDDLE EAR 
523 
tagmus also representing the reaction from the left or well 
ear; because as already stated, the stimulation from an ampulla 
whose hair cells are bent toward the utricle is twice as great as 
when the cells are bent in the opposite direction. 
Caloric tests, the significance and technic of which were 
established by Barany of Vienna, depend upon the fact that if 
a normal ear is irrigated with water io° below the body tem- 
perature there will be produced rotary nystagmus toward the 
other ear. There is also produced vertigo and marked ataxia. 
If hot water is used, there is nystagmus toward the irrigated 
ear. In either instance the nystagmus is increased by the 
patients looking in the direction of the nystagmus. If the 
vestibular nerves are irritated, for example by a small circum- 
scribed abscess, there will be spontaneous nystagmus toward 
the affected side and syringing will produce a positive reaction. 
If the nerve endings are rapidly destroyed as for example 
by diffuse suppuration, there will be spontaneous nystagmus 
for a few days or weeks toward the sound side; its origin being 
the sound ear and syringing the diseased ear will yield no 
response. When such a case is of sufficiently long standing 
for the nystagmus to have disappeared, there will be neither 
spontaneous nystagmus nor response to functional tests. 
Finger test is made after syringing. After cold syringing, 
the patient falls toward the syringed ear, if standing with his 
eyes closed and misses the finger held a short distance from his 
face when asked to touch it. The examiner and patient stand 
facing each other. The patient then closes his eyes or is 
blindfolded. He extends the arm to be tested straight in 
front of him with his index-finger, palmar surface up, pointed 
toward the examiner who places his own forefinger firmly on 
it. The patient is then instructed to drop his arm into a 
hanging or vertical position and then slowly raise it so that 
his forefinger will again touch that of the examiner. 
The normal individual does this without difficulty. Cere- 
bellar abscess on the same side as the arm examined will cause 
a deviation of the arm away from the body when the arm is 524 
DISEASES OF THE NOSE, THROAT, AND EAR 
lowered and again when it is raised so that the patient misses 
the examiner's finger by a considerable distance. In other 
words, the finger when lowered and elevated describes a V 
away from the body. When the cerebellar disease is unilateral 
the pointing or finger test is normal on the unaffected side. 
If as the result of the pointing test a cerebellar abscess, 
for example, is suspected on the right side, the suspicion is 
corroborated by syringing the left ear with cold water. This 
produces a transient rotary nystagmus to the right and a 
tendency to fall toward the left. If during this period the 
Fig. 223.-Semi-schematic representation of two labyrinths showing 
relative positions of semicircular canals to each other (modified after 
Mackenzie). 
pointing test is applied, in normal individuals both hands 
will deviate toward the left, but when a right cerebellar abscess 
is present the right forefinger will still deviate toward the right 
when the pointing test is applied. 
Electric tests apply only to the auditory nerves and have no 
bearing on the labyrinth. If a patient shows no reaction to 
either the turning or caloric tests, but a normal reaction to 
electric tests, a normal vestibular nerve and a destroyed laby- 
rinth is probable. If there is no reaction to the three tests, OPERATIONS UPON THE MIDDLE EAR 
525 
disease of the nerve trunk or even the vestibular nucleus is 
present. The galvanic test is usually made by the patient 
holding one sponge in his hand while the other is applied to 
the ear to be tested. In a normal ear, nystagmus and ver- 
tigo result from the passage of 4 or 5 Kathode or anodal 
milliamperes. 
Fistula Test.-When a fistula leads into the external semi- 
circular canals if the labyrinthine contents are compressed by 
quickly squeezing a politzer bag whose nozzle is fitted tightly 
into the meatus, vertigo and rotory nystagmus toward the 
diseased ear is produced. Suction by'means of the bag causes 
vertigo and rotary nystagmus toward the sound ear. The 
nystagmus is in the opposite direction when the fistula is at 
the oval window. 
Labyrinthitis may be circumscribed or diffuse. The cir- 
cumscribed is either paralabyrinthitis, inflammation of the 
bony capsules; or perilabyrinthitis, inflammation of the peri- 
lymph; or a combination of the two. Endolabyrinthitis, or 
inflammation of the endolymph spaces never occurs independ- 
ently. Therefore the diffuse form is either a combined peri- 
and endolabyrinthitis, that is empyema; or panlabyrinthitis 
which is a combination of para-, peri- and endolabyrinthitis. 
Both the circumscribed and the diffuse forms may be either 
acute or chronic, exudative, plastic or necrotic, and the exuda- 
tion, serous or purulent. 
Pathology.-No undoubted case of primary labyrinthitis 
has been reported. The disease is either meningeal, tympanic 
or metastatic in origin. The tympanic form is by far the most 
common and may result for scarlatina, cholesleatoma, tuber- 
culosis, trauma, etc. The most common location of circum- 
scribed labyrinthitis is a semicircular canal, usually the hori- 
zontal. Circumscribed inflammation of the cochlear usually 
involves the first half of the basal whorl. Infection through 
the oval window may result in a localized inflammation of the 
cisterna perilymphatica; which may spread to other peri- 
lymphatic spaces without involving those of the endolymph. 526 
DISEASES OF THE NOSE, THROAT, AND EAR 
Diffuse labyrinthitis may be such from the beginning or a 
circumscribed inflammation may break down its barriers and 
become diffuse. In some cases a circumscribed abscess at the 
fundus of the internal auditory canal in the subarachnoid 
space is walled off by the attachment of the arachnoid sheath 
of the nerve to the dural lining of the canal which is an 
anatomical peculiarity of this region. Purulent inflammation 
in the middle ear may induce serous inflammation in the 
labyrinth or purulent inflammation in part of the labyrinth, 
may induce serous inflammation of another portion. Laby- 
rinthitis ends either in recovery with restoration of function; 
healing with permanent changes or extension to the intra- 
cranial cavity; the route of infection being the internal 
auditory canal, the aqueductus cochlea, theaqueductus vestbuli 
or along vessels of the fossa subarcuata. 
Symptoms.-Stimulation of the cochlea nerve causes 
tinnitus; destruction, deafness. Stimulation of the static 
labyrinth causes vertigo, disturbances of equilibrium, nausea, 
vomiting and a nystagmus toward the stimulated labyrinth 
(stimulated disharmony). Similar symptoms follow destruc- 
tion of the labyrinth but the nystagmus is directed to the 
sound side. (Destruction disharmony.) The vomiting differs 
from that caused by intracranial lesions; because it is never 
of the projectile type and is always accompanied by nausea. 
Even in diffuse suppuration the temperature is usually 
normal; therefor fever is usually indicative of commencing 
meningitis. At least 80 per cent, of necrotic cases are com- 
plicated by facial paralysis. The tendency to fall is in the 
direction of the slow component of the nystagmus. If a 
nystagmus to the right exists, the body will tend to fall to 
the left. If the face is turned to the right shoulder the body 
will tend to fall forward; toward the left shoulder, backward. 
This is not the case when the disturbances of equilibrium are 
not of vestibular origin. 
Circumscribed Labyrinthitis causes symptoms of stimulated 
disharmony of sudden onset and often transient duration, OPERATIONS UPON THE MIDDLE EAR 
527 
brought on by stooping, straining or moving the head rapidly. 
There may be spontaneous nystagmus. Rotation shows both 
labyrinths functionating normal and the caloric and fistula 
tests are positive. 
Diffuse Serous Labyrinthitis may occur after a radical 
mastoid operation, removal of polypi or even spontaneously 
as the result of circumscribed disease. After operation it 
occurs in from one to three days. Destructive disharmony 
resulting from mechanical injury of the labyrinth occurs at 
once. There is great diminution in hearing and a disposition 
to lie on the sound side so that the eyes may be directed toward 
the slow component of the nystagmus when these Symptoms 
last for one or two weeks as they sometimes do; there usually 
results some permanent loss of function. However even at 
the height of the attack there is usually reaction to either the 
turning, caloric or fistula test or perhaps to all of these tests, 
and so long as some function remains, infection of the intra- 
cranial contents rarely or never occurs. Moreover in cases 
that go on to suppuration; when all function has been destroyed 
there is an interval of some hours or days before the infection 
extends to the meninges as it usually does. 
Diffuse Suppurative Labyrinthitis is either manifest or latent. 
In contradistinction to diffuse serous labyrinthitis the symptoms 
are most violent. There is sudden complete deafness; per- 
sistent nausea and vomiting; rotatory nystagmus to the sound 
side and disturbances of equilibrium to the extent that the 
patient is unable to walk without assistance and lies in bed 
upon the side of his sound ear. The difuse latent form is as 
dangerous as it is insidious. There is frequently neither his- 
tory or symptoms except there is complete deafness and the 
caloric and fistula tests are negative. If the disease has 
lasted so long that the intralabyrinthine spaces are filled with 
a new bone formation, the after-turning nystagmus of the 
sound side equals that of the diseased side but both are shorter 
than normal. The same anomalous reaction occurs after 
sequestration in necrosis. Except in these cases, when latent 528 
DISEASES OF THE NOSE, THROAT, AND EAR 
suppurative labyrinthitis exists, polyp extraction or even a 
radical mastoid must be looked upon as an incomplete operation 
and exceedingly dangerous; because of the frequency of intra- 
cranial extension of the labyrinthine infection. 
Differential Diagnosis.-Labyrinthine inflammation must 
be differentiated from hysteria, affections of the auditory 
nerve, meningitis and abscess or tumor of the cerebellum. In 
hysteria the middle ear may show no pathological changes. 
If nystagmus is present it is not of the vestibular type; nor 
are the disturbances of equilibrium of that type, that is the 
body will have a tendency to fall backward or forward or to 
the side according to no definite rule and not always toward 
the direction of the slow component of the nystagmus. Deafness 
may be simulated but the static labyrinth will react to the 
functional tests. The diagnosis between affections of the 
auditory nerve and labyrinth are made by the caloric and 
galvanic tests. The caloric test determines the comparative 
susceptibility of the two labyrinths; the galvanic of the two 
auditory nerves. If nystagmus toward the side of the de- 
stroyed labyrinth develops after a labyrinthine operation, it 
indicates either disease of the other labyrinth, meningitis or 
cerebellar abscess. If functional tests exclude disease of the 
unoperated labyrinth, in the presence of intracranial symp- 
toms, exploration of the posterior fossa and perhaps cerebellum 
is justifiable. When a labyrinth has been destroyed by disease 
and not operated on, the diagnosis from meningitis or cere- 
bellar abscess is never easy. However there is temperature, 
and pressure symptoms and turbid cerebrospinal fluid 
obtained by lumbar puncture. In cerebellar abscess, tumor or 
localized meningitis there is spontaneous nystagmus toward 
the diseased side. Therefore if there be spontaneous nystag- 
mus for a time toward the well side succeeded by nystagmus 
toward the diseased side, cerebellar abscess is probable. 
Nystagmus in a normal ear suggests cerebellar tumor; with 
suppuration of the middle ear, deafness and no response to 
the caloric test, cerebellar abscess is probable. The disturb- OPERATIONS UPON THE MIDDLE EAR 
529 
ance of balance do not diminish in cerebellar abscess as in 
labyrinthitis. 
Treatment.-Most cases of labyrinthitis recover without 
operative treatment; some with complete or partial restorative 
of function. The fatal cases are usually of the diffuse purulent 
type; but even such cases heal spontaneously. This is 
especially true of cases complicating scarlet fever. More 
frequent than spontaneous healing is a subsidence into a 
latent chronic stage which may last for years and finally 
produce serious intracranial complications, especially if a middle- 
ear operation be done. No case of circumscribed labyrinthitis 
should be operated on unless a complete operation be done 
because the breaking down of the barriers that nature has 
erected to the spread of the disease is extremely dangerous 
without the adequate drainage of a complete operation. A 
radical mastoid should not be done where diffuse, purulent 
labyrinthitis is present, but many chronic and subacute cases 
admit of an interval of some days between the radical mastoid 
operation and exenteration of the labyrinth. Alexander 
believes that no extensive operation should be done on the 
labyrinth without exposing the dura and exploring the region 
of the sacculus endolymphaticus as extradural abscess is 
common in this locality, when circumscribed labyrinthitis 
occurs in chronic suppuration, cholesteatoma is usually 
present and a radical mastoid is therefore necessary. If 
during the operation the fistula, usually at the eminence of the 
external semicircular canal is discovered, it should neither 
be probed nor curetted, but the patient should be carefully 
watched for the occurrence of either diffuse serous or purulent 
labyrinthitis which usually occurs if at all, on the second 
or third day after the operation. If there is complete loss of 
hearing and negative functional tests with some elevation of 
of temperature, the labyrinth should be exenterated in the hope 
of preventing the spread of the infection to the cranial cavity. 
On the other hand cases of diffuse serous labyrinthitis usually 
subsides in a week or two and it is not necessary to operate. 530 
DISEASES OF THE NOSE, THROAT, AND EAR 
The occurrence of facial paralysis in chronic suppuration 
when the functional tests are negative is positive proof of a latent 
labyrinthitis. 
Non-operative treatment of labyrinthitis consists simply of 
rest in bed, the patient determining for himself the position 
best suited for diminishing vertigo and nystagmus. He should 
remain in bed as long as vertigo exists; from a few days to 
several weeks. Bromides, io grains three or four times a 
day, lessen the nervous irritation and galvanism sometimes 
relieves the vertigo. An electrode is placed in front of each 
ear, the anode on the side toward which the nystagmus is 
directed. 
Labyrinthine operations consist of labyrinthotomy or open- 
ing the labyrinthine spaces, and labyrinthectomy or removal 
of the labyrinth as far as practical. In the first group belong 
the operations of Hinsberg, Richards and Bouquets; to the 
second those of Jansen and Neumann. The simple enlarge- 
ment of a fistula is of no value for draining an infected laby- 
rinth and a wide opening of the vestibule and basal whorl of the 
cochlea is necessary. When there is involvement of the bony 
capsule a labyrinthectomy should be done. In sequestration 
of a portion of the labyrinth, the sequestrium is removed 
and the rest of the labyrinth left intact in order not to destroy 
protective granulations. 
Hinsberg's Operations.-The oval window is enlarged at the 
expense of its lower margin after removal of the stapes if 
present; the chisel being directed toward the round window so 
that the bridge of bone between the oval and round windows 
is removed. He sometimes also removes the promontory 
exposing the basal whorl of the cochlea. 
Neumann's operation is done after a complete radical mas- 
toid. The inner table over the lateral sinus is removed with a 
large gouge and also the intervening bone over the dura 
forward to the labyrinthine capsule either with chisel or ron- 
geur. The dura is now carefully separated from the posterior 
surface of the pyramid which is somewhat difficult because of OPERATIONS UPON THE MIDDLE EAR 
531 
the depressions into which processes of dura extend. The 
posterior surface of the pyramid is removed layer by layer 
with a gouge. A derivation of the chiseling upward endangers 
the superior petrosal sinus; downward, the jugular bulb and 
outward the facial nerve. The chiseling is continued forward 
until the pyramid of bone containing the semicircular canals is 
removed and the 7th and 8th nerves are exposed in the internal 
auditory canal. As the chiseling proceeds there appears at the 
level of the round window the convexity of the posterior 
semicircular canal. There next appears the lower limb of the 
posterior semicircular canal on a level with the round window 
and the common limb of the posterior and superior canals on a 
level' with the lower margin of the oval window. A third 
opening soon appears between the other two, the posterior 
limb of the external canal. A probe passed either through the 
common limb or the external canal enters the vestibule 
readily. The external canal is uncapped by the chisel until 
the vestibule is opened. Jansen advises that the operation 
cease at this stage but Newmann continues the chiseling of 
the posterior surface of the petrous pyramid until the posterior 
wall of the internal meatus is removed. If the dura is acci- 
dentally torn the opening is enlarged to | inch as only small 
tears are dangerous. Starting at the oval window and 
directing the stroke of the chisel downward and forward, 
the lower half of the basal whirl of the cochlea is opened and 
when the cochlea is a mass of sequestra pus and granulations, it 
is scraped out with a curette. 
After-treatment is the same as after a radical mastoid opera- 
tion. The bone cavity fills with granulations and becomes 
covered by epidermis. FORMULAS 
AQUEOUS DETERGENTS, SPRAYS, AND WASHES USED TO 
CLEANSE MUCOUS MEMBRANES 
Dobell's Solution 
i. 1$. Sodii bicarbonatis, 
Sodii biboratis, aa 3 j; 
Acidi carbolici, gr. xlviij; 
Glycerini, 3iii|; 
Aquas, Oij.-M. 
The above is stated to be Dr. Horace Dobell's original formula. Diluted 
with an equal amount of water. It may be used either as a spray to cleanse 
the mucous membrane of the nose, throat, and larynx, or may be pre- 
scribed as a wash for the patient's use at home. The temperature of a 
spray is not materially altered by that of the fluid in the atomizer-bottle, 
but when used as a nose-wash with a syringe or douche or by "sniffing up 
the nose," the solution should be warmed to about no° to 1300 F. Higher 
temperatures are sometimes of advantage in acute inflammation. 
2. I|. Sodii bicarbonatis, 
Sodii biboratis, aa 3j; 
Sodii salicylatis, gr. iij; 
Menthol, 
Thymol, aa gr. j; 
Glycerini, f§j; 
Aquae torridi, . f§iv.-M. 
Sig.-Add enough water to make 1 quart and use with an atomizer or as 
a nose-wash. 
This formula yields a wash nearly as unirritating as Dobell's solution, 
and it has not the objectionable odor of carbolic acid. The concentrated 
wash is sufficiently antiseptic to preserve small anatomic specimens 
indefinitely, and the diluted wash will preserve them for a considerable 
time. The solid ingredients of the wash may be compressed into a tablet 
of such size that one added to 4 tablespoonfuls of water will make a wash 
of the requisite concentration. Under such circumstances borax should be 
substituted for the glycerin of the formula in sufficient quantity to yield a 
wash of a specific gravity of 1020, because a wash of greater or less specific 
gravity than 1020 is irritating to the nasal mucous membrane. 
Both Dobell's solution and the formula above, should be compounded at 
least three or four days before being used. During this time carbonic acid 
gas escapes, and glyceroles and other compounds are formed that render 
the solutions much more bland and unirritating to the nasal mucous mem- 
brane. Of the two, Dobell's solution, probably because of the sedative 
533 534 
DISEASES OF THE NOSE, THROAT, AND EAR 
qualities of dilute solutions of carbolic acid, is less irritating, but has the 
disadvantage of the smell and taste of carbolic acid, which is very objec- 
tionable to some patients, especially ladies. The following is a good deter- 
gent wash: 
3. I). Liquor antiseptici alkalinis (N. F.), f§iv. 
Sig.-Dilute with 7 parts of water and use as a spray for cleansing the 
nose. 
4. 1$. Liquor antiseptici, fgiv. 
Sig.-Dilute with 7 parts of water and use with an atomizer or nasal 
syringe. 
This preparation has an acid reaction and is somewhat irritating to nasal 
mucous membranes, but for this very reason is sometimes prescribed in 
atrophic rhinitis. 
5. I). Potassii chloridi, 0.2 gm. or gr. iij; 
Sidii bicarbonatis, 0.2 gm. or gr. iij; 
Sodii chloridi, 9 gm. or gr. cxl; 
Aquae, q. s. ad. liter j or f§xxxiii|.-M. 
(Ringer.) 
Sig.-Normal salt solution for intravenous injection, hypodermoclysis, 
etc. 
Normal salt solution is used as a detergent wash. For this purpose it is 
probably less effectual than Dobell's solution and other bland alkaline 
washes. In surgery it is sometimes used for irrigation, instead of sterile 
water. In threatened collapse from hemorrhage or other causes 1 or 2 
pints may be injected into the median cephalic vein, or fluid may be added 
to the general circulation by rectal injection (enteroclysis), or by subcu- 
taneous injection into the cellular tissue of the thigh, abdomen, or buttocks 
(hypodermoclysis). 
6. I). Sodii bicarbonatis, § ss; 
Aquae destillatae, f Biij.-M. 
Sig.-Saturated solution of sodium bicarbonate. Use clear fluid above 
the undissolved bicarbonate as a detergent. 
7. 1$. Acidi borici (crystals), gij-iv; 
Aquae fervidi, fgiv.-M. 
Sig.-Place the boric acid in a wide-mouthed bottle and add the warm 
water. Syringe the ear with this saturated solution and add hot water as 
required from time to time to secure a saturated solution of suitable tem- 
perature for syringing the ear. As the boric acid crystals dissolve, add 
more, so that a portion always remains undissolved. 
Useful in the "cleansing treatment" of chronic otorrhea. However, in 
most cases with extensive destruction of the drum-head, better results 
are secured by home syringing with corrosive sublimate (1:5000 to 
1:10,000). 
8. I|. Hydrargyri bichloridi, gr. viiss; 
Aquae destillatae, Oj.-M. 
Sig.-Bichlorid of mercury solution (1:1000). FORMULAS 
535 
Bichlorid of mercury solutions should rarely, if ever, be used in the nose, 
or accessory cavities as they are extremely irritating even when very dilute. 
Because under ether an unknown quantity may pass through the Eus- 
tachian tube and be swallowed, it is better to irrigate mastoid wounds with 
sterile water or normal salt solution. When the operation is completed, 
only enough bichlorid solution to blanch the tissues and prevent capillary 
oozing may be used with safety. Periostitis and inflammation of the cel- 
lular tissue, after mastoid and other operations, is probably best treated 
by saturating the dressings with bichlorid solution. For this purpose 
i: 3000 or 1: 5000 solutions are strong enough, as some skins are so sensitive 
as to blister if a more concentrated solution is used. If deemed necessary 
the attic may be syringed with an intratympanic syringe with 1:1000 
bichlorid without any decided reaction occurring, but for the patient's 
home syringing, in the so-called " cleansing treatment" of chronic otorrhea, 
stronger solutions than 1:5000 or 1:10,000 should not be. employed. 
According to McClintock mercuric iodid and bicarbonate of sodium yield a 
solution of greater germicidal power, and at the same time less irritating to 
the tissues than bichlorid of mercury. The author has used the following 
1:5000 solution for syringing the attic: 
9. I}. Hydrargyri biniodidi, gr. viiss; 
Sodii bicarbonatis, 5 vss; 
Aquas, q. s. ad. Oj.-M. 
Sig.-Diluted with 5 to 10 parts of water for syringing the attic. 
10. Hydrogen dioxidi. 
Commercial hydrogen peroxid is sold usually as a 3 per cent., equal to 
a 15 volume, solution of the gas. Its strength can readily be increased by 
evaporating the solution in a shallow vessel at a temperature considerably 
below the boiling-point, as under such circumstances the evaporation is 
much more rapid than the decomposition of the solution, and a strength of 
100 volumes or even more is readily obtained. The stronger solutions are 
caustics, quickly destroying living tissue. The ordinary 15-volume solu- 
tion is very irritating to the mucous membrane of the nose and pharynx 
and, therefore, it should not be prescribed indiscriminately in catarrhal 
affections. 
Its chief use in rhinology and otology is for the removal of pseudomem- 
branes, the cleansing of pus-cavities, and as a hemostatic, but when used 
for any of these purposes its irritating qualities should be borne in mind. 
When brought into contact with organic substances hydrogen peroxid 
is decomposed with the liberation of nascent oxygen, which unites with the 
organic substance, often greatly increasing its bulk. When applied to a 
pseudomembrane in the pharynx the membrane is not only softened and 
decomposed, but its increase in bulk greatly facilitates its removal. For 
the removal of pseudomembranes the peroxid is best applied by means of a 
swab, made by wrapping cotton about the end of an applicator. In this 
manner the peroxid may be not only rubbed into the pseudomembrane, 
but the rubbing assists in detaching it from the mucous membrane. Of 
course the "rubbing" should be done with judgment and gentleness, and 
it is rarely necessary to use a solution stronger than 3 per cent. The action 
of the swab may be assisted, if necessary, by spraying the membrane, if 
desirable, by means of an atomizer. 
For cleansing the middle ear, the antra of Highmore, or other cavities of 
pus, 3 per cent, peroxid, diluted with 1 or 2 parts of water, is generally 536 
DISEASES OF THE NOSE, THROAT, AND EAR 
sufficiently strong. Care should be used in injecting peroxid into a cavity 
that there is an opening sufficiently large to permit the easy escape of the 
gases generated by the decomposition of the peroxid. Should this not be 
the case, the pressure generated may be sufficient to cause great pain and, 
in the case of the middle ear, syncope and vertigo. In fact, it is injudicious 
to inject peroxid through a small opening in the drum-head or a narrow 
sinus leading upward into the attic and mastoid antrum. It is stated that 
in the attic peroxid is capable of doing more harm than good by carrying 
pus into localities previously unaffected during its ebullition and thus 
spreading the infection. In the antra of Highmore peroxid is valuable 
for loosening and disintegrating masses of adherent mucopus, and it is 
judicious to use at least one syringeful of diluted peroxid when cleansing 
that cavity. 
As a hemostatic peroxid acts by causing an immediate clotting of the 
blood with which it is brought into contact, and the clot formed under such 
circumstances.is very bulky and firm. When pledgets of cotton soaked 
in peroxid are inserted into a bleeding nostril the blood coming into contact 
with the peroxid is immediately clotted, and until the peroxid is exhausted 
the more bleeding the more clotting, and consequently the more pressure 
upon the bleeding vessel. Remedies like adrenalin, that cause contraction 
of the blood-vessels, are generally of little use for controlling nasal hemor- 
rhage, because the flow of blood prevents them from coming into contact 
with the nasal mucous membrane and producing any effects. 
LOCAL ANESTHETICS 
ii. Cocain. 
When it is desired to produce local anesthesia of any portion of the inte- 
rior of the nose for the purpose of operation, a cotton pledget saturated 
with a i: 2000 adrenalin solution should be applied to the parts for ten 
minutes, and then, by means of a cotton-tipped applicator, a saturated 
solution of cocain should be well rubbed into the mucous membrane with 
especial reference to the line of incision. 
Anesthesia of the larynx is produced by covering with a fine spray 
of a 10 per cent, cocain solution the laryngeal mucous membrane, and 
repeating the procedure after an interval of two or three minutes. The 
sensibility of the larynx should then be tested with a cotton-tipped appli- 
cator dipped in a 10 per cent, solution of cocain from time to time, until 
the applicator can be moved about freely in the larynx without producing 
a reflex spasm, as there is little use in beginning an operation on the larynx 
when every touch of an instrument is followed by spasm or retching and 
gagging. Anesthesia of the larynx, produced by the application of a 
solution of cocain, appears quickly after the application and lasts only a 
short time. Apparently cocain can be used more freely in the larynx than 
in either the nose or ear without danger of poisonous effects. 
Watery solutions are not absorbed with sufficient facility by the skin to 
render their use inside the auditory canal at all satisfactory for producing 
local anesthesia. Diminished sensibility of the drum-head and of the wall 
of the canal may, however, be secured by a 10 per cent, ointment of cocain 
in lanolin, and this ointment is probably better than preparations of mor- 
phin, atropin, etc., for the relief of the pain of otalgia. When prescribed 
for this purpose it is simply inserted within the meatus, due care being FORMULAS 
537 
exercised when the drum-head is absent not to use a sufficient quantity to 
produce a poisonous effect. When the drum-head is present the ointment 
will remain for days in contact with it and be slowly absorbed. Its seda- 
tive effects are, under such circumstances, followed by no reaction. 
For the production of local anesthesia for the removal of aural polypi 
a pledget of cotton saturated with a 4 per cent, solution may be allowed to 
remain for five minutes in contact with the parts. This method, however, 
is not adequate for the production of local anesthesia in removal of the 
ossicles or, in fact, any of the more painful and tedious intratympanic op- 
erations, which ordinarily necessitate the almost complete local anesthesia 
resulting from the subcutaneous injection of equal amounts of a 1 per cent, 
solution of cocain and a 1:1000 solution of adrenalin in several places be- 
neath the skin of the canal at the junction of the bony and cartilaginous 
portions. An ordinary hypodermic syringe with a small needle connected 
by a bayonet-shaped metal tube 3 inches long is convenient for these injec- 
tions as well as injecting the tonsils, 10 or even 20 minims may be required 
to produce complete anesthesia of the middle ear. 
For local anesthesia of the tonsils the same syringe answers every pur- 
pose. Moss, quoted by Ballenger, recommends a 4 per cent, solution of 
cocain diluted with an equal amount of a 1:2000 solution of adrenalin, 1 
drop should be injected into the anterior and posterior pillars in the middle, 
above and below and into the supratonsillar space, with perhaps a drop or 
so in the tonsil itself; practically 10 drops for each tonsil. After the 
removal of one tonsil, inject the second in the same manner as the first. 
This equals about | gr. of cocain for both tonsils. 
Yankauer advocates injecting a few drops of a 1 per cent, solution of 
cocain into the neighborhood of the accessory palatine foramina, by which 
means the entire region supplied by the middle and posterior palatine 
nerves, including the tonsil, is anesthetized. The point of the needle is 
inserted obliquely through the mucous membrane to the bone at a point 
1 cm. above and 1 mm. posterior to the posterior edge of the gum of the 
third molar, or should this tooth be absent, 1 cm. obliquely upward and 
forward from the tip of the hamular process. 
For the relief of earache and the production of sufficient local anesthesia 
for a paracentesis or the removal of an aural polypus Ballance advocates 
instilling into the ear a drop of the fluid resulting from the mixture of equal 
parts of carbolic acid, menthol, and cocain crystals. The resulting fluid 
is not caustic, as might be inferred from its composition, but the degree and 
duration of the anesthesia resulting from its instillation into the ear is 
inferior to that produced by Ballin's subcutaneous injections of cocain and 
adrenalin, and for the cocain in the formula may be substituted camphor 
with apparently equally good results as far as aleviating otalgia is con- 
cerned. Smilie states that corypfin is superior to the menthol-phenol- 
cocain formula for the relief of pain. 
Eucain, alypin, stovain, and several other substances have been offered 
as substitutes for cocain, the claim being that they possess anesthetic 
qualities similar to those of cocian and are less liable to produce toxic 
effects. 
In cases that are known to be sensitive to the toxic effects of cocain it 
would be well to employ one of these substances. The fact that neither 
alypin or stovain contract the tissues render them valuable anesthetics 
in operations upon posterior nasal hypertrophies. 
Hypodermic tablets can be obtained from manufactures containing 
suitable amounts of synthetical cocain and adrenalin to make solutions 538 
DISEASES OF THE NOSE, THROAT, AND EAR 
for either surface applications or hypodermic injections. These syn- 
thetical products are said to be less toxic than cocain and adrenalin and 
equally satisfactory for producing local anesthesia. 
The symptoms of cocain poisoning are rapid and shallow respiration, 
feeble or absent pulse, mental anxiety, restlessness and finally unconscious- 
ness. Death may occur from asphyxia after feeble respirations of the 
Cheyne-Stokes type. According to Engstad the inhalation of ether by 
the drop method up to mild anesthesia is the most prompt and effective 
antidote. Ether at first stimulates the vasomotor system, is a tonic to 
the heart muscle and increases the pulmonary circulation. 
ASTRINGENTS 
Astringent sprays for the nose, pharynx, and larynx of zinc and copper 
sulphate, alum and zinc sulphocarbonate may be used of a strength of 5 to 
10 gr. perchlorid of iron, nitrate of silver, and tannin in the strength of 3 to 
5 gr. per ounce to decrease congestion and lessen secretions. Usually zinc 
sulphate yields the best results. Alum has been a favorite for a long time, 
but its use as an astringent spray for the larynx has been superseded to a 
considerable extent by alumnol, which is less irritating and can be used in 
strengths of 10 to 20 gr. to the ounce. Astringent sprays are not fre- 
quently employed in the nose and should be used after cleansing the nasal 
mucous membrane with a detergent. The astringent is best dissolved in 
oil or, better still, used as an ointment by the patient, who should throw 
his head well back and retain it in that position until by gentle sniffing the 
ointment melts its way through the nasal passages and is hawked into the 
mouth and expectorated. If preferred, the astringent may be incorporated 
with cocoa-butter and employed as a nasal suppository. 
12. I|. Zinci sulphatis, gr. x-xx; 
Glycerini, f 3 ij; 
Aquae, q. s. ad. f 3 j.-M. 
Useful as an application by means of a brush or a dossil of absorbent 
cotton to the pharynx and larynx in subacute and chronic laryngitis, and 
to the nasopharynx in subacute nasopharyngeal catarrh. 
13. I|. Tincturae ferri chloridi, 
Glycerini, aa fgss.-M. 
Useful as an application to erosions over varicose vessels in chronic nose- 
bleed. 
14. 1$. Acidi gallici, gr. v-x; 
Petrolati, 3j.-M. 
Sig.-For patient's use in recurrent nasal hemorrhage and in the chronic 
rhinitis of children. A piece the size of a pea should be inserted in each 
nostril night and morning. 
15. I). Pil. atropiae sulphatis, gr. 
Sig.-One every three or four hours. 
Useful in controlling excessive nasal secretion in coryza, hay-fever, and 
nasal hydrorrhea. FORMULAS 
539 
i6. Alcohol, 95 per cent. 
Useful as an application to the tympanic mucous membrane when it is 
covered by granulations and small polypi. For the patient's use at home, 
to cause shrinking of granulations and polypi, alcohol, diluted with an 
equal amount of water, may be prescribed, to be dropped into the auditory 
canal several times a day. Should this cause only momentary smarting, 
the patient should on the next occasion use alcohol 2 parts diluted with 
water 1 part, and so on until undiluted 95 per cent, alcohol is dropped into 
the ear four or five times a day. Practically the ear will then contain 
alcohol all the time. It acts as a dehydrating agent on polypi and exuber- 
ant granulations, destroying their vitality and promoting cicatrization. 
Its value as an antiseptic also plays its part in bringing about a good result. 
Boric acid dissolved in the alcohol is sometimes prescribed for the patient's 
use, but, as under such circumstances when the alcohol evaporates the boric 
acid is deposited as sharp-pointed crystals on the mucous membrane, it is 
probable that the boric acid is a source of irritation. The same may be 
said to a less degree of the addition to the alcohol of other dehydrating 
agents like glycerin and sulphuric ether. In order to secure the best 
results from instillations of alcohol the patient should lie down with the 
affected ear uppermost and then straighten the canal by pulling the auricle 
upward, outward, and backward. The canal should then be filled with 
alcohol, which should be forced into the tympanum by manipulating the 
tragus. This procedure also serves to float outward particles of pus and 
other materials. Polypi of considerable size may be destroyed by this 
method, but it is somewhat tedious if the polypi are large, and hence such 
growths should be removed by snare or forceps. Alcohol is also a valuable 
antiseptic and astringent in the treatment of inflammation of the accessory 
sinuses, pharynx and larynx. In the accessory sinuses it is used in the 
same manner and with the same precautions as in the middle ear. 
17. Liq. argenti nitratis, 2 to 20 per cent. 
Silver nitrate (10 per cent.) is useful as an application to the pharynx or 
tonsils in acute pharyngitis or tonsillitis. When applied sufficiently early 
it will often abort the disease if used two or three times a day. When 
painted upon the lateral walls of the pharynx it produces at once a feeling 
of relief and comfort which persists for some time; when painted upon the 
posterior wall of the pharynx, a sensation of dryness and great discomfort. 
Hence it should not be used in this portion of the pharynx except for touch- 
ing small areas of granulation tissue, etc. However, 2 per cent, solutions 
are permissible. 
Solutions of silver nitrate (20 per cent.) also may be used as an astringent 
application to small polypi and exuberant granulation tissue in the tym- 
panum. However, for this purpose it is far inferior to strong alcohol. 
Even the solid stick of silver nitrate when applied to granulations in the 
ear produces only a superficial destruction of tissue, and in this respect is 
far inferior to chromic or trichloracetic acids. 
18. Protargol. 
19. Argyrol. 
The above are two of the best of the organic compounds of silver. Of 
the two, argyrol is probalby the more valuable in controlling inflammations 
of mucous membranes. Protargol may be used as a spray to the pharynx 540 
DISEASES OF THE NOSE, THROAT, AND EAR 
or larynx in 10 per cent, solutions and argyrol in 20 per cent, solutions. 
Neither stain the skin, but each produce ugly stains of linen, that of argyrol 
being easily removed by soaking in bichlorid solution. They stop up 
atomizer tubes somewhat quickly, and hence are not well adapted for 
patients' use at home. Protargol and argyrol, when applied to mucous 
membranes, are somewhat astringent antiseptics, are nearly devoid of the 
irritating effects of silver nitrate, and penetrate the tissues more deeply. 
Argyrol in 5 per cent, solution is especially serviceable in the recurrent 
attacks of otorrhea where the drum-head has been destroyed. If applied 
at an early stage of the. attack a single application by means of a cotton- 
tipped probe will sometimes abort the disease. If more than one applica- 
tion is. required, it should be repeated every day. It is valuable as a non- 
irritating antiseptic injection by means of Blake's cannula into the attic 
of the tympanum in attic otorrhea, often bringing about a cessatiomof the 
discharge. 
20. Tr. benzoini comp. 
Formerly, the compound tincture of benzoin was somewhat popular as 
an application to the nasal mucous membranes, either full strength or 
diluted with an equal amount of glycerin as a mild antiseptic astringent 
and deodorizer. Gauze moistened with the tincture will remain for sev- 
eral days within the nose without becoming fetid. The odor of a foul- 
smelling otorrhea can be corrected by mopping the canal and middle ear 
dry and applying compound tincture of benzoin every two or three days. 
ALTERATIVES 
21. I). Hydrargyri bichloridi, gr. j; 
Potassii iodidi, 3 ij; 
Aquas, fgiij.-M. 
Sig.-i to 3 teaspoonfuls after meals. 
This formula, sometimes called " i, .2, 3 mixture," may be ordered when 
it is desired to employ the mixed treatment in syphilis. 
"lodid of potassium and sodium are very diffusible and are rapidly ex- 
creted, setting free nascent oxygen and iodin at the points of elimination. 
They are remotely irritant to the mucous membrane. They induce great 
waste and rapid elimination of waste products, causing anemia, emacia- 
tion, and depression. Mercury salts in small doses are blood tonics, 
improving the. general condition, increasing the number of red corpuscles 
and body weight. They soon, however, begin to promote waste by 
stimulating the lymphatic system." (Wilson.) 
22. 3. Tablet triturat. hydrarg. protiodidi, gr. 
Sig.-1 tablet may be taken three or four times a day or even oftener, 
with a sufficient quantity of opium, if necessary, to prevent diarrhea. 
Useful in the treatment of primary and secondary syphilis. 
23. Salvarsan is a name given by its discoverer Ehrlich to an arsenical 
compound, probably the most active and speedy antisyphilitic known. In 
some primary cases a single injection has apparently brought about a cure. 
During the secondary and tertiary periods relapses are the rule and 
injections should be repeated as required. In some tertiary cases the FORMULAS 
541 
results are inferior to those obtained by mercury and iodid of potassium; 
but in most instances a single injection has aproximately the same result 
as four or five months treatment by other methods. As salvarsan is highly 
poisonous the technique should be thoroughly mastered before attempting 
to use it. 
24. 1$. Bichlorid of mercury, gr. viij; 
Phenol (carbolic acid), Tfiviij; 
Physiologic salt solution, §j.-M. 
The above is the original formula of Dr. E. C. Hay, who states that the 
average dose is 15 to 30 minims (1 to 2 cc.) every other day. 
Heidingsfeld injects deep into the gluteal muscles 2 to 3HI of equal 
parts by weight of metallic mercury and pure hydrated wool-fat. The 
ingredients should be thoroughly rubbed together, but not sterilized by 
heat. 
25. I|. Syrupus acidi hydriodici (N. F.). 
Containing 1 per cent. HI by weight. Prepared from diluted hydriodic 
acid, it is of definite strength and does not readily decompose if properly 
protected against the atmosphere and the light. 
Sig.-4 cc. or 1 fl. dr. in a wineglassful of water after meals. 
Alterative, substitute for the alkaline iodids. 
26. I). Hydrargyri cum cretae, 
Sig.-1 to 4 gr. three times a day. Gray powder is sometimes useful 
in the treatment of infantile syphilis. 
In a small proportion of cases mercury or iodid of potassium produce a 
violent reaction, the syphilitic lesions, for the time at least, being rendered 
worse instead of better by the exhibition of these drugs. Other cases, 
because of the disturbance of the gastro-intestinal tract, cannot tolerate 
either the iodids or mercury. Such cases generally do well on the follow- 
ing prescription: 
27. Dionin. 
Dionin has been used by Randall and others to stimulate the circulation 
in middle ear catarrh and thus aid the absorption of scar tissue, cicatricial 
bands, adhesions, etc. One or two minums of a 2 to 4 per cent, solution 
should be blown through a Eustachian catheter by means of a Politzer 
bag. The fluid enters the Eustachian tube as a coarse spray, some of 
which when the tube is dilated in the advanced stages of middle ear catarrh, 
reaches the tympanum. Congestion of the drum head indicates that the 
remedy has reached its goal. Improvement as regards hearing and 
tinnitus appear after several applications which are repeated at intervals 
of three or four days. 
As the sedative dose of dionin by the mouth is about 7 grains, it is a 
comparatively safe drug to use in the manner described. It sometimes 
causes trancient vertigo as any watery solution would do if blown into 
the middle ear through a catheter. In Randall's practice twenty appli- 
cations complete the course; which after an interval may be repeated. 
28. I). Thiosinamin. 
Favorable results are reported from this remedy as a resolvent in chronic 
catarrh of the middle ear in doses of gr. | to two or three times a day. 542 
DISEASES OF THE NOSE, THROAT, AND EAR 
It is said to promote the absorption of newly formed fibrous tissue and 
hence relieve tinnitus and improve the hearing. It is given in capsules 
or tablet triturates; or hypodermically, 1 or 2 gr. every third day. 
With the exception of the galvanocautery the caustics most employed 
in rhinology and otology are chromic and trichloracetic acids. As the de- 
struction of tissue produced by applications of even the solid stick of 
nitrate of silver is very superficial, it scarcely can be considered a caustic. 
Battey's solution is sometimes used as a mild caustic to destroy hyper- 
trophied follicles in follicular pharyngitis. The formula is as follows: 
29. 1$. lodin resublim., gr. clx; 
Phenol, gr. ccxl; 
Gly cerini, f 5 vj.-M. 
Owing to the anesthetic effects of the carbolic acid, simply touching 
four or five hypertrophied follicles gives little pain or subsequent uneasi- 
ness. The remedy may also be used to contract hypertrophied tonsils by 
wrapping a few fibers of cotton about the end of an applicator and after 
dipping in the solution passing the applicator to the bottom of a crypt 
or one or two drops injected into the crypt with a suitable syringe. 
Three or more crypts in each tonsil should be treated at intervals of a week 
or ten days. 
30. 1$. Zinci chloridi, 5j; 
Aquae des til., 3j.-M. 
Useful in cauterizing the ulcers of malignant growths to secure healing 
or at least diminish pain and fetor. The application should be preceded 
by cocainization. 
Carbolic acid is sometimes used as a mild caustic to destroy granula- 
tions in the middle ear. Either the crystals, to which a sufficient amount 
of glycerin has been added to render them fluid, or one of Calvert's solu- 
tions may be applied by means of a cotton-tipped probe to the exuberant 
granulations. Care should be exercised not to apply any of the carbolic 
acid to the skin of the canal. After a few moments alcohol should be 
dropped into the ear to check further action of the acid and the parts 
mopped dry and boric acid insufflated. 
Various methods of employing trichloracetic acid and chromic acid as 
caustics have already been described in the text. 
CAUSTICS 
COUGH MIXTURES 
Although remedies designed to affect the respiratory tract are best 
administered by means of an atomizer or nebulizer, and when that is im- 
possible or inconvenient, in the form of a lozenge, yet the cough mixture 
still retains at least a measure of its former popularity. The following 
formulas are effective and sometimes convenient to prescribe: 
31. 1$. 'Syrupi ipecacuanhas, f$ss; 
Syrupi scillae, f 3 vj; 
Liq. potass, citratis, . fgj; 
Mucil. acaciae, q. s. ad. f 3iij.-M. 
Sig.-A teaspoonful in water every three hours. FORMULAS 
543 
Useful for controlling the coughs of children. 
32. T$. Ammonia bromidi, 3ss; 
Potassii cyanidi, gr. iss; 
Ext. pruni virginiani fl., f 3 ss; 
Ext. grindelia robusta fl., f3iij; 
Elixir adjuvantis, q. s. f§iv.-M. 
Sig.-A teaspoonful in water four times a day. 
Useful in the so-called "useless or dry cough" of nervous individuals 
due to pharyngeal irritation. 
33. 1$. Morphina sulphatis, gr. ss-ij; 
Potassii cyanidi, gr. iij; 
Acidi sulphurici aromatici, f5j-ij; 
Syrupi pruni virginiana, q. s. ad. f§iij.-M. 
Sig.-A teaspoonful every two or three hours if required to prevent 
coughing. 
Useful as an anodyne, but somewhat stimulating cough mixture. 
34. I}. Tinctura gelseminii, 
Tinctura lobelia, aa 5j; 
Potassii bromidi, 5 ss.-M. 
Sig.-20 drops in water every three hours. (Burnett.) 
The above is said to be almost a specific as regards relief in asthma. 
35. 3. Elixir terpini hydratis cum codeina, N. F. 
4 cc., or 1 fl. dr., representing 0.06 gm. (1 gr.) terpin hydrate, and 0.008 
gm. (i gr.) codein. 
Sig.-A teaspoonful every three hours if required to prevent coughing. 
36. 1^. Elixir terpini hydratic cum heroina, N. F. 
4 cc. or 1 fl. dr., representing 0.06 gm. (1 gr.) terpin hydrate, and 0.0040 
gm. (^ gr.) heroin. 
Sig.-A teaspoonful every three hours if required to prevent coughing. 
37. I). Ext. grindelia robusta fl., f 3 j; 
Tinct. lobelia, 
Tinct. belladonna, aa f 3ij; 
Potassii iodidi, 3 iss; 
Syrupi, fgj; 
Aqua, q. s. ad. f§iv.-M. 
(Edwards.) 
Sig.-One teaspoonful four times a day in the treatment of bronchial 
asthma. 
CLIMATOLOGY 
All catarrhal diseases are favorably influenced by an atmosphere free 
from dust. This is especially true of atrophic rhinitis, where proximity 
to large bodies of water and consequent moist atmosphere exerts a favor- 
able influence. In chronic hypertrophic catarrh and bronchitis generally 
a dry atmosphere such as the sandy districts remote from large bodies of  DISEASES OF THE NOSE, THROAT. AND EAR 
544 
water is beneficial. Usually such localities are covered by evergreen and 
not deciduous trees, so that the atmosphere is saturated with piney odors. 
It is probable that temperature, provided there are few sudden changes, 
does not exert a very decided influence, although excessive and long- 
continued heat is debilitating and very excessive cold discourages the 
remaining out of doors for long periods of persons not in robust health. 
The altitude of a locality and the consequent rarification or condensation 
of its atmosphere exerts a considerable influence. Tuberculous individ- 
uals are generally benefited by residence in places where the altitude is 
considerable, but where there are extensive lung lesions it is important 
that the change from ordinary to high altitudes should be made very 
gradually because of the danger of pulmonary hemorrhage and for other 
reasons. Dr. Guy Hinsdale gives the following list of popular resorts as 
favorable for the treatment of diseases of the upper respiratory tract: 
Chronic Catarrh of the Pharynx, Larynx, and Nose.-Summer: The 
Long Island and Massachusetts coast; the interior resorts of Maine, 
Moosehead Lake, Rangeley Lakes, Poland Springs; the White Moutains 
of New Hampshire; the Adirondacks, N. Y.; Pocono Mountains, Eagles 
Mere, Kane, Pa.; the Virginia Springs, the mountains of West Virginia 
and North Carolina; the southern coast of California, San Diego, Coronado, 
Santa Barbara; Castle Hot Springs, Arizona; Honolulu, Nassau. 
Hay-fever.-The highlands of Ontario, comprising the Muskoka Lakes, 
the Lake of Bays, the Magnetawang district, Penetag, Midland, Honey 
Harbor, Georgian Bay, and Kawartha Lakes; Port Arthur and the neigh- 
borhood of Thunder Bay, Lake Superior; Yarmouth, Nova Scotia; Cape 
Breton; Charlottetown, Prince Edward Island; St. Andrews, Digby, Dal- 
housie, Campobello, New Brunwick, Eastport, Vinal Haven, Isle au 
Haut, Katahdin Iron Works, Moosehead Lake and Rangeley Lakes, 
Maine; Bethlehem, Maplewood, Profile, Twin Moutain, Mount Pleasant, 
Fabyans, Crawford, Jefferson, Dixville Notch, N. H.; the Isles of Shoales, 
N. H.; Baker Island, Rock Island, Nantucket, Mass.; the higher Adiron- 
dack resorts, e.g., Undercliff, Ruisseaumont and Whiteface, Lake Placid; 
Ampersand, Saranac Lake; Paul Smith's, Blue Mountain Lake, Raquette 
Lake, and Loon Lake; Beach Haven, N. J.; Put-in-Bay, Ohio; Marquette, 
Sault Ste. Marie, Mackinac, Mich.; Coronado Beach, Catalina Island, 
Cal. 
Asthma, the Neurotic or Spasmodic Form.-Elevated sunny regions, 
e.g., Colorado Springs, Manitou, Glenwood Springs, Colo.; Castle Hot 
Springs, Ariz.; Hot Springs, Va.; Lake Placid, N. Y.; the White Mountains, 
N. H.; Kane, Pa. The higher elevations are counterindicated in aged 
persons. 
Tubercular Laryngitis.-Florida and Southern California. 
Chronic Fibroid Phthisis.-The interior Florida resorts in winter; the 
sand belt of Georgia, South Carolina, and North Carolina. The coast 
resorts of the southern Atlantic seaboard, including Atlantic City, are suit- 
able for selected cases. 
Pidmonary Tubercidosis.-Gravenhurst, Ontario; Lahl Ghur, Ste. 
Agathe, Quebec; Long Lake, Gabriels, Ray Brook, Saranac Lake, Paul 
Smith's, N. Y.; Liberty, N. Y.; Rutland, Mass.; Sharon, Mass.; East 
Bridgewater, Mass.; New Canaan, Conn.; South Scituate, R. I.; Lake- 
wood, Hammonton, Vineland, N. J.; Kane, Glen Summit, Pocono, Mont 
Alto, White Haven, Penna.; Ashville, N. C.; Southern Pines, N. C.; 
Aiken, Camden, S. C.; Thomasville and Summerville, Ga.; Palatka, 
Enterprise, Fla.; San Antonio, El Paso, and Western Texas; Santa Fe, FORMULAS 
545 
Las Cruces, Las Vegas, Hot Springs, Fort Bayard, Fort Stanton, Silver 
City, and Albuquerque, New Mexico; Colorado Springs, Denver, Estes Park 
Cannon City, Boulder, Colo.; Phoenix, Tucson, Tempe, and Prescott, Ariz.; 
the interior resorts, such as Redlands, Riverside and Idyllwild, near San 
Jacinto Mt., Monrovia, Pasadena, Mentone, Esparanza, Altadena, 
Santa Barbara, San Diego, Southern California; in summer the Rocky 
Mountains of Idaho, Montana, and British Columbia. In cases compli- 
cated with kidney disease, and in any advanced stage, high altitudes 
should be avoided, but hemorrhage is not a counterindication. 
GARGLES 
Gargles are of little value unless employed with more than usual care. 
Pope, by means of experiments with methylene-blue and other substances, 
demonstrated that as ordinarily performed gargling does not bring a 
medicament in contact with the fauces further back than the anterior 
pillars. When necessary to prescribe a. gargle the patient should be 
instructed to close the nose tightly, throw the head far back, and gargle. 
By this method the probability of the fluid reaching the posterior wall of 
the pharynx is increased. Children cannot use a gargle, and rarely is it 
practical to teach a patient to gargle properly during an office visit. 
Gargles as ordinarily employed rarely reach the posterior wall of the 
pharynx and never the larynx. However, the following are cheap as- 
tringent gargles, and they may at some time be convenient to prescribe. 
The small amount of the gargle swallowed is, of course, effective. 
38. R. Glycerol tannici, 3j. 
Sig.-A teaspoonful in a half-tumbler of water. Use as a gargle. 
39. R. Alcoholis, 95 per cent. 
Sig.-Use as a gargle. 
40. R. Acidi tannici, 
Acidi gallici, aa gr. xx.-M. 
Sig.-Add to a tumblerful of iced water. Gargle and swallow a portion 
every few moments until the hemorrhage ceases. 
As a styptic after tonsillotomy to control oozing of blood. 
41. 1$. Hydrogen dioxid, 15 volumes (3 per cent.). 
Sig.--Use as a gargle to control oozing of blood after tonsillotomy. 
HEMOSTATICS 
42. Adrenalin. 
Adrenalin is the active blood-pressure-raising principle obtained from the 
suprarenal capsule of beeves or sheep. Epinine is a synthetic compound 
having similar properties to adnephin and its solutions can be sterilized by 
boiling. These substances are usually sold in i :ioo solution, containing 
an antiseptic to prevent decomposition. For this reason adrenalin is 
prepared by some manufacturers in tablets, one or which dissolved in 15 
minims of water yields a 1 :iooo solution. The solutions prepared by dis- 
solving one of the tablets contains no antiseptic to irritate the nose, and 546 
DISEASES OE THE NOSE, THROAT, AND EAR 
for this reason is somewhat better in the treatment of hay-fever and other 
conditions where the nasal mucous membrane is irritable. In the same 
class of cases the drug dissolved in albolene yields better results than a 
watery solution. 
To produce local ischemia in mucous membranes preparatory to a 
surgical operation a i: rooo solution is generally employed. 
The best results are obtained by applying pledgets of cotton within the 
nose saturated with 1:1000 solution. After ten minutes a saturated 
solution of cocain is gently rubbed into the parts by means of a cotton- 
tipped applicator that has first been dipped into a cocain solution, and 
then, after pressing out the drip, into a bottle of coarsely powdered cocain 
crystals. 
When used in this manner nasal operations can be done without the loss 
of a drop of blood unless a vessel of considerable size be encountered. 
However, secondary hemorrhage occurring one or two hours after a nasal 
operation is more common when adrenalin has been employed, because 
the ischemia of mucous membranes so produced is followed by congestion 
when the effects of the drug have passed off. 
The fact that applications of adrenalin to the nasal mucous mem- 
brane are followed by congestion as soon as the effects of the drug have 
passed, prevents the remedy being entirely satisfactory in the treatment of 
hay-fever. The best results are obtained by somewhat frequent applica- 
tions, say once in two or three hours, of a solution not stronger than i: 5000 
or 1:10,000 or one of the oily preparations of adrenalin. However, in 
spite of every precaution, after a few days the condition of a hay-fever 
patient using local applications of adrenalin is in nowise improved, and 
is usually worse, At best it gives only temporary relief. 
In some cases where even weak solutions of adrenalin are employed to 
prolong the effects of cocain, symptoms resembling atropin-poisoning 
occur. The nose is greatly congested and occluded. There are frequent 
attacks of sneezing and both nose and throat are hot and dry. To pro- 
long the ischemic effects of cocain, antipyrin is safer than adrenalin. 
The effects of adrenalin on the heart are similar to those of digitalis, 
with the difference that it acts with great rapidity, its effects are not as 
prolonged, and the blood-pressure-raising effect is more apparent. It 
slows the pulse and strengthens the cardiac systole while it shortens and 
renders diastole less perfect. It is a valuable cardiac stimulant and may 
be used hypodermically in heart failure during chloroform anesthesia. 
Adrenalin is usually classed among the alkaloids because it is a 
nitrogenous compound forming salts with acids. It probably exists in the 
suprarenal capsules in combination with some organic acid. It is decom- 
posed by prolonged contact with alkalis and, therefore, should not be 
prescribed in conjunction with an alkaline nose-w'ash. It is a reducing 
agent and, therefore, should not be used in conjunction with hydrogen 
dioxid, permanganate, etc. It attacks many metals, tarnishing them and 
producing a black precipitate, therefore adrenalin solutions should not 
be allowed to remain of any great length of time in atomizers with metal 
tubes. 
43. 3- Acidi tannici, 
Acidi gallici, aa gr. xx.-M. 
Sig.-Add to a tumblerful of water and slowly sip the mixture, or gargle 
and swallow a portion every few moments until the bleeding stops. 
Useful in controlling oozing of blood from the wound after tonsillectomy. FORMULAS 
547 
44. I|. Ergotin. (aq. ext.), 5j; 
Ext. hyoscy. ale., gr. iij.-M. 
Ft. cap. No. xx. 
Sig.-One every three hours in hemoptysis. 
45. I). Acidi gallici, 5iss-iij; 
Vini rectif., gss; 
Glycerini, giiiss.-M. 
Sig.-A teaspoonful every two hours in hemoptysis. 
46. 1$. 01. terebinth., gj; 
Muc. acaciae, 5iij; 
01. gaultheriae, Tffij.-M. 
Sig.-A teaspoonful every hour with water in hemoptysis. 
47. 1$. Calcii chloridi, gr. xl. 
Ft. cap. No. viii. 
Sig.-One every hour until the bleeding is controlled. 
The effects of calcium chlorid is to increase the coagulability of the 
blood, but if too large a quantity of the drug is given the opposite result 
is caused, namely, diminished coagulability. On this theory 2 or even 
3 capsules (10 to 15 gr.) may be given at intervals of an hour in severe 
cases, but the amount of 80 gr. should not be exceeded in as many hours. 
Even in cases where the hemorrhage has not been completely controlled, 
if 80 gr. have been given within eighty hours, it is best to wait several 
hours before again resorting to the drug. However, in nasal hemorrhage 
resulting from diminished coagulability of the blood, better results 
follow the injection of 10 to 30 cc. of horse serum. 
48. 1$. Trional, gr. x-xxx. 
49. ij. Sulphonal, gr. x-xxx. 
50. 1$. Paraldehyd, . fgss; 
Olei gaultheria;, Tffx; 
Pulveris acacia;, o ij J 
Elixir simplicis, q. s. ad. f§iv.-M. 
Sig.-J to 1 tablespoonful in water every hour or two in the restlessness 
and insomnia following mastoid operations. 
51. 1$. Chloral hydratis, gr. x; 
Codein sulphatis, gr. 
Strychninse sulphatis, gr. -M. 
Ft. chartae No. i. 
Sig.-To relieve restlessness and insomnia after mastoid operations. 
Dissolve in half-tumberful of water and repeat dose in three hours if 
necessary. 
After many severe operations on the nose, throat, or ear the patient for 
the first night or two will complain of pain, restlessness, and inability to 
sleep. This is especially true in neglected mastoid cases that have been 
operated on only after weeks of needless suffering and consequent demor- 
alization and debility. In some such instances a hypodermic of | gr. of 
morphin will be required in order to soothe the patient's sufferings. In 
other cases a reliable hypnotic produces the desired results. Under such 
HYPNOTICS 548 
DISEASES OF THE NOSE, THROAT, AND EAR 
circumstances the choice of a hypnotic in the patient's debilitated condition 
is by no means a matter of indifference, as all hypnotics are to a greater or 
less degree depressants. Sodium bro mid (10 gr.) combined with chloral 
(5 gr.) repeated every hour, if necessary, yielded good results in the prac- 
tice of the writer for several years. More recently, however, he has relied 
either on Formula 50 or 51. It should be observed that any possible 
depressant effect of chloral on the heart is guarded by the addition of a 
small proportion of strychnin in Formula 51. 
HAY-FEVER 
52. 3. Pulv. salis Vichyani fact, efferv. (N. F.), 3iv. 
Sig.-Take a teaspoonful in a glass of water four times a day. Or, if 
the action of lithium is desired, the pulvis salis Vichyani factiti effervescens 
cum lithio (N. F.) may be prescribed. 
53. 3- Hyoscin® hydrobromatis, gr. T^; 
Camphor® monobromat®, gr. ij; 
Sacchari lactis, q. s.-M. 
Misce et tritura bene. Divide in tabulas vel capsulas No. xx. 
Sig.-1 tablet or capsule at intervals of from ten to ninety minutes until 
the sneezing and running of the nose are controlled, after which 1 tablet 
may be taken every second, third, or fourth hour, as may be necessary to 
maintain the effect. 
The following may be given in the same way: 
54. I). Atropin® sulphatis, gr. ^4; 
Camphor® monobromat®, gr. v; 
Balsami peruviani, q. s.-M. 
Misce. fac. capsul® No. xx. 
Dr. H. H. Curtis, recommends the following tablet: 
55. T^. Strychnin® arsenatis, gr. f; 
Atropin® sulphatis, gr. 
Camphor®, gr. xxv; 
Ipecacuanh®, gr. v.-M. 
Fiat massa in pilul® No. c dividenda. 
Sig.-One pill from three to six times a day. 
56. 1$. Heroin, gr. j; 
Atropin® sulph. gr. tj'j; 
Caffein cit., gr. xv; 
Salophen, gr. Ixxv.-M. 
Ft. caps. No. xv. 
Sig.-One every two hours until 3 or 4 are taken and the nasal symptoms 
are alleviated, then 1 every three or four hours. 
57. 3. Menthol, gr. j; 
Cocain® hydrochlor., gr. j; 
Orthoform, gr. v; 
Petrolati albi, 5j--M. 
Sig.-Apply to the nasal mucous membrane every two or three hours in 
acute rhinitis or hay-fever. FORMULAS 
549 
58. 1$. Acidi nitromuriatici (concentrated, freshly prepared), fg j 
Sig.-5 to io drops in a tumberful of water one hour after meals and at 
bedtime. 
In a proportion of cases of hay-fever the above formula will eliminate 
all symptoms of the disease within forty-eight hours. If after two or three 
days' use of the remedy there is no improvement in the symptoms, it is 
probable that nitromuriatic acid will prove useless, no matter how long 
continued. 
Mineral acids in the treatment of hay-fever are said to owe their effi- 
ciency to the fact that they diminish the alkalinity of the blood to an extent 
that it is no longer capable of holding in solution uric acid, and hence the 
mucous membranes are not irritated by the secretion of this substance. 
However, nitromuriatic acid has been employed for several generations 
as an alterative and tonic in gastro-intestinal diseases and in diseases of 
the liver, where it is said to increase the biliary secretions. It is probable, 
therefore, that when exhibited in the treatment if hay-fever that it not 
only frees the blood from uric acid but also, by improving metabolism, 
limits the formation of uric acid and perhaps other products of defective 
metabolism. Mineral acids were formerly used more frequently than at 
present in the treatment of diseases of the upper respiratory tract, io drops 
of dilute nitric acid every two hours in water beng an old but usually 
effective remedy in the treatment of the aphonia of singers and orators. 
The use of nitromuriatic acid may be commenced at any time before or 
during the hay-fever season. It is important that the acid be freshly pre- 
pared. At first a colorless liquid, it becomes within a few days yellow. 
The yellow color deepens almost to brown, but finally again becomes 
lighter, until at length the mixture is colorless. During this period of 
change in color fumes are given off a:nd the remedy is then thought to be 
most active in its effects upon the gastro-intestinal tract. When io drops 
are diluted with a tumblerful of water the water is only slightly sour to 
the taste, but is is well enough as a precaution against possible injury to 
the teeth to rinse out the mouth either with pure water or water to which a 
pinch or two of baking soda has been added. 
If the use of nitromuriatic acid is successful in eliminating the symptoms 
of hay-fever, it is probable that they will cease to recur as long as the 
patient continues to take the remedy regularly. However, should he 
neglect to take a single dose, more especially the evening dose, it is prob- 
able that some symptoms of the disease will be quickly manifested. For 
example, if the evening dose be omitted, it is probable that the patient 
will wake up the next morning with his nose occluded and irritable and 
very likely will have several attacks of sneezing. 
Prolonged use of nitromuriatic acid is apparently harmless. Some of 
the writer's earlier cases have used the acid for months at a time year after 
year during the hay-fever season, and occasionally some of them during 
the winter season as well, without noticing any deleterious effects. In 
cases where the remedy is effective it is curative to the extent that it 
almost completely controls the symptoms during the hay-fever season, 
and there seems a tendency for the attacks to become less and less severe 
from year to year. 
In neurotics suffering from hay-fever much benefit sometimes results 
from: 550 
DISEASES OF THE NOSE, THROAT, AND EAR 
59. I). Acidi hydrobromici diluti, f 5 ij. 
Sig.-15 to 30 drops in a tumblerful of water one hour after meals. 
Hydrobromic acid also yields in a majority of cases somewhat better 
results in the treatment of tinnitus than bromid of sodium or the mixed 
bromids. 
FORMULAS FOR THE BOTTLE INHALER, CROUP 
KETTLE, ETC. 
The steam from a kettle containing unslaked lime has been used for 
many years in the treatment of croup and diphtheria. 
A croup kettle consists of a vessel usually with a long spout, to which a 
rubber hose is attached, by means of which steam is conveyed to the 
vicinity of a patient or under a croup tent erected over a bed. As the 
quantity of unskaled lime that will dissolve in water is not great, a piece 
of lime the size of a walnut is more than sufficient for several quarts of 
boiling water. 
The following formula may be used with the bottle inhaler or added to 
the water in a teapot containing boiling water. 
60. 3. Tr. benzoin comp. 
Sig.-Add | teaspoonful to a bottle inhaler half-full of hot water. Use 
the inhaler four or five times a day. 
Useful in most forms of laryngeal inflammation. To the above formula, 
when requisite, an expectorant-ammonia muriat., fluidextract of senega, 
or ipecac-may be added. When it is desired to diminish expectoration 
and at the same time produce a sedative effect upon the laryngeal mucous 
membrane, fluidextract of belladonna or hyoscyamus in combination with 
the compound tincture of benzoin will yield satisfactory results. 
61. I). Creosoti, 
Alcoholis, aa fgj.-M. 
Sig.-6 or 8 drops on the sponge of a perforated zinc inhaler every hour 
or two. Where there is much irritating cough, 30 per cent, of chloroform 
may be added to the formula. The zinc inhaler should be worn upon the 
face as much as possible both day and night. 
LOZENGES 
Lozenges, when well made, are superior to cough syrups or gargles for 
the treatment of throat affections. They should be so made as to dissolve 
slowly and evenly in the mouth, thereby giving a more prolonged local FORMULAS 
551 
effect than is possible with gargles or a spray, and a quicker and more 
pronounced result than can be obtained by a greater quantity of the 
medicant introduced into the stomach. 
The favorite excipients seem to be black-currant paste and gelatin. 
Because of the length of time required for the drying of lozenges, druggists 
cannot quickly make them from the prescription of a physician, and it is, 
therefore, better to rely on the manufactured product of lozenge-makers, 
some of whom have national or international reputations. 
A business man can carry a bottle of lozenges in his vest pocket and 
take one as required from time to time, when he would be embarassed by 
the use of an atomizer. 
However, it should be remembered that lozenges produce both a local 
and a constitutional effect and are only especially useful when this effect 
is desired. 
Lozenges have in common with cough mixtures a notorious reputation 
or disordering the stomach. Most of the following formulas have been 
selected from the stock lozenges of manufacturers. 
"In cases of deep tonsillitis there is, fortunately, a remedy which if ad- 
ministered at the outset of the attack, will almost always cut short the 
crescent inflammation. This is guaiacum. I prescribe it as a lozenge. 
Taken in this way it seems to have a local as well as a constitutional effect." 
-Morell Mackenzie. 
62. 1$. Troch. guaiac. 
The lozenges are stimulant and alterative, and are capable of arresting 
recent inflammation of the tonsils. 
These lozenges should contain 2 gr. of the resin of guaiacum and made 
in accoordance with Mackenzie's formula, so as to be entirely soluble in the 
mouth. They are useful in the treatment of acute and subacute inflam- 
mation of the pharynx and acute follicular disease of the tonsils. 
63. Troch. guaiac, comp. 
3. Resin guaiac., gr. i j; 
Potassii iodidi, gr. j.-M. 
(Wm. Pepper.) 
Stimulant and alterative; is especially useful when in acute inflamma- 
tions of the tonsils there is a sensation of dryness, as the iodid increases 
secretion. A lozenge may be used every one or two hours. 
64. Troch. guaiac, et acidi tannici. 
T|. Resin guaiac., gr. iss; 
Acidi tannici, gr. |.-M. 
Sig.-A lozenge to be dissolved slowly on the tongue every one or two 
hours. 
Stimulant and astringent, probably the most useful of the guaiacum 
GUAIACUM AND ITS COMBINATIONS 552 
DISEASES OF THE NOSE, THROAT, AND EAR 
lozenges in acute and subacute inflammation of the tonsils, pharynx, and 
larynx. Useful in the so-called "relaxed throats" of public speakers. 
The astringent action of the tannic acid is assisted by the alterative effect 
of the guaiacum. 
65. Troch. guaiac, and benzoic acid. 
I). Resin guaiac., gr. ij; 
Acidi benzoici, gr. j.-M. 
(J. F. Martenet.) 
Stimulant in nervomuscular weakness of the throat. It is somewhat 
useful in the treatment and the loss of control of the laryngeal muscles 
experienced by nervous actors, singers, and orators. In addition to the 
lozenge, fa gr. of strychnin or 1 dram of fluidextract of cocoa in 1 ounce of 
sherry wine may be prescribed, to be taken a few moments before going 
upon the stage or platform. 
CAMPHOMENTHOL AND ITS COMBINATIONS 
66. 1$. Troch. camphomenthol, gr. fa. 
Sig.-A lozenge to be dissolved on the tongue every one or two hours, 
as required. 
These lozenges check excessive discharges, and liquefy tenacious mucus. 
They are sedative, an antiseptic tonic to catarrhal conditions of the mem- 
brane, and a voice stimulant. 
67. Troch. camphomenthol et eucalypti. 
1$. Eucalyptus rostrate (red gum), gr. j; 
Camphomenthol, gr. fa.-M. 
Sig.-A lozenge to be dissolved on the tongue every one or two hours, 
as required. 
A pleasant antiseptic astringent and sedative. 
When greater anodyne effect is desired, in acute or chronic bronchitis, 
and in grip cough, the following is an efficient and reliable sedative: 
68. Troch. codein comp. 
Codeinae, gr. 
Camphomenthol, gr. fa.-M. 
Sig.-A lozenge to be dissolved slowly on the tongue every one or two 
hours. 
69. Troch. heroin. 
I). Heroin, gr. 
Camphomenthol, gr. /j.-M. 
Sig.-A lozenge every two hours if required to relieve cough. 
70. Troch. orthofdrm comp. 
I|. Orthoform, gr. j; 
Camphomenthol, gr. fa.-M. 
Sig.--One ten minutes before meals or as required, as a safe analgesic 
after throat operations and other painful conditions of the pharynx and 
larynx. (McConachie.) FORMULAS 
553 
Instead of the orthoform lozenge, either of the two following may be 
employed in the dysphagia of tuberculous laryngitis, where greater anal- 
gesia is required: 
71. Troch. cocain comp. 
I). Cocain hydroch., gr. 
Extract, hyoscyami, gr. fa 
Extract, opii, gr. 
Tincturas aconiti, Hiss.--M. 
Sig.-A lozenge a few moments before eating and every two or three 
hours. J. J- Chisholm.) 
This combination is of considerable value as an anesthetic and anodyne 
in the laryngeal lesions of phthisis and to control the paroxysms of asthma. 
COCAIN AND ITS COMBINATIONS 
AMMONIUM SALTS AND THEIR COMBINATIONS 
Ammonium salts have long been used in the treatment of pharyngitis 
and bronchitis. They may be given in the form of a lozenge for the local 
effect on the pharynx, but the lozenge should be so made that the ammo- 
nium salts do not dissolve more rapidly than the other ingredients of the 
lozenge. 
72. Troch. glycyrrhiza comp. 
Sig.-A lozenge every two or three hours. 
Brown mixture lozenges should be so made that each lozenge corre- 
sponds to a teaspoonful of the well-known "brown mixture." 
73. Troch. ammonias iodidi comp. 
I|. Ammonias iodidi, gr. j; 
Ammoniae chloridi, gr. ij; 
Codeinae, gr. f; 
Morphinae acetatis, gr. 
Ext. prunis virginianae, q. s.-M. 
Sig.-One every three hours as an alterative, sedative, expectorant. 
(Hayes.) 
MISCELLANEOUS LOZENGES 
Some of the prescriptions under this heading are old favorites and have 
been popular with many physicians for years. 
The next three lozenges may be given to children and adults who strenu- 
ously refuse any remedy having an unpleasant taste, as they are a pleas- 
ant confection: 
74. Troch. mucilag. ulmi (mucilage of slippery elm). 
3. Mucilag. ulmi, q. s. facio troch. No. i. 
75. 1$. Ipecacuanha. 
These are large gum-arabic pastils of the same strength as the lozenges 
of the British Pharmacopoeia. They are readily taken by children and 554 
DISEASES OF THE NOSE, THROAT, AND EAR 
exert the expectorant effects of ipecacuanha with the demulcent character- 
istics of the lozenge. 
76. Troch. acidi borici composite. 
I|. Acidi benzoici, gr. ss; 
Acidi borici, gr. j; 
Ext. erythrox. cocas, gr. iss.-M. 
Fiat troch. No. i. (Faulkner). 
This lozenge is sedative, demulcent, and of a pleasant taste. It is a 
valuable voice lozenge in cases of orators and singers of the neurotic tem- 
perament, who dread that their voice will fail them in the presence of an 
audience because of nervous muscular weakness. One should be slowly 
dissolved in the mouth every four hours. When used as a "voice lozenge" 
one should be taken one-quarter of an hour before using the voice and 
fluids should be avoided. 
77. Troch. acidi carbolici. 
I). Acidi carbolici, gr. j. 
Fiat troch. No. i. (Morell Mackenzie.) 
This formula has long been a favorite as an analgesic, antiseptic lozenge. 
MISCELLANEOUS 
78. Contractile collodion. 
Contractile collodion is sometimes applied to a cicatricial or atrophic 
drum-head to hold it in a more favorable position for hearing. For this 
purpose, after inflation by Politzer's method, only a small amount of the 
collodion should be painted upon the drum-head at one time, as there is 
some danger of producing myringitis if too large an amount of the remedy 
is painted on the drum-head at one sitting. 
79. Phosphorated oil. 
Formerly many ointments and solutions were applied to the membrana 
tympani for the relief of tinnitus and deafness caused by catarrh of the 
middle ear. Although this form of medication has largely been aban- 
doned, phosphorus dissolved in olive oil, if applied to the drum-head, will 
sometimes bring about improvement of the hearing in deafness due to 
senility. 
80. Chloroform. 
81. 3- lodin. 
82. 1$. Tincturae iodini, f5j; 
Chloroformi, fgj.-M. 
83. Menthol. 
The vapor of these substances is sometimes used as an application to 
the mucous membrane of the middle ear. They should be preserved 
ready for use in wide-mouthed, glass-stoppered bottles, so that the 
Politzer air-bag can be filled with their vapor by placing the nozzle of the 
bag within the neck of the bottle while the bag is expanding. Ether and FORMULAS 
555 
chloroform vapor will sometimes penetrate into the middle ear through 
the Eustachian tube when it is impossible to inflate the middle ear with 
simple air by Politzer's method or the use of the catheter. 
84. 1$. Ac. carbol., gr. xxx; 
Ammon, carb., §j; 
Pul. carbo, lig., 5j; 
01. lavend., Tfixx; 
Tr. benzoin co., gss; 
Gum camphor, 5ij.-M. 
Sig.-Smelling salts for acute nasal catarrh. 
85. I). Paraffin, giv; 
Albolene, gv.-M. 
Melt together in container surrounded by boiling water. 
Sig.-For use as a subcutaneous injection for the correction of nasal 
deformities, etc. 
For subcutaneous injections sterile paraffin, with a melting-point of 1120 
F., is usually employed. When the melting-point is much higher than 
this, it is not readily forced through a long needle and does not as readily 
penetrate the spaces of the cellular tissue. When the melting-point is 
much lower than 112° F., paraffin behaves more like ordinary oil, per- 
meates the tissues more readily, and may enter a vessel and cause embolus. 
Ordinary commercial paraffin, whose melting-point is usually 128° F., 
may be reduced to a melting-point of 1120 F. by adding 5 parts of albolene 
to 4 parts of paraffin, the mixture sterilized by boiling it and its container 
in water, and preserved for future use. 
Thus prepared the melted paraffin should be drawn into a suitable 
syringe (Fig. 69), the nozzle of which is then closed with its screw cap. 
The syringe with the paraffin it contains and the necessary needle are then 
sterilized by boiling in water. The syringe and paraffin contained in it 
are then cooled in sterile water, the screw cap removed, the needle screwed 
in its place, and the instrument is then ready for use. 
86. 3- Ext- cimicifugee racemosae, f^ij. 
Sig.-15 to 20 drops after meals and at bedtime. 
The above is sometimes useful in tinnitus. When effective its beneficial 
results are manifested within a few days. However, a rather large pro- 
portion of cases of tinnitus from chronic middle-ear catarrh are not benefited 
in the least by the use of cimicifuga. 
87. I|. Atropinae sulphatis, gr. |; 
Acidi sulphurici aromatici, f 3 ij; 
Aquae rosae, q. s. ad. f 3 j.-M. 
Sig.-20 to 30 drops at bedtime, repeated if necessary. Useful in the 
night-sweats of phthisis. 
88. B- Acidi carbolici, gr. iij; 
Pulveris camphorae, 
Resorcini, aa gr. xx; 
Acidi borici, gr. xxx; 
Unguenti zinci oxidi, 5 j.-M. 
Fiat unguentum. 
Sig.-Use twice a day as an external application in acne rosacea of the 
nose. 556 
DISEASES OF THE NOSE, THROAT, AND EAR 
8g. I). Pilocarpine hydrochloras, gr. 
Pilocarpin may be given hypodermically once a day in conjunction with 
potassium iodid three times a day by the mouth in effusion or hemorrhage 
into the labyrinth, tertiary syphilis, and traumatism involving the internal 
ear. The average dose of pilocarpin is about gr. hypodermically, but 
much larger amounts have been used with impunity. When administered 
for its action on the internal ear a sufficient amount should be taken to pro- 
duce profuse sweating or salivation. The remedy should be continued a 
sufficient number of days to produce the desired result, unless the patient 
becomes greatly prostrated by its continued use or it is manifestly unavail- 
ing. When no improvement is manifest after a week's use of the drug it 
should be abandoned. It rarely is of use except in acute cases. 
Pilocarpin is a drug whose action should be carefully watched, because 
serious and even fatal consequences have resulted from the injection of 
medicinal doses. Shoemaker cites a case where the patient suddenly 
expired after an injection of pilocarpin. In another case the same author 
states that the employment of | gr. was followed by profuse diaphoresis, 
salivation, lacrimation, a discharge from the nose, sickness of the stomach, 
difficulty in breathing, and a sense of cardiac oppression. Internal and 
external stimulation caused the symptoms to disappear. Atropin is a 
physiologic antidote to pilocarpin. 
Pilocarpin may be given by the mouth instead of hypodermically, but 
its effects are longer in manifesting themselves (fifteen to twenty minutes) 
and more uncertain. Politzer advises the injection of 6 to 8 drops of 
warm 2 per cent, solution through the Eustachian catheter into the 
Eustachian tube in sclerosis of the middle ear. Mendosa, in 3 cases, 
relieved urgent dyspnea from edema of the larynx by hypodermic injections 
of pilocarpin. 
90. I). Tincture aconiti, TTlxxxvj; 
Aquas destil., fgiss.-M. 
Sig.-A teaspoonful in water every half-hour until three doses are taken; 
then every hour. 
Useful in tonsillitis when the fever is high. Should be used after thor- 
oughly evacuating the bowels with a saline. 
91. I). Sodii salicylatis, 
Potassii citratis, aa gr. xx; 
Elix, adjuvantis, N. F., f^iij.-M. 
Sig.-Teaspoonful every two hours for a child of four years with 
tonsillitis. 
92. 1$. Menthol, gr. xi| (0.75 gm.); 
Cocain, gr. iii| (0.25 gm.); 
Chloral, gr. ii| (0.15 gm.); 
Petrolatum, gr. lxv(5 gm.).-M. 
Ft. unguentum. 
Sig.-Ointment for neuralgia. Apply to the painful part and cover with 
a gauze bandage if the neuralgia is periorbital or hemicranial. 
93. 1$. Hexamethelamin (Urotropin), 5iv.-M. 
In Capsule No. xxiv dividenda. 
Sig.-One capsule three or four times a day is a prophylactic in threat- 
ened septic meningitis. FORMULAS 
557 
According to John Hopkins Hospital reports after therapeutic doses a 
sufficient amount of urotropin appears in the cerebrospinal fluid to exer- 
cise a decided inhibitory effect on the growth of microorganisms; 30 to 60 
gr. a day may be given in otic cases at the onset of meningeal symptoms. 
It is excreted also by the nasal and aural mucous membranes and may be 
given with advantage in commencing infections of these cavities. 
94. The growth of epithelium over granulations is greatly facilitated 
by the application of Scarlet Red either as a powder or ointment, of from 
5 to 10 per cent. The use of a 5 per cent, ointment very greatly hastens 
the healing after the radical mastoid operations when skin grafts are not 
employed. 
95. I}. Tinctura Gelsemii, M. xv.-xx. 
Morse states that 15 to 20 drops of the tincture of Gelsemium taken 
internally will usually abort an acute coryza at once. The dose should 
not be repeated. 
96. 1$ chromii sulphatis, 3ii M. 
In capsulae No. xxx dividends. 
Sig.-One after meals and at bed time. 
According to Echelberger and other chromium sulphate is a specific in 
simple hypertrophy of the thyroid gland. (Goiter.) 
OPHTHALMO-CUTANEOUS DIAGNOSTIC REACTIONS IN 
TUBERCULOSIS 
Technic and Course of the Cutaneous Reaction.-The skin is cleansed 
with green soap and alcohol. A space, the size of a dime, is then scarified 
as in ordinary vaccination and a 25 per cent, solution of Koch's old tuber- 
culin rubbed in. Control vaccinations of 5 per cent, glycerin and | per 
cent, carbolic acid (the strength of these substances in tuberculin) are 
also made, because in certain individuals irritation follows slight traumat- 
ism of the skin. The positive reaction is manifested within a few hours 
and reaches its greatest intensity within twenty-four hours, as either a 
simple erythema or a more intense inflammation with the formation of 
papules. The reaction disappears, according to its intensity, in forty- 
eight hours or persists for weeks. 
Technic and Course of the Conjunctival Reaction.-'One or more drops of 
Koch's old tuberculin diluted with 5 parts normal salt solution is placed in 
the conjunctival sac. In from six to twenty-four hours the conjunctiva 
begins to redden and in milder reactions nothing more is noticed. How- 
ever, there may be all the symptoms of a severe conjunctivitis. The test 
is contra-indicated in individuals who have had disease of the ocular uveal 
tract, and the cutaneous test is generally preferable in children, as the con- 
junctival test sometimes sets up a phlyctenular conjunctivitis. 
Failure to react in persons manifestly tuberculous indicates that the 
system lacks the power to combat the poisons of tuberculosis with its pro- 
tective forces and, therefore, indicates an unfavorable prognosis. A large 
number of advanced progressive cases show no reaction to the tuberculin 
test. 
In order to be successfully nebulized a fluid must have sufficient vis- 
cidity. Glycerin nebulizes fairly well, but its nebulizing qualities are 
FORMULAS FOR USE WITH NEBULIZERS 558 
DISEASES OF THE NOSE, THROAT, AND EAR 
greatly improved by the addition of a small proportion of tincture of ben- 
zoin. The benzoin should be added drop by drop with constant shaking 
of the bottle which contains the glycerin in order to evenly diffuse the 
benzoin through the glycerin, which becomes white and opaque from 
minute particles of benzoin suspended in the liquid. The mixture is com- 
paratively stable and the benzoin contained in about i dram of the tinc- 
ture can thus be suspended in 4 ounces of glycerin. 
Ordinary bleached petrolatum oil or albolene, with or without the pro- 
portion of benzoin it can be made to dissolve, nebulizes fairly well. 
Alcohol made viscid by the solution of one of the balsams, preferably 
benzoin, nebulizes fairly well. However, alcohol is somewhat irritating 
to the bronchial mucous membranes, and in use the product of a nebulizer 
containing an alcoholic solution is best diluted by the product of one con- 
taining a bland oily solution. 
The alcohol evaporates somewhat rapidly during the process of nebu- 
lization, so that the fluid in the nebulizer becomes more and more concen- 
trated, until, finally, the dissolved balsams are deposited within the 
nebulizer tubes and clog them up to an extent to prevent the instrument 
working unless more alcohol is added from time to time to replenish that 
which has evaporated. 
Any substance can be nebulized successfully if reduced to a fluid state 
by solution in one of the above three liquids. Essential oils and cam- 
phors are best dissolved in albolene for nebulization; substances insoluble 
in oil, either in the glycerin mixture or in alcohol. 
The following formulas may prove useful when used with a nebulizer. 
They should not be used with an atomizer, because the amount of fluid 
deposited on mucous membranes by an atomizer is many times greater 
than that derived from a nebulizer, and some of the following solutions 
are sufficiently concentrated to produce deleterious results if applied to 
the nose or pharynx by means of an atomizer. The fact that only a 
minute amount of nebulized fluid is deposited on the mucous membrane 
of the upper respiratory tract during the. short time available for the 
treatment of a patient during an ordinary office visit, probably accounts 
for the lack of enthusiasm manifested by most specialists for this method 
of treatment. The atomizer will probably always be the favorite instru- 
ment for applying remedies to the nose, pharynx, and larynx of office 
patients. 
97. I). Fl. ext. ipecacuanha, f^ss; 
Glycerini, f 3 j; 
Tinctures benzoini, Tfixv.-M. 
Stimulating expectorant of considerable value in the early stages of 
bronchitis with scanty secretions and a sense of tightness across the chest; 
also in the early stages of coryza to increase secretions and render them 
more fluid. It relieves sensations of dryness in the nose and fauces from 
whatever cause. Asthmatic seizures are alleviated by nebulizing this 
formula with the addition of antispasmodics. Two fluidrams of the 
tincture of hyoscyamus, lobelia, and gelsemium, with 1 or 2 drops of chloro- 
form forms a suitable addition for this purpose. While being used alcohol 
will have to be added from time to time to prevent the fluid becoming too 
thick for nebulization. 
98. Acidi tannici, oj; 
Glycerini, f5j--M. FORMULAS 
559 
Simple astringent useful in relaxed conditions of the mucous membrane 
of the upper respiratory tract. 
99. I|. Camphorse, gr. x; 
Olei eucalypti, fpij; 
Petrolati albi liquidi (albolene), q. s. ad. fgj; 
Tincturse benzoini, TTlx.-M. 
Sedative and lubricant. Useful as a diluent of other sprays, especially 
those containing alcohol. 
100. 3- cinnamomi, TTlxx; 
Olei eucalypti, Flxx; 
Menthol, gr. xl; 
Camphor, gr. Ixxx; 
Petrolati albi fluidi, fgviij.-M. 
(Porch.) 
Antiseptic, emollient. 
101. 3- Mentholis, 
Camp horse, aa gr. x; 
Eucalyptalis, TQ.v; 
Liq. albolines, f 3 j; 
01. rosae comp., TTlv.-M. 
Sig.-As an emollient to inflamed mucous membranes. (Byrne.) 
For acute and subacute coryza, catarrh in the head passages, dry 
catarrh, ozena, and rhinitis. May be used regularly by public speakers, 
singers, actors, etc. A pleasant stimulant and protective. 
102. 1$. Chloretone, gm. 1; 
Camphoris, gm. 2.5; 
Mentholis, gm. 2.5; 
01. cinnamomi, gm. 0.5; 
Petrolati albi liquidi (albolene), gm. 93.5.-M. 
(McClintock.) 
Anodyne, antiseptic, emollient. Useful in acute and subacute catarrh 
and bronchitis. 
103. 3. Menthol, gr. xxx; 
Camphorse, gr. xxx; 
Cocainse muriatis, gr. xv; 
Tincturse benzoini, q. s. f§iv.-M. 
Use with nebulizer for acute bronchitis, pneumonia, and all acute 
inflammatory affections of the air-passages. Alcohol should be added 
occasionally, as the fluid becomes too thick from evaporation. 
109. 3- dei caryophylli (cloves), Flxxx; 
Creosotse (beechwood), 5j; 
Olei picis liquidse, 5j; 
lodini, _ gr. xxx; 
Tincturse benzoinse, q. s f§iv.-M. 560 
DISEASES OF THE NOSE, THROAT, AND EAR 
Use with nebulizer for pulmonary and laryngeal tuberculosis, and in 
any condition requiring an active antiseptic. Alcohol should be added 
occasionally, as the fluid becomes too thick from evaporation. 
105. 3. Olei cassiae, Blxxx; 
Camphor-menthol, 3 ij; 
Cocainae, gr. viij; 
Tincturae benzoini, q. s. f§iv.-M. 
Use with nebulizer for acute colds, sore throat, and in all cases of acute 
inflammation or congestion of the upper air-passages and middle ear. 
io6. I|. Ichthyol, Sijj 
Adeps lanse, 
Petrolati, aa 3j.-M. 
107. I|. Unguenti hydrargyri, 
Unguenti iodini, 
Unguenti belladonna, aa 3j--M. 
Both of the above ointments are effective applications in commencing 
mastoiditis and adenitis, etc. They should be smeared thickly over the 
parts and covered with waxed paper and a bandage. However, in spite 
of these precautions the ointments are liable to stain clothing, bed linen, 
etc. Therefore, an iodine ointment (Menley & James) which does not 
have these disadvantages is sometimes preferable. 
109. I}. Hydrargyri oxidi flavi, gr. vj; 
Olei petrolati, q. s.; 
Petrolati, 3j.-M. 
Useful as an application in eczema of the auricle after all scabs and crusts 
have been removed by means of hydrogen peroxid. This ointment should 
be well rubbed into the inflamed tissues, and a few applications is some- 
times sufficient to bring about a cure if care be exercised that purulent dis- 
charges from the tympanum are not allowed to come into contact with the 
skin of the auricle. 
In eczema of the canal the following is sometimes more effective: 
109. I). Acidi salicylici, gr. xxx; 
Zinci oxidi, 
Pulver is amyli, Sa $vi; 
Petrol, molis, gii.-M. 
no. 1$. Cocainae hydrochloridi, gr. xij; 
Adeps lanae, 3ij--M. 
Useful in relieving the pain of subacute catarrh of the middle ear, 
furunculosis, etc. An ointment penetrates the skin of the canal more 
readily than a watery solution. For the relief of the pain of aural neu- 
ralgia or acute catarrh the ointment is simply placed as deeply within the 
canal as possible. For the relief of the pain of furunculosis the ointment 
is smeared upon a cone of cotton, which is wedged into the meatus with as 
much pressure as the patient conveniently can bear. The pressure, at 
first painful, ultimately relieves congestion and discomfort. 
OINTMENTS FORMULAS 
561 
nr. 3. Phenol, 
Camphorae, 
Cocain hydroch, aa 5 ss.-M. 
When these three solids are mixed a liquid results. One drop placed 
in contact with the drum-head is more quickly effective in easing the 
pain of acute otitis than cocain ointment. 
PIGMENTS 
112. I|. lodini, gr. v-xv; 
Potassii iodidi, gr. xv-xlv; 
Glycerini, fgij.-M. 
113. I|. Boroglycerid, 50 per cent. 
114. 1$. Acidi tannici, gr. xl; 
Glycerini, f 5 j.-M. 
Formula 114 is an excellent application to the nasopharynx in the post- 
nasal catarrh of adults. In children Formula 112 generally yields better 
results. 
Formulas 112-114 may be used in the treatment of chronic hypertrophic 
rhinitis. The effects of the application vary with the amount of the solu- 
tion used. No more of the iodin solution should be applied at one time 
than will produce a momentary sensation of discomfot. Applied inside 
the crypts of the tonsils by means of a cotton-tipped probe bent at a right 
angle it often brings about a rapid absorption of the hypertrophied glands. 
However, Battey's solution (see Caustics) usually yields better results. 
DUSTING -POWDERS 
There is a well-founded prejudice against the use of dusting-powders in 
the larynx; same authors stating that they never should be used, because 
when thrown from the powder-blower they strike a blow upon the inflamed 
mucous membrane and remain as a foreign body until dissolved or expec- 
torated. However, as a matter of fact, the application of a powder to the 
laryngeal mucous membrane when gently and skilfully done is generally 
less disagreeable to the patient than the application of a fluid by means of 
a swab, and because of the prolonged action of the powder, as it slowly 
dissolves, sometimes produces better results. It should be borne in mind 
that a large amount of any powder thrown violently into the larynx fre- 
quently produces alarming spasm of the glottis. 
115. I). Menthol, gr. j; 
Sodii bicarbonatis, gr. ij; 
Magnesii carb, (levis), gr. iij; 
Cocainae hydrochloridi, gr. iv; 
Sacchari lactis, 3iss--M. 
Sig.-Use as snuff every two or three hours. 
The most marked relief follows the use of this powder, and a few appli- 
cations will do much to abort acute rhinitis. Its effects are immediate, 
highly agreeable to the patient, and continue for a number of hours. The 
preparation should be dispensed in a tightly corked vial to prevent evapo- 562 
DISEASES OF THE NOSE, THROAT, AND EAR 
ration of the menthol, and a pinch should be sniffed up into each nostril 
every two or three hours or sufficiently often to maintain the nose in a 
patulous condition and limit the secretions. As the result of the use of 
the snuff the patient remains practically free from all nasal symptoms 
during the attack, and there is no danger of contracting the cocain-habit 
where the laws, as in Pennsylvania, forbid the refilling of a prescription 
containing cocain without the consent of the physician. 
116. 1$. Argenti nitratis, gr. xxx; 
Zinci stearatis, 3j-M. 
The above is useful in the treatment of atrophic rhinitis. It should 
be applied either as a snuff or with the powder-blower to the nasal mucous 
membrane; its use is followed by a moderate amount of smarting and 
increased nasal discharge. 
117. I|. Zinci sulphatis 3j-iv; 
Sacchari lactis, §j; 
Acaciae, gr. x.-M. 
118. I|. Alumnol, 3j; 
Sacchari lactis 3ij.-M. 
Useful as applications to the laryngeal mucous membrane in acute and 
chronic laryngitis. In cases in which bronchitis as well as laryngitis is 
present the powder should be applied during deep inspiration, in order 
that it may reach the trachea and bronchi. 
119. 1$. lodoformis, ' gr. xxx; 
Acidi tannici, gr. xx; 
Bismuthi subnitratis, 3j.-M. 
Useful as an application in syphilitic and tubercular laryngitis 
120. I). Bismuth, subnitratis, 5ij; 
Acacias, gr. x; 
lodoformis, 5 ss; 
Morphiae sulphatis, gr. xx; 
Acidi tannici. gr. xxx.-M. 
Useful as an application to the laryngeal mucous membrane in tuber- 
cular and syphilitic laryngitis, in the earlier stages of acute laryngitis, or 
in any laryngeal affection characterized by irritability and pain. 
121. Orthoform. 
This nearly insoluble substance has the property of producing analgesia 
when applied to exposed nerve-endings. It is, therefore, especially valu- 
able as an application to irritable ulcers after they have been cleansed 
with Dobell's solution or hydrogen peroxid. Its anesthetic effects are 
increased by a previous application of a solution of cocain and persist for 
four or five hours. When insufflated into a tubercular larynx the powder 
produces a momentary smarting, followed by analgesia more or less 
complete, which persists as long as the powder adheres, to an abraded 
surface or an ulcer. The powder possesses decided antiseptic qualities 
and promotes the healing of tubercular ulcerations. It has little effect FORMULAS 
563 
upon the unbroken mucous membrane and its prolonged application to 
the skin in the neighborhood of ulcerations sometimes causes eczema. 
A nurse or one of the patient's friends can be taught to insufflate ortho- 
form into a tubercular larynx ten minutes before each meal, and in many 
instances thus secure complete relief from dysphagia. Orthoform is said 
to be non-toxic, and hence may be used locally in liberal quantities. In 
a certain proportion of cases anesthesin gives better results than otho- 
form in securing relief from pain. When ulcers exist, healing is best secured 
by insufflations of omorol: an'insoluble albuminate of silver. 
122. 3. Pulvis acidi borici. 
It is absolutely necessary that the powdered boric acid, insufflated 
within the tympanum as an application in the treatment of purulent 
inflammation, should be impalpable and free from all grit, as the sharp- 
pointed crystals of this substance are extremely irritating. A good plan 
is to test the powdered boric acid by rubbing a small quantity upon the 
lip with the tip of a finger, rejecting as unfit for use inside the ear those 
specimens that are "gritty." 
It is important also that too large a quantity of boric acid should not be 
thrown into the ear at one time or it may form a hard mass and thus pre- 
vent the escape of discharges. 
123. I). Acetanilid, 3 j; 
Acidi borici, gj.-M. 
Sig.-Use as a dusting-powder to infected or foul-smelling wounds after 
mastoid operations. 
Acetanilid, a derivative of anilin, is a white powder but slightly soluble 
in water and possessing decided antiseptic properties. It is, either alone 
or diluted with boric acid powder, a somewhat popular hospital dressing 
for superficial wounds "that are not doing well." It is especially useful 
in wounds after a mastoid operation where the discharges are foul smelling 
and the chiseled bone remains long uncovered by granulations. The 
powder, under such circumstances, should be thickly dusted into the 
wound. lodin is liberated when the substance is brought into contact 
with organic matter and acts as an antiseptic. 
124. Xeroform. 
Bismuth oxid, 49 per cent.; 
Tribromphenol, 50 per cent.-M. 
Xeroform or bismuth tribromphenol is an oderless synthetic product of 
the manufacturing chemists, and presumably has the sedative and as- 
tringent properties of bismuth combined with the marked antiseptic 
qualities of bromin and carbolic acid. As it has been given internally (5 
to 7 gm. daily) by Hueppe, during the cholera epidemic at Hamburg, in 
1893, with excellent results, it may be assumed that its local application to 
wounds and mucous membranes is absolutely devoid of danger of toxic 
effects. . Upon wounded or inflamed mucous membranes it is an astringent, 
analgesic, and an antiseptic. 
125. Novargan. 564 
DISEASES OF THE NOSE, THROAT, AND EAR 
May be used as an application to the nasal and tympanic mucous mem- 
brane in 2 to 15 per cent, solutions. It is proteinate of silver and soluble 
in water up to 50 per cent. 
126. T$. Aspirin (acetyl-salicylic acid). 
Sig.-Apply with a powder-blower to the tonsils three times a day after 
gargling with an alkaline solution. 
Dr. C. F. Kieffer, after investigation of the records of the army hospital 
at Fort Russell, Wyo., during ten years, states that 21.3 per cent, of the 
cases of acute articular rheumatism had a previous attack of tonsillitis, the 
time between the attacks averaging twenty-four days. He, therefore, 
treated a number of cases of acute tonsillitis by alkaline gargles and liberal 
applications of aspirin three times a day with the result of great local 
comfort and an average duration of the disease of three days. However, 
the duration of the disease was not lessened by the internal administra- 
tion of aspirin or salicylates. 
PROTECTIVES 
A useful formula as a protective to the nasal mucous membrane and for 
injection through a catheter into the middle ear is the following: 
127. 1$. Menthol, gr. v; 
Camphor, gr. xx; 
Petrolati albi liquidi, fgij.-M. 
Sig.-Use with an antomizer. 
To the above 1 or 2 drops of oil of eucalyptus, oil of pine-needles, or oil 
of cinnamon may be added. 
SEDATIVES 
128. Strontii bromidi, 5j; 
Sodii bromidi, 
Potassii bromidi, aa 5ij; 
Essentia pepsini, fgiv.-M. 
Sig.-i or 2 teaspoonfuls in a tumbler one-half full of water after meals 
and at bedtime. 
Useful in the useless cough of hysteric individuals. 
129. 3. Acidi hydrobromici diluti, f §ij. 
Sig.-15 to 30 drops in a tumbler of water one hour after meals. 
Hydrobromic acid also yields in the majority of cases somewhat better 
results in the treatment of tinnitus than bromid of sodium or the mixed 
bromids. 
130. 1$. Sumbul, gr. ij; 
Camphor, gr. j; 
Valeriani, gr. j; 
Ext. hyoscyam., gr. ss.-M. 
Pil. No. i. Ft. pit No. xxx. 
Sig.-One every two hours. 
Useful in cases where bromids are not advisable. FORMULAS 
565 
LOCAL SEDATIVES 
i31. Antipyrin, 
A solution of antipyrin of 2 to 4 per cent, strength, when sprayed upon 
the mucous membrane of the nose or pharynx, has the power of con- 
tracting the capillaries and of producing an artificial anemia, which effect 
is maintained for from three to five hours. Solutions of antipyrin may be 
used with the atomizer in all acute inflammations of the mucous membrane 
of the upper respiratory tract. When used after the application of cocain 
to the interior of the nose a 4 per cent, solution will maintain the contractile 
effect of cocain upon the erectile tissue for several hours. When sprayed 
upon the nasal mucous membrane without the previous application of 
cocain a 4 per cent, solution gives rise to a smarting sensation, which, how- 
ever, quickly subsides. Antipyrin solutions of the proper concentration 
applied to mucous membranes produce analgesia, but not local anesthesia. 
From 25 to 50 per cent, solution is extremely useful as a daily 
application to the larynx in all forms of laryngeal inflammation. 
A brush or a dossil of absorbent cotton wrapped about a bent 
probe should be saturated with the solution and applied to the 
glottis. The application of antipyrin solutions of the strength of 
50 per cent, and upward produces a burning sensation, quickly 
followed by a sensation of relief and comfort. Applied in this manner to 
the larynx antipyrin is not an anesthetic, but an analgesic, whose effects 
persist for several hours. In the strength of 5 to 10 per cent, solutions 
antipyrin is superior as an antiseptic to Van Swieten's liquid. In thera- 
peutic doses antipyrin acts as an antispasmodic, diminishing the reflex 
excitomotor power of the spinal cord, and also as an analgesic, relieving the 
pain of neuralgia and migraine, whether due to reflex nasal irritation or to 
some other cause. Applications of strong solutions of antipyrin to the 
larynx should be supplemented by the patient inhaling five or six times a 
day the spray from an atomizer containing a 4 per cent, solution. The 
effects of antipyrin upon the heart should, of course, be borne in mind 
and the patient, if weak, should be cautioned not to swallow any portion of 
the spray deposited in the mouth, and not to use too large a quantity of 
the solution at one time, although in a 4 per cent, solution there is in 1 
ounce only about 20 gr. of antipyrin, and much more than this amount in 
twenty-four hours probably could be used with impunity by most 
patients. 
132. I|. lodoformi, gr. lx; 
Ether, gij.-M. 
Sig.-Use as a spray for the larynx. 
133. 3. Resorcinol, gr. v; 
Adrenalin chlor., gr. ss; 
Acidi borici, gr. xv; 
Aquae camphorae (ferv.), §ss; 
Glycerini, $ss; 
Aquae dest. q. s. ad. gij.-M. 
Sig.-Use as a spray in nose four or five times daily as a local 
sedative. (Ingals.) 566 
DISEASES OF THE NOSE, THROAT, AND EAR 
134. 1$. Menthol, gr. j; 
Olei gaultheriae, Tfliij; 
Camphorae, gr. xv; 
Eucalyptol, TH.v; 
Adrenalin (1:1000), TH.xxiv; 
Petrolati albi, 
Adipis lanae, aa § ss.-M. 
Sig.-Apply to the inside of the nose every two hours as a sedative in 
acute rhinitis. (Byrne.) 
TONICS 
135. 3- Hydrarg. bichlor., gr. 
Acidi arseniesi, gr. J; 
Ferri pyrophos., gr. vj; ■ 
Quinise sulph., gr. xv.-M. 
Ft. pil. No. xxiv. 
Sig.-One after meals. (Seiler.) 
Useful as a tonic pill in catarrh of the nose and throat, with a debilitated 
condition of the system. 
136. I|' Ext. bellad. fol. ale., gr. iv; 
Quin, sulph., gr. xxij; 
Ferri sulph, exsic., gr. vij; 
Strych. sulph., gr. 
Acidi arsenosi, gr. 
Oleoresinae piperis, TTlviiss.-M. 
Ft. pil. No. xv. 
Sig.-A pill three times a day. 
In the treatment of the neuralgia of the ear, which is often a sign of 
defective nutrition and associated with anemia, the above combination is 
sometimes useful. 
137. Elixir ferri quininae et strychninae phosphatum. 
4 cc., or 1 fl. dr., representing about 0.06 gm. (1 gr.) ferric phosphate, 
0.03 gm. (j gr.) quinin, and 0.001 gm. (^ gr.) strychnin. 
Hematinic and nervine. 
138. Elixir glycerophosphatum, N. F. 
4 cc., or 1 fl. dr., representing 0.06 gm. (1 gr.) absolute sodiumglycero- 
phosphate and 0.03 gm. (J gr.) calcium glycerophosphate. 
Nerve tonic, reconstructive. 
139. 3. Hydrarg. chlor, corrosiv., gr. 
Arsen, triox., gr. J; 
Acidi hydrochloridi dil., fgiss; 
Tincturse ferri chlor., f 3iv; 
Elixir, calisaya, q. s. ad. f^iij.-M. 
Sig.-Teaspoonful in water after meals. INDEX 
Abductor paralysis of larynx, 
293 
spasmodic, 293 
Abscess, extradural, from otic 
disease, 496 
in mastoid, perforation of, 472 
of cerebellum from otic disease, 
497 
of cerebrum from otic disease, 
497 
of membrana tympani, 384 
of nasal septum, 144 
peritonsillar, 211 
treatment of, 212 
retropharyngeal, 241 
treatment of, 242 
subdural, from otic disease, 496 
Accessory sinuses of nose, dis- 
eases, 150 
differentiation, 155 
inflation, by Valsalva's 
method, 163 
operations on, accidents 
and dangers of, 191 
Acetanilid, 563 
Acetyl-salicylic acid, 564 
Acid, acetyl-salicylic, 564 
boric, 534 
powdered, 563 
carbolic, 542 
chromic, 542 
in otitis media suppurativa 
acuta, 421 
in treatment of anterior 
nasal hypertrophies, 81 
hydrobromic, 564 
in hay-fever, 108 
nitric, in aphonia, 549 
nitromuriatic, in hay-fever, 
108, 549 
trichloracetic, 542 
in treatment of anterior 
nasal hypertrophies, 81 
Acoustics, 330 
Actinomycosis of pharynx, 240 
of pharynx, treatment, 241 
Adam's apple, 250 
Adams' septum forceps, 146 
Adductor muscles, spasm of, 288 
paralysis of larynx, 291 
Adenoid curettes, 202 
forceps, Juracz's, 201 
Adenoids complicating otitis 
media catarrhalis sub- 
acuta, 400 
of pharyngeal tonsil, 199 
Aditus ad antrum, 320 
Adrenalin, 545 
effect of, on heart, 546 
in hay-fever, no, 546 
in nasal hemorrhage, 117 
secondary hemorrhage after, 
.546 
Aerial vibrations, 330 
Agger nasi, 59 
Air-bag, Politzer's, 343 
in otitis media catarrhalis 
acuta, 398 
Air-compressors for atomizers, 45 
Air-pump, water, 45 
Alse of nose, 56 
Albolene as nebulizer, 558 
Albuminuria in diphtheria, 301 
Alcohol, 539 
as nebulizer, 558 
Alexander's mastoid gouges, 469 
Allen's nasal applicator, 40 
with Gottstein's cotton 
Plug, 93 
probe, 41 
as applicator in Eustachian 
tube, 349 
for removing cerumen, 374 
speculum, 32 
Alligator forceps, 179 
Alteratives, 540 
Alypin as local anesthetic, 537 
Ammonium salts, lozenges, 553 
567 568 
INDEX 
Anemia of labyrinth, 516 
of larynx, 260 
Anesthesia, local, for removal of 
aural polypi, 537 
of ear, 537 
of tonsils, 537 
of larynx, 286, 536 
of nasal mucous membrane, 
106 
of pharynx, 243 
Anesthetic in tracheotomy, 308 
Anesthetics, local, 536 
Aneurysm of aorta, laryngeal 
paralysis from, 258 
Angina, Ludwig's, 233 
treatment of, 233 
Vincent's, 234 
treatment of, 235 
Angioma of larynx, 280 
of nose, 121 
Angle, hypertrophied, of nasal 
septum, 126 
Annulus tympanicus, 320, 455 
Anosmia, 106, 158 
Antipyrin, 565 
Antitoxin for hay-fever, 111 
Antrum, mastoid, 325 
of Highmore, illumination, 161 
inflammation, 158 
Caldwell-Luc, operation, 
167 
Cowper's treatment, 164 
Denker's operation, 169 
diagnosis, 160 
etiology, 158 
Janson's operation, 167 
pathology, 159 
prognosis, 163 
radical operations, 166 
symptoms, 160 
treatment, 163 
soft spot, 161 
Anvil bone of ear, 321, 322 
Aorta, aneurysm of, laryngeal 
paralysis from, 258 
Aphonia, nitric acid in, 549 
Aponeurosis, pharyngeal, 193 
Argyrol, 539 
Arteries of auricle of ear, 315 
of Eustachian tube, 325 
of larynx, 257 
of nasal fossae, 61 
of nose, 58 
of pharynx, 194 
Arteries of tympanum, 323 
Aryepiglottic fold, 27 
Arytenoid cartilages, 27, 252 
Arytenoideus muscle, 254 
Arytenoids, pyriform, 275 
Aspirin, 564 
Asthma, climate for, 544 
hay-, 107 
miller's, 107 
Astringents, 538 
Atomizer, 41 
air-compressors for, 45 
DeVilbiss, 42 
for home use, 41, 44 
sterilization of, 52 
Atrium of tympanum, 318 
Atrophic pharyngitis, 229 
treatment, 229 
rhinitis, 91. See also Rhinitis, 
atrophic. 
Attic of tympanum, 318 
Auditory canal, external, 315. 
See also External audi- 
tory canal. 
nerve, 329 
Aural auscultation-tube, 341 
cholesteatoma, 433 
polypi, 428 
removal of, anesthesia for, 
537 
stethoscope, 341 
Auricle of ear, 314 
arteries of, 315 
burns of, 356 
cleft lobule, 354 
congenital defects, 350 
cutaneous diseases, 354 
cyst of, 356 
dermatitis of, 355 
eczema of, 361 
erysipelas of, 359 
phlegmonous, 360 
frost-bite of, 355 
gangrene of, 360 
hematoma of, 352 
herpes of, 357 
hyperemia of, 355 
impetigo contagiosa of, 357 
keloid of, 354 
lupus vulgaris of, 357 
muscles of, 315 
nerves of, 315 
new growths on, 362 
othematoma of, 352 INDEX 
569 
Auricle of ear, perichondritis of, 
352 
chronic, 353 
skin diseases, 354 
syphilis of, 358 
veins of, 315 
vessels of, 315 
wounds of, 353 
Auscultation of ear, 346 
Auscultation-tube, aural, 341 
Toynbee's, 342 
Autolaryngoscopy, 25 
Autophony, 406 
Autumnal catarrh, 107 
Axial ligament of malleus, 321 
Babinski's sign in intracranial 
complications of dis- 
eases of ear, 491 
Bacteria in blood, 493 
Bacteriemia, 493 
Ballance's method of skin-graft- 
ing, 483 
Ballenger's double elevator, 139 
ethmoid knife, 183 
modification of Gleason's opera- 
tion for deviated sep- 
tum, 136 
operation for ethmoiditis, 183 
septum knife, 138 
swivel knife, 141 
Basophiles, 494 
Battey's solution, 542 
Beckmann's scissors, 85 
Bellocq's cannula in nasal hemor- 
rhage, 120 
Bell's palsy from otic disease, 509 
Benzoin, compound tincture of, 
48, 540 
Bernay's sponge, 115 
Bichlorid of mercury, 534 
Bifid uvula, 247 
Bing's test for hearing, 337 
Biniodid of mercury, 535 
Bismuth tribromphenol, 563 
Blake's cannula, 44 
polypus snare, 421 
Blood, bacteria in, 493 
coagulation time of, 493 
discharge of, from labyrinth, 
significance, 517 
examination of, in intracranial 
complications of mas- 
toiditis, 492 
Blood-plaques, 493 
Blood-supply of tonsils, 197 
Boekel's automatic cut-off, 46 
Bone drills, 89 
electric-motor, 90 
for exostoses of septum, 89 
Boric acid, 534 
powder, 563 
Bosworth's operation for devi- 
ated septum, 130 
saw, 88 
tongue-depressor, 25 
Bottle-inhaler, 48 
Boucheron's specula, 37 
Bougies, Eustachian, 349 
Breathing, mouth-, 77 
Bridge of nose, flattening, 146 
Bright's disease, otitis media 
from, 441 
Bronchitis in diphtheria, 301 
Bronchopneumonia in diphtheria, 
301 
Bronchoscopy, direct, 29 
Brown and Price's modification 
of Gleason's operation 
for deviated septum, 
136 
Bucklin's saw, 88 
Buried tonsil, 214 
Burns of auricle, 356 
Bursitis, chronic, 206 
Cabinet, Pynchon's, 47 
Calcium chlorid, 547 
Caldwell-Luc operation for in- 
flammation of antrum 
of Highmore, 167 
Callus, provisional, of nasal sep- 
tum, 126 
Caloric tests for nystagmus, 523 
Camphomenthol lozenges, 552 
Canalis reuniens, 325, 328 
Cannula, Bellocq's, in nasal 
hemorrhage, 120 
Blake's, 44 
Hartmann's frontal sinus, 174 
Carbolic acid, 542 
Carcinoma of larynx, 282- 
treatment, 284 
of nose, 121, 125 
treatment, 125 
Caries in mastoiditis, 459, 460 
of temporal bone, 430 
Carter's nasal splint, 146 570 
INDEX 
Cartilage, columnar, dislocation 
of, 143 
cricoid, 251 
sesamoid, 56 
supravomerine, 57 
thyroid, 250 
triangular, of nose, 57 
vomerine, 57 
Cartilages, arytenoid, 27, 252 
of larynx, 250 
of Santorini, 2 53 
of Wrisberg, 27, 253 
pitcher-shaped, 252 
Santorini's, 27 
Catarrh, acute, 65 
autumnal, 107 
chronic, 65 
of larynx, climate for, 544 
of nose, climate for, 544 
of pharynx, climate for, 544 
of frontal sinus, 170 
of middle ear, 392. See Otitis 
media. 
postnasal, 199 
Catching cold,. 63 
Catheter, Eustachian, 343 
Hartmann's, 344 
inflation of middle ear 
through, 347 
introduction of, into Eusta- 
chian tube, 344 
medication through, 348 
spraying through, 347 
test of patency of Eustachian 
tubes, 343 
Catheterization of Eustachian 
tubes, 343 
introduction of catheter, 
344 
obstacles to, 345 
Caustic, hydrogen peroxid as, 535 
Caustics, 542 
Cautery knives, 82 
Cells, ethmoid, diseases of, 181 
hyperplasia of, 181 
inflammation of, 181 
Ballenger's operation, 183 
Hajek's operation, 184 
suppuration of, 181 
hearing, 328 
sphenoidal, empyema of, 186 
Hajek's operation, 188 
Skillern's modifica- 
tion, 189 
Cells, sphenoidal, empyema of, 
treatment, 187 
Cerebellar nystagmus, 521 
Cerebellum, abscess of, from otic 
disease, 497 
Cerebrospinal rhinorrhea, 113 
Cerebrum, abscess of, from otic 
disease, 497 
Cerumen, impacted, 375 
removal of, 376 
Chalk deposits on membrana 
tympani, 386 
Chemic rhinitis, 63 
Chink of glottis, 27, 256 
Chisel, Killian's frontal sinus, 168 
Chloroform, 554 
Choanae, 30 
Cholesteatoma, aural, 433 
Chorda tympani nerve, 323 
Chorea, laryngeal, 287 
Chromic acid, 542 
in otitis media suppurativa 
acuta, 421 
in treatment of anterior 
nasal hypertrophies, 81 
Chromium sulphate, 557 
Cleft lobule of auricle, 354 
Clergyman's sore throat, 227 
Climate for asthma, 544 
for chronic fibroid phthisis, 544 
for hay-fever, 544 
for pulmonary tuberculosis, 544 
for tubercular laryngitis, 544 
Climatology, 543 
Coagulation time of blood, 493 
Coagulose in hemophilia, 120 
Cocain, 536 
in hay-fever, 109, no 
in lanolin, 536 
lozenges, 553 
poisoning, 538 
Cochlea, function of, 329 
Cold, catching, 63 
cow, 107 
horse, 107 x 
in head, 64, 68 
peach, 107 
rose, 107 
snow, 107 
Collodion, contractile, 554 
Columnar cartilage, dislocation, 
143 
Comedones, 58 
Concussion of labyrinth, 517 INDEX 
571 
Conjunctival reaction in tuber- 
culosis, 557 
Contractile collodion, 554 
Corti's organ, 328 
rods, 328 
Coryza, 64 
vasomotoria periodica, 107 
Cotton applicator, 40 
Cough, laryngeal, spasmodic, 287 
mixtures, 542 
useless, 228 
Cow cold, 107 
Cowper's treatment of inflamma- 
tion of antrum of High- 
more, 164 
Crest, vomerine, 58 
Crico-arytenoideus lateralis mus- 
cle, 254 
posticus muscle, 255 
Cricoid cartilage, 251 
Cricothyroid muscle, 254 
Crisis, laryngeal, 293 
Croup, false, 288 
kettle, 550 
formulas for use with, 550 
Croupous inflammation of 
Schneiderian mem- 
brane, 65 
tonsillitis, 206 
Crypts of tonsils, 196 
Curet, adenoid, 202 
Fetterolf's, 202 
Gleason's, 468 
Gottstein's, 202 
Whiting's, 466 
Curvature of membrana tym- 
pani, changes in, 379 
Cutaneous diseases of auricle, 354 
reactions in tuberculosis, 557 
Cyst of auricle, 356 
of larynx, 280 
of nose, 121, 123 
of tonsil, 214 
Cystocele of frontal sinus, 181 
Davidson's powder-blower, 49 
Deafness from otitis media sup- 
purativa chronica, oper- 
ation for, 446 
hysteric, 517 
in otitis media catarrhalis 
chronica, 405 
middle-ear and internal-ear, 
differentiation, 515 
Debility, otitis media from, 442 
Delstanche's masseur, 40 
Denker's operation for inflamma- 
tion of antrum of High- 
more, 169 
Dermatitis of auricle, 355 
Destruction disharmony, 526 
Detergents, aqueous, 533 
De Vilbiss atomizer, 42 
Diabetes, otitis media from, 441 
Dilator, Jansen's, 468 
Dionin, 541 
Diphtheria, 296 
albuminuria in, 301 
bronchitis in, 301 
bronchopneumonia in, 301 
classification, 297 
complications, 300 
diagnosis, 301 
endocarditis in, 301 
epistaxis in, 300 
etiology, 296 
extubation in, 307 
faucial, 297 
intubation in, 304 
accidents following, 306 
feeding in, 308 
inability to breathe after, 
3°7 
treatment of patient, 307 
laryngeal, 297, 299 
malignant, 297 
mild, 297 
nasal, 297, 299 
otitis media from, 438 
otorrhea in, 301 
paralysis in, 299' 
pathology, 296 
pericarditis in, 301 
pleurisy in, 301 
prophylaxis, 302 
serum treatment, 303 
severe, 297 
symptoms, 297 
systemic infection, 300 
toxemia in, 300 
tracheotomy in, 308. See also 
Tracheotomy. 
treatment, 301, 302 
local, 302 
operative, 304 
prophylactic, 302 
serum, 303 
well-marked, 297 INDEX 
572 
Diphtheritic inflammation of 
Schneiderian membrane, 
66 
paralysis, 299 
Diploetic mastoid, 457 
Disharmony, destruction, 526 
stimulated, 526 
Dislocation of columnar cartilage, 
_ 143 
of nasal septum, 145 
Dobell's solution, 533 
Dog nose, 99 
Drill, bone, 89 
electric-motor, 90 
for exostoses of septum, 89 
Gleason's, 90 
Drum-head, 316. See also Mem- 
brana tympani. 
Ductus cochlearis, 325, 327, 328 
Dusting-powders, 561 
Dysacousma, 406 
Dysesthesia acoustica, 406 
Ear, 314 
anatomy of, 314 
anesthesia of, 537 
auscultation of, 346 
anvil bone of, 321, 322 
auricle of, 314. See also 
A uricle of ear. 
cholesteatoma of, 433 
diseases of, intracranial com- 
plications, 490 
pathologic conditions of nose 
causing, 339 
of pharynx causing, 339 
examination of, 54 
external, 314. See also Exter- 
nal ear. 
forceps, Politzer's, 385 
hammer bone of, 321 
internal, 314, 325. See also 
Labyrinth. 
lobule of, 315 
middle, 314, 316. See also 
Middle ear. 
polypi in, 428 
removal of, anesthesia for, 
537 
specula, 36 
stirrup bone of, 321, 322 
syringe, soft-rubber, 43 
Ear-spout, metal, 378 
Ecchondroma of nose, 121 
Ecchondroses of septum, 85 
treatment, 86-90 
Eczema of auricle, 361 
Edema, infraglottic, 270 
of glottis, 270 
of larynx, acute, 270 
Electric tests for nystagmus, 524 
Electrolysis in stricture of Eusta- 
chian tube, 350, 414 
Elevator, Ballenger's double, 139 
Freer's, 140 
Elongation of uvula, 248 
Empyema of labyrinth, 525 
of sphenoidal cells, 186 
Hajek's operation, 188 
Skillern's modifica- 
tion, 189 
treatment, 187 
Encephalitis, diffuse, 498 
localized, 498 
Encephaloscope, Whiting's, 500 
Endelmann-Galton whistle, 332 
Endocarditis in diphtheria, 301 
Endolabyrinthitis, 525 
Endolymph, 326 
Entotic use of speaking-trumpet 
in testing hearing, 338 
Eosinophiles, 494 
Epiglottis, 250, 253 
muscles of, 256 
turban-shaped, 275 
Epilepsy, laryngeal, 290 
Epinine, 545 
Epistaxis, 113. See also Nasal 
hemorrhage. 
Epithelial plug in auditory canal, 
378 
Equinia of pharynx, 239 
Erectile tissue of nose, 60 
Ermold's tonsillotome, 216 
Erysipelas of auricle, 359 
phlegmonous, 360 
of pharynx, 231 
treatment, 232 
Ethmoid cells, 152 
diseases of, 181 
hyperplasia of, 181 
inflammation of, 181 
Ballenger's operation, 183 
Hajek's operation, 184 
suppuration of, 181 
hook, Hajek's, 184 
knife, Ballenger's, 183 
Ethmoiditis, 181 INDEX 
573 
Eucain as local anesthetic, 537 
Eustachian bougies, 349 
catheter, 343 
Hartmann's, 344 
inflation of middle ear 
through, 347 
introduction of, into Eusta- 
chian tube, 344 
medication through, 348 
spraying through, 347 
tube, 324 
Allen's probe as applicator 
in, 349 
arteries of, 325 
catheterization of, 343 
introduction of catheter, 
344 
obstacles to, 345 
examination, 55 
introduction of catheter into, 
344 
muscles of, 324 
nerves of, 325 
patency of, 341 
catheter test, 343 
in chronic otitis media, 410 
Politzer's test, 341 
Valsalva's test, 341 
pharyngeal mouths of, 341 
stricture of, 413 
diagnosis, 413 
electrolysis in, 350, 414 
inflation in, 414 
massage in, 414 
phonomassage in, 415 
pneumomassage in, 415 
tinnitus in, 416 
treatment, 414 
Ewald's law, 520 
Examination of patients, 53 
Exostoses of external auditory 
meatus, 370 
of nose, 121 
of septum, 85 
treatment, 86-90 
External auditory canal, 315 
circumscribed inflamma- 
tion of acute, 362 
diseases of, 362 
epithelial plug in, 378 
exostosis of, 370 
foreign bodies in, 371 
removal, 373 
furunculosis of, 362 
External auditory canal, hyperos- 
tosis of, 370 
inflammation of, 362. See 
also Otitis. 
insects in, 371 
mycosis of, 368 
osteoma of, 370 
washing out of, 377 
ear, 314 
congenital defects, 350 
diseases, 350 
fistula about, 350 
of newborn, 452 
Extradural abscess from otic 
disease, 496 
Extubation in diphtheria, 307 
Eye syringe, soft-rubber, 43 
Face, frog, 123 
Facial nerve in newborn, 455 
wounding of, in mastoid 
operation, 479 
paralysis from otic disease, 509 
diagnosis, 513 
prognosis, 514 
symptoms, 511 
treatment, 514 
False croup, 288 
vocal cords, 256 
Falsetto voice, 259 
Farcy of pharynx, 239 
Fatigue, excessive, otitis media 
from, 442 
Faucial diphtheria, 297 
tonsils, 195 
Fenestra ovalis, 320 
rotunda, 320 
Fetterolf's curet, 202 
files, 137 
Fibroma, nasopharyngeal, 123 
of larynx, 280 
of nose, 121, 123 
Files, Fetterolf's, 137 
Finger test for nystagmus, 523 
Fissure, Glaserian, 320 
Fistula about external ear, 350 
test for nystagmus, 525 
Flattening of bridge of nose, 146 
Follicular pharyngitis, 226 
chronic, 227 
tonsillitis, acute, 206 
treatment of, 209 
chronic, 210 
treatment of, 210 574 
INDEX 
Foramen of Rivini, 379, 389 
Forceps, Adams' septum, 146 
alligator, 179 
Hartmann's, 466 
foreign body and polyp, 385 
Juracz's adenoid, 201 
Politzer's ear, 385 
Struycken's, 84 
Foreign bodies in external audi- 
tory canal, 371 
removal, 373 
in larynx, 284 
treatment, 285 
in nose, 104 
in pharynx, 245 
treatment, 246 
Formulas, 533 
alteratives, 540 
anesthetics, local, 536 
aqueous detergents, 533 
astringents, 538 
caustics, 542 
cough mixtures, 542 
dusting-powders, 561 
for croup kettle, 550 
for hay-fever, 548 
for inhaler, 550 
for nebulizers, 557 
gargles, 545 
hemostatics, 545 
hypnotics, 547 
local sedatives, 565 
lozenges, 550 
miscellaneous, 554 
ointments, 560 
pigments, 561 
protectives, 564 
sedatives, 564 
sprays, 533 
tonics, 566 
washes, 533 
Fossa mastoid, 474 
supratonsillaris, 195 
Fossae of nose, arteries, 61 
nerves, 61 
Foster's speculum, 140 
Fox's head-band, 18 
Frambesia, 99 
Freer's elevators, 140 
septum knife, 138 
Frog face, 123 
Frontal sinus, catarrh of, 170 
cystocele of, 181 
diseases, 169 
Frontal sinus, inflammation of, 
169 
treatment, 171 
mucocele of, 181 
purulent disease of, chronic, 
J 74 
Killian's operation 
for, 177 
Frontonasal canal, 171 
Frost-bite of auricle, 355 
Furunculosis of external auditory 
canal, 362 
Galton-Edelmann whistle, 332 
Galvanocautery for removal of 
anterior nasal hyper- 
trophies, 78 
handle, 81 
in chronic follicular pharyn- 
gitis, 229 
Galvanopuncture for hypertro- 
phied tonsils, 215 
Gangrene of auricle, 360 
Gangrenous inflammation of 
neck, 233 
Gargles, 545 
Gelle's test for hearing, 337 
Genital spots, nasal, 107 
Glanders of pharynx, 239 
Glaserian fissure, 320 
Glass instruments, sterilization, 
5i 
Gleason's antrum rasp, 166 
curette, 468 
electric-motor drill, 90 
head-band, 19 
nasal tubes, 135 
operation for deviated septum, 
130 
Ballenger's modifica- 
tion, 136 
modifications, 136 
Price and Brown'S modi- 
fication, 136 
speculum, 32 
Globus hysterias, 244 
Glosso-epiglottic fold, 27 
fossae, 27 
Glottis, 27, 256 
chink of, 27, 256 
edema of, 270 
Glycerin as nebulizer, 557 
Goiter, lingual, 225 
Gottstein's curet, 202 INDEX 
575 
Gottstein's curet, treatment of 
atrophic rhinitis, 93 
Gouges, Alexander's, 469 
Goundou, 99 
Granular spots on membrana 
tympani, 384 
Gruber's method of catheteriza- 
tion of Eustachian tubes, 
345 
Guaiacum lozenges, 551 
Habitus lymphaticus, 203, 222 
Hajek's ethmoid hook, 184 
operation for empyema of 
sphenoidal cells, 188 
Skillern's modifica- 
tion, 189 
operation for ethmoiditis, 184 
Hall's saws, 88 
Hammer bone of ear, 321 
Hard tonsil, 214 
Hard-rubber nozzles, steriliza- 
tion, 51 
Harmony, 333 
Hartmann's Eustachian catheter, 
344 
forceps, 466 
foreign body and polyp forceps, 
385 
frontal sinus cannula, 174 
Haseltine's operation for septal 
perforations, 145 
Hassler's site of predilection, 433 
Hay-asthma, 107 
Hay-fever, 107 
adrenalin in, no, 546 
antitoxin for, in 
climate for, 544 
cocain in, 109, no 
etiology, 107 
hydrobromic acid in, 108 
hypersensitiveness, 109 
mineral acids in, 108, 549 
nitromuriatic acid in, 108, 549 
pollantin in, in 
prognosis, in 
remedies for, 548 
symptoms, 108 
treatment, 108 
Head, cold in, 64 
noises in otitis media catar- 
rhalis chronica, 407 
Head-band, Fox's, 18 
Gleason's, 19 
Hearing cells, 328 
in mastoiditis, 463 
in otitis media catarrhalis 
chronica, 405 
tests for, 54, 330, 332 
Bing's, 337 
entoticuse of trumpetfor, 338 
Gelle's, 337 
pressions centripetes, 337 
Rinne's, 335 
Schwabach's, 337 
voice, 339 
watch, 338 
Weber's, 334 
Heart, effect of adrenalin on, 546 
Heath's radical mastoid opera- 
tion, 486 
Hematoma of auricle, 352 
of nasal septum, 143 
treatment, 144 
Hemoconias, 493 
Hemophilia, 113 
treatment, 120 
Hemophysis, remedies for, 547 
Hemorrhage into labyrinth, 518 
nasal, 113. See also Nasal 
hemorrhage. 
secondary, from adrenalin, 546 
Hemostatic, hydrogen peroxid 
as, 536 
Hemostatics, 545 
Henpue, 99 
Herpes of auricle, 357 
Heryng's laryngeal lancets, 
knives, and curettes, 
271 
Hexamethelamin, 556 
Hiatus semilunaris, 171 
Highmore, antrum of, inflamma- 
tion, 158. See also 
Antrum of Highmore, 
inflammation. 
Hinsberg's operation for laby- 
rinthitis, 530 
Hogge's law, 520 
Holmes' nasopharyngoscope, 36 
Horse cold, 107 
serum in nasal hemorrhage, 547 
Hot-air apparatus, 49 
Hydrargyrum, 540, 541 
Hydrobromic acid, 564 
in hay-fever, 108 
Hydrogen dioxid, 535 
peroxid, 535, 536 576 
INDEX 
Hydrorrhea, nasal, m 
treatment of, 112 
Hyperemia of auricle, 355 
of labyrinth, 516 
of larynx, 260, 286 
Hyperesthesia of nasal mucous 
membrane, 106 
of pharynx, 244 
Hyperkeratosis of pharynx, 230 
treatment, 231 
Hyperosmia, 106 
Hyperostosis of external auditory 
canal, 370 
Hyperplasia of ethmoid cells, 181 
Hyperplastic rhinitis, 75 
Hypertrophic rhinitis, 75 
Hypertrophied angle of nasal 
septum, 126 
Hypertrophies, anterior nasal, 
removal of, 78 
chromic acid for, 81 
galvanocautery for, 78 
trichloracetic acid for, 81 
posterior nasal, removal of, 82 
Hypertrophy of lingual tonsil, 224 
of pharyngeal tonsil, 199 
of tonsils, 214 
chronic, 214 
galvanopuncture in, 215 
soft, 214 
tonsillectomy in, 217 
tonsillotomy with tonsillo- 
tome in, 215 
treatment, 215 
Hypnotics, 547 
Hypotympanic space, 481 
Hysteric deafness, 517 
Hurd's separator and pillar re- 
tractor, 211 
Illumination of antrum of 
Highmore, 161 
Immunity, functions of tonsils 
and, 198 
Impached cerumen, 375 
removal, 376 
Impetigo contagiosa of auricle, 
357 . 
Incudostapedial articulation sev- 
ering of, 442 
Incus, 321, 322 
malleus, and membrana tym- 
pani, removal of, in 
suppurative cases, 447 
Infiltration, submucous, of nasal 
septum, 145 
Inflammation, acute circum- 
scribed, of external audi- 
tory canal, 362 
gangrenous, of neck, 233 
of antrum of Highmore, 158. 
See also Antrum of 
Highmore, inflammation. 
of ethmoid cells, 181 
Ballenger's operation, 183 
Hajek's operation, 184 
of frontal sinus, 169 
treatment, 171 
of mucous membrane of nose, 
65. See also Schneider- 
ian membrane, inflam- 
mation of. 
of submucous tissue of larynx, 
270 
of uvula, 246 
treatment, 247 
Influenza, otitis media from, 439 
Infraglottic edema, 270 
laryngoscopy, 26 
Infundibulum, 171 
Inhaler, formulas for, 550 
Inhalers, 48 
bottle-, 48 
Insects in external auditory canal, 
371 
Instruments for examination, 
sterilization, 50 
for tracheotomy, 309 
for treatment, sterilization, 
glass, sterilization of, 51 
sterilization of, 50 
Internal ear, 314, 325. See also 
Labyrinth. 
Intracranial complications of otic 
disease, 490 
Intubation in diphtheria, 304 
in diphtheria, accidents follow- 
ing, 306 
feeding in, 308 
inability to breathe after, 307 
treatment of patient, 307 
lodid of potassium, 540 
of sodium, 540 
lodin, 554 
Iter chordae anterius, 320 
posterius, 320 
Jacobson's nerve, 323 INDEX 
577 
Jansen's dilator, 468 
operation for inflammation of 
antrum of Highmore, 
167 
Jarvis' snare, 78 
Joint, malleo-incudal, 322 
Juracz's adenoid forceps, 201 
Kahler tracheobronchoscope, 27 
Keloid of auricle, 354 
Keratosis obturans, 378 
Kernig's sign in intracranial com- 
plications of diseases of 
ear, 491, 492 
Killian's apparatus for suspen- 
sion laryngoscopy, 28 
frontal sinus chisel, 168 
operation for chronic purulent 
disease of frontal sinus, 
177 
speculum, 31 
O'Reilly's modification, 31 
Knife, Ballenger's ethmoid, 183 
Ballenger's septum, 138 
swivel, 141 
cautery, 82 
Freer's septum, 138 
Myles' tonsil, 211 
Korner's method of skin-grafting, 
, 483 
Krause s nasal and laryngeal 
snares and curette for- 
ceps, 283 
Kyle's operation for deviated 
septum, 137 
Labyrinth, 314, 325 
and middle-ear deafness, differ- 
entiation, 515 
anemia of, 516 
bloody discharge from, sig- 
nificance, 517 
concussion of, 517 
empyema of, 52.5 
hemorrhage into, 518 
hyperemia of, 516 
inflammation of, 525. See also 
Labyrinthitis. 
osseous boundaries of, 325 
contents of, 325 
saccule of, 325 
static, diseases of, 519 
syphilis of, 517 
utricle of, 325 
Labyrinth, vestibule of, 325 
Labyrinthitis, 525 
circumscribed, 525, 526 
differential diagnosis, 528 
diffuse, 525 
serous, 527 
suppurative, 527 
Hinsberg's operation for, 530 
Neumann's operation for, 530 
treatment, 529 
La grippe, otitis media from, 439 
Lamina papyracise, 179 
reticularis, 328 
spiralis ossea, 326 
Laryngeal chorea, 287 
cough, spasmodic, 287 
crisis, 293 
diphtheria, 297, 299 
epilepsy, 290 
image, 26 
bringing into view, 23 
normal, 26 
mirror, 17 
introduction, 22 
temperature, 22 
nerve, recurrent, 258 
superior, 258 
paralysis from aneurysm of 
aorta, 258 
sound, 40 
vertigo, 290 
treatment, 291 
Laryngismus stridulus, 288 
treatment, 289 
Laryngitis, acute, 261 
treatment of, 262 
chronic, 266 
treatment of, 267 
sicca, 268 
treatment, 269 
subacute, 263 
treatment of, 265 
syphilitica, 271 
tubercular, 273 
climate for, 544 
differential diagnosis, 275 
treatment of, 277 
Laryngology, 21 
Laryngopharynx, 194 
Laryngoscope, 17 
Killian's, 28 
laryngeal mirror of, 17 
reflector of, 17, 18 
method of wearing, 19 578 
INDEX 
Laryngoscopy, 21 
direct, 27 
advantages of, 30 
infraglottic, 26 
Killian's apparatus for, 28 
laryngeal mirror of introduc- 
tion, 22 
temperature, 22 
light for, 19 
obstacles to, 23 
source of light in, 20 
suspension, 27-29 
tongue in, controlling, 23 
Laryngotomy, 310 
Laryngotracheotomy, 310 
Larynx, 250 
anatomy of, 250 
anemia of, 260 
anesthesia of, 286, 536 
angioma of, 280 
arteries of, 257 
carcinoma of, 282 
treatment, 284 
cartilages of, 250 
catarrh of, chronic, climate for 
544 
cyst of, 280 
diseases of, 260 
edema of, acute, 270 
fibroma of, 280 
foreign bodies in, 284 
treatment, 285 
hyperemia of, 260 
hyperesthesia of, 286 
leprosy of, 279 
treatment, 280 
ligaments of, 254 
mucous membrane of, 257 
muscles of, 254 
myxoma of, 280 
nerves of, 258 
neuroses of, 286 
motor, 287 
sensory, 286 
papilloma of, 280 
paralysis of, 291. See also 
Paralysis of larynx. 
paresthesia of, 286 
size of, 258 
spasm of, 287 
submucous tissue, inflamma- 
tion of, 270 
syphilis of, 271 
tumors of, 280 
Larynx, tumors of, treatment, 281 
veins of, 257 
ventricles of, 257 
ventricular bands, 256 
Law, Ewald's, 520 
Hogge's 520 
Semon's, 293 
Leeches in otitis media catar- 
rhalis acuta, 396 
Leprosy of larynx, 279 
treatment, 280 
of nose, 102 
Leprous pharyngitis, 237 
Leptomeningitis, purulent, from 
otic disease, 501 
serous, from otic disease, 495 
Leukocytes, 494 
Leukocytosis in intracranial com- 
plications of diseases of 
ear, 494 
Levator palati muscle, 324 
Ligaments of larynx, 254 
Ligamentum obturatorium stape- 
dius, 322 
Light for laryngoscopy, 19 
Line, Zuckerkandl's, 187 
Linea temporalis, 474 
Lingual goiter, 225 
tonsils, 195 
diseases, 224 
hypertrophy of, 224 
Liquor antiseptici, 534 
alkalinis, 534 
argenti nitratis, 539 
Little wonder pump, 45 
Lobule of auricle, cleft, 354 
of ear, 315 
Lowenburg's method of catheteri- 
zation of Eustachian 
tubes, 345 
Lozenges, 550 
ammonium salts, 553 
camphomenthol, 552' 
cocain, 553 
guaiacum, 551 
miscellaneous, 553 
voice, 554 . 
Ludwig's angina, 233 
treatment, 233 
Lumbar puncture in intracranial 
complications of dis- 
eases of ear, 491 
Lupus, 101 
congestiva, 101 INDEX 
579 
Lupus erythematosa, 101 
sebaceous, 101 
superficialis, 101 
vulgaris, 101 
of auricle, 357 
of pharynx, 238 
treatment, 239 
treatment, 102 
Lymphatics of nose, 61 
of pharynx, 195 
Lymphocytes, 494 
Macewen's triangle, 474 
Maggots in nose, 103 
Malignant growths of tonsils, 
best way of removing, 
. 197 
Malleo-incudal joint, 322 
Malleus, 321 
axial ligament of, 321 
ligaments of, 321 
membrana tympani, and incus, 
removal of, in suppura- 
tive cases, 447 
Martin's tonsil snare, 218 
Massage of middle ear in stric- 
ture of Eustachian tube, 
414 
Masseur of Delstanche, 40 
Mastoid antrum, 325 
curette, Whiting's, 466 
fossa, 474 
gouges, Alexander's, 469 
operation, 465 
accidents during, 476 
after-technic, 475 
incision for, 467 
instruments for, 465 
opening horizontal semicir- 
cular canal in, 479 
posterior cranial fossa in, 
477. 
preparation of patient, 465, 
466 
radical, 480 
causes of failure after, 
483 
skin-grafting after, 482 
Ballance's method, 483 
Korner's method, 483 
Panse's method, 482 
Passow's modifica- 
tion, 483 
Thiersch's method, 483 
Mastoid operation, radical, sinus 
thrombosis after skin- 
grafting, 504 
technic, 465 
wounding facial nerve in, 479 
wounding lateral sinus in, 477 
process, abscess in, perforation 
°f, 472 
diploetic, 457 
in adults, 456 
of temporal bone, 325 
pathologic importance of 
types, 457 
pneumatic, 456 
pneumodiploetic, 457 
sclerosed, 457 
tip of, removal, 472 
Mastoiditis, 452 
atypical cases, 462 
caries in, 459, 460 
complications, 460 
etiology, 458 
hearing in, 463 
latent, 462 
necrosis in, 459, 460 
operation for, 465. See also 
Mastoid operation. 
operative cases, 461 
otorrhea in, sudden cessation, 
461 
pathology, 458 
prognosis, 465 
sudden cessation of discharge 
in, 461 
symptoms, 460 
tenderness in, 462 
treatment, 463 
Measles, otitis media from, 438 
Meati of nose, 59, 60 
Membrana basilaris, 326 
flaccida, 316 
propria, 317 
sectoria, 328 
tensor, 317 
tympani, 316 
abscess of, 384 
artificial contrivance for in- 
troducing, 392 
Toynbee's, 392 
chalk deposits on, 386 
curvature of, changes in, 379 
discharge from, 384 
diseases of, 379 
granular spots on, 384 580 
INDEX 
Membrana basilaris, tympani in 
otitis media catarrhalis 
chronica, 408 
inflammation of, 381 
chronic, 383 
malleus, and incus, removal 
of, in suppurative cases, 
447 
nerves of, 318 
of children, examination, 455 
perforation of, 388 
treatment, 390 
polypi on, 384 
puncture of, in otitis media 
catarrhalis acuta, 398 
rupture of, 386 
treatment, 388 
secundaria, 320 
vessels of, 318 
vibrans, 317 
Membranous rhinitis, 72 
semicircular canals, 328 
Meniere's disease, 408, 518 
Meningitis, external, from otic 
disease, 496 
Menthol, 554 
Mercury, 540, 541 
bichlorid of, 534 
biniodid of, 535 
Metastasis, ear conditions from, 
518 
Middle ear, 314, 316 
catarrh of. See Otitis media. 
cleansing of, hydrogen per- 
oxid for, 535 
deafness and internal ear 
deafness, differentia- 
tion, 515 
diseases of, 379 
exenteration of, 480 
inflation of, by Eusta- 
chian catheter, 347 
massage of, in stricture of 
Eustachian tube, 414 
of newborn, 452 
operations upon, 442 
Miller's asthma, 107 
Mineral acids in hay-fever, 108, 
549 
Mirror, laryngeal, 17 
introduction of, 22 
temperature of, 22 
Mixture, "l, 2, 3," 540 
Mixtures, cough, 542 
Motor neuroses of larynx, 287 
of nose, 105 
Mouth-breather, 76 
Mucocele of frontal sinus, 181 
Mucous membrane of larynx, 257 
of nose, 60. See also 
Schneiderian membrane. 
of pharynx, 194 
remedies for cleansing, 533 
Music, 330 
Musical notes, 258 
loudness of, 259 
qualities of, 259 
Muscles of auricle of ear, 315 
of epiglottis, 256 
of Eustachian tube, 324 
of larynx, 254 
of nose, 58 
of pharynx, 194 
of tympanum, 322 
Mycosis of external auditory 
canal, 368 
of pharynx, 230 
Myiasis, nasal, 103 
treatment of, 104 
Myles' tonsil knife, 211 
punches, 215 
Myringitis, 381 
chronic, 383 
treatment of, 383 
Myxoma of larynx, 280 
Nares, 30 
congenital occlusion, 141 
treatment, 142 
Nasal cavities, 58 
diphtheria, 297, 299 
genital spots, 107 
hemorrhage, 113 
adrenalin in, 117 
Bellocq's cannula in, 120 
etiology, 113 
horse serum in, 547 
in diphtheria, 300 
pathology, 115 
pressure-cone for, 118 
prognosis, 115 
recurrent, 116 
remedies for, 547 
treatment, 115 
hydrorrhea, in 
tieatment, 112 
myiasis, 103 
treatment, 104 INDEX 
581 
Nasal saws, 88 
Bosworth's, 88 
Bucklin's, 88 
Hall's, 88 
Sajous', 88 
septum, 56, 57 
abscess of, 144 
deviation of, 125 
Bosworth's operation for, 
.130 
etiology, 125 
Gleason's operation for, 
130 
Ballenger's modifica- 
tion, 136 
modifications, 136 
Price and Brown's 
operation, for, 136 
Kyle's operation for, 137 
operations for, 130 
factors interfering with, 
129 
pathology, 127 
submucous resection for, 
138 
symptoms, 127 
diseases of, 125 
dislocation, 145 
ecchondroses of, 85 
treatment, 86-90 
exostoses of, 85 
treatment, 86-90 
hematoma of, 143 
treatment, 144 
hypertrophied angle of, 126 
perforation of 144 
treatment, 145 
provisional callus of, 126 
redundancy of, 129 
resiliency of, 130 
submucous infiltration, 145 
space, posterior, 194 
speculum, 31 
splint, Carter's, 146 
tubes, Gleason's, 135 
Nasopharyngeal fibroma, 121, 
123 
Nasopharyngoscope, Holmes', 36 
Nasopharynx, 30, 194 
diseases of, 199 
Nebulizer, 47 
Nebulizers, formulas for, 557 
Neck, gangrenous inflammation, 
Necrosis in mastoiditis, 459, 460 
of temporal bone, 430 
Nerves of auricle of ear, 315 
of Eustachian tube, 325 
of larynx, 258 
of membrana tympani, 318 
of nasal fossae, 61 
of nose, 58 
of pharynx, 194 
of tympanum, 323 
Neumann's operation for laby- 
rinthitis, 530 
Neuroses of larynx, 286 
motor, 287 
sensory, 286 
of nose, 105 
motor, 105 
reflex, 106 
sensory, 106 
of pharynx, 243 
Neutrophiles, 494 
Newborn, external ear of, 452 
facial nerve in, 455 
middle ear of, 452 
osseous canal in, 455 
Shrapnell's membrane in, 455 
temporal bone of, 454 
Nitric acid in aphonia, 549 
Nitromuriatic acid in hay-fever, 
108, 549 
Noises, 330 
Nose, 56 
accessory sinuses, diseases of, 
150 
differentiation, 155 
inflation, by Valsalva's 
method, 163 
operations on, accidents 
and dangers of, 191 
alse of, 56 
anatomy of, 56 
angioma of, 121 
arteries of, 58 
bony arch, 56 
framework, injuries and de- 
formities, 145 
bridge of, flattening, 146 
bulbous enlargement of end, 
Rodman's operation for, 
150 
Roe's operation for, 150 
carcinoma of, 121, 125 
treatment, 125 
cartilaginous arch, 56 582 
INDEX 
Nose, catarrh of, chronic, cli- 
mate for, 544 
cavities of, 58 
cyst of, 121, 123 
deformities of, congenital, 149 
diseases of, 66 
causing disease of ear, 339 
effect on other parts of body, 
66 
dog, 99 
ecchondroma of, 121 
erectile tissue, 60 
examination of, 53 
exostosis of, 121 
external, 56 
fibroma of, 121, 123 
foreign bodies in, 104 
fossae of arteries, 61 
nerves, 61 
leprosy of, 102 
lymphatics of, 61 
maggots in, 103 
meati of, 59, 60 
mucous membrane, 60. See 
also Schneiderian mem- 
brane. 
muscles of, 58 
nerves of, 58 
neuroses of, 105. See also 
Neuroses of nose. 
olfactory region, 60 
osteoma of, 85, 121 
packing of, after operation, 
90 
papilloma of, 121, 124 
polypus of, 121 
treatment, 122 
pug, 58 
respiratory region, 60 
saddle-back, 146 
sarcoma of, 121, 124 
skin covering, 58 
sterilization of, 52 
triangular cartilage, 57 
tumors of, 121 
turbinated bones of, 59 
twitching of, 105 
vestibular region, 60 
wings of, 56 
Nosebleed, 113. See also Nasal 
hemorrhage. 
Novargan, 563 
Nozzles, hard-rubber, steriliza- 
tion of, 51 
Nystagmus, 520 
cerebellar, 521 
vestibular, 520 
caloric tests for, 523 
electric tests for, 524 
finger test for, 523 
fistula test for, 525 
functional tests for, 522 
horizontal, 520 
oblique, 520 
production of, by turning, 522 
rotary, 520 
spontaneous, 521 
vertical, 520 
Octave, definition, 333 
O'Dwyer's intubation set, 304 
Oil, phosphorated, 554 
Ointments, 560 
Operator, preparation of, 52 
Ophthalmocutaneous diagnostic 
reactions in tuberculo- 
sis, 557 
O'Reilly's modification of 
Killian's speculum, 31 
Organ of Corti, 328 
Oropharynx, 194 
diseases of, 206 
Orthoform, 562 
Osseous canal in newborn, 455 
Ossicles, 320 
Osteoma of external auditory 
canal, 370 
of nose, 85, 121 
Ostium frontale, 171 
Othematoma of auricle, 352 
Otitis externa crouposa, 369 
diffusa acuta, 365 
chronica, 366 
diphtheritica, 368 
hasmorrhagica, 366 
media catarrhalis acuta, 392 
bacteriology, 395 
dry heat in, 397 
etiology, 393 
leeches in, 396 
pathology, 394 
Politzer's air-bag in, 398 
prognosis, 395 
puncture of drum-head 
in, 398 
symptoms, 396 
treatment, 396 
chronica, 402 INDEX 
583 
Otitis media catarrhalis chronica, 
deafness in, 405 
etiology, 404 
head noises in, 407 
hearing in, 405 
membrana tympani in, 
408 
otosclerosis in, 404, 408 
patency of Eustachian 
tube in, 410 
pathology, 402 
prognosis, 410 
symptoms, subjective, 
405 
tinnitus in, 407 
treatment, 411 
vertigo in, 408 
subacuta, 400 
adenoids complicating, 
400 
inflammation of mucous 
glands in, 401 
from Bright's disease, 441 
from debility, 442 
from diabetes, 441 
from diphtheria, 438 
from excessive fatigue, 442 
from influenza, 439 
from la grippe, 439 
from measles, 438 
from pneumonia, 441 
from scarlatina, 437 
from syphilis, 441 
from tuberculosis, 440 
from typhoid fever, 439 
suppurativa acuta, 418 
treatment, 420 
chronica, 422 
cleansing ear in, 426 
deafness in operation 
for, 446 
otorrhea in, 425 
tinnitus from, operation 
for, 446 
treatment, 425 
systemic diseases causing, 
437 
Otoliths, 328 
Otomycosis, 368 
Otorrhea in diphtheria, 301 
in otitis media suppurativa 
chronica, 425 
sudden cessation, in mastoidi- 
tis, 461 
Otosclerosis, 404, 408 
treatment, 412 
Otoscopic reflector, 36 
Otoscopy, 36 
obstacles to, 38 
reflector in, 36 
relative positions of patient 
and observer in, 37 
specula for, 36 
method of introducing, 37 
Oval window of tympanum, 320 
Ozena, 92 
Packing nose after operation, 
90 
Palate, hard, 60 
Panlabyrinthitis, 525 
Pause's method of skin-grafting, 
482 
Passow's modification, 483 
Papilloma of larynx, 280 
of nose, 121, 124 
Paracusis diplacusis, 406 
duplicata, 406 
Willisii, 406 
Paraffin, 555 
prothesis, 147 
syringe for, 147 
subcutaneous injection, 555 
syringe, Smith's, 147 
Paralabyrinthitis, 525 
Paraldehyd, 547 
Paralysis, Bell's, from otic dis- 
ease, 509 
diphtheritic, 299 
facial, from otic disease, 509. 
See also Facial paralysis. 
of larynx, 291 
abductor, 291, 293 
spasmodic, 293 
from aneurysm of aorta, 
258 
treatment, 295 
of pharynx, 245 
of tensors of vocal cords, 287, 
294 
Paresthesia of larynx, 286 
of nasal mucous membrane, 
106 
of pharynx, 244 
Parosmia, 106, 158 
Passow's modification of Panse's 
method of skin-grafting, 
483 584 
INDEX 
Patency of Eustachian tube, 341. 
See also Eustachian tube, 
patency of. 
of Eustachian tube in chronic 
otitis media, 410 
Patients, examination of, 53 
Peach cold, 107 
Pendulum vibration, 331 
Perceptive apparatus, diseases of, 
.515 
Perforation of abscess in mastoid, 
472 
of membrana tympani, 388 
treatment, 390 
of nasal septum, 144 
treatment, 145 
whistle, 388, 422 
Pericarditis in diphtheria, 301 
Perichondritis of auricle, 352 
chronic, 353 
Perilabyrinthitis, 525 
Perilymph, 326 
Perimeningitis from otic disease, 
496 
Peritonsillar abscess, 211 
treatment, 212 
Petrolatum as nebulizer, 558 
Petrosal artery, 323 
Pharyngeal aponeurosis, 193 
mouths of Eustachian tubes, 
34i 
tonsil, 195 
adenoid vegetations of, 199 
hypertrophy of, 199 
Pharyngitis, acute, 225 
treatment of, 225 
atrophic, 229 
treatment of, 230 
chronic, 226 
treatment of, 226 
follicular, 226 
chronic, 227 
leprous, 237 
phlegmonous, 232 
treatment of, 232 
syphilitic, 236 
treatment of, 237 
tubercular, 238 
Pharynx, 193 
actinomycosis of, 240 
treatment, 241 
anatomy of, 193 
anesthesia of, 243 
arteries of, 194 
Pharynx, attachments of, 194 
catarrh of, chronic, climate 
for, 544 
diseases of, causing disease of 
ear, 339 
divisions of, 194 
equinia of, 239 
erysipelas of, 231 
treatment, 232 
farcy of, 239 
foreign bodies in, 245 
treatment, 246 
glanders of, 239 
hyperesthesia of, 244 
hyperkeratosis of, 230 
treatment, 231 
leprosy of, 237 
lupus vulgaris of, 238 
treatment, 239 
lymphatics of, 195 
mucous membrane of, 194 
muscles of, 194 
mycosis of, 230 
nerves of, 194 
. neuroses of, 243 
paralysis of, 245 
paresthesia of, 244 
relations of, 193 
syphilis of, 236 
tuberculosis of, 238 
tumors of, 243 
ulcer of simple, 235 
simple, treatment of, 236 
Phlegmonous erysipelas of au- 
ricle, 360 
pharyngitis, 232 
treatment, 232 
tonsillitis, 213 
Phonomassage in stricture of 
Eustachian tube, 415 
Phosphorated oil, 554 
Phthisis, chronic fibroid, climate 
for, 544 
Pigments, 561 
Pilocarpin, 556 
Pinna, 314. See also A uricle. 
Piston-syringe, 40 
Pitch, 259, 332 
Pitcher-shaped cartilages, 252 
Pituitary membrane, 60 
Pleurisy in diphtheria, 301 
Plexus, tympanic, 323 
Pneumatic mastoid, 456 
Pneumodiploetic mastoid, 457 INDEX 
585 
Pneumomassage in stricture of 
Eustachian tube, 415 
Pneumonia, otitis media from, 451 
Poisoning, cocain, 538 
Politzer's air-bag, 343 
in otitis media catarrhalis 
acuta, 398 
ear forceps, 385 
test of patency of Eustachian 
tubes, 342 
Pollantin in hay-fever, 111 
Polypus, aural, 428 
removal of, anesthesia for, 
537 
nasal, 121 
treatment of, 122 
on membrana tympani, 384 
snare, Blake's, 421 
Postnasal catarrh, 199 
space, 30 
diseases of, 199 
Potassium iodid, 540 
Powder-blower, 49 
Davidson's, 49 
Pressions centripetes, 337 
Pressure symptoms in intra- 
cranial complications of 
diseases of ear, 492 
Pressure-cone for nasal hemor- 
rhage, 118 
Price and Brown's modification 
of Gleason's operation 
for deviated septum, 
136 
Probe, Allen's, 41 
as applicator in Eustachian 
tube, 349 
for removing cerumen, 374 
Skillern's sinus, 173 
Processus auditorius, 455 
cochleariformis, 320 
Protargol, 539 
Protectives, 564 
Protector, Stacke's, 474 
Prothesis, paraffin, 147 
syringe for, 147 
Provisional callus of nasal sep- 
tum, 126 
Prussak's space, 317 
Pseudacousma, 407 
Pseudomembranous uvulitis, 246 
Pug nose, 58 
Pulmonary tuberculosis, climate 
for, 544 
Pump, Little Wonder, 45 
Punches, Myles' tonsil, 215 
Puncture, lumbar, in intracranial 
complications of dis- 
eases of ear, 491 
of drum-head in otitis media 
catarrhalis acuta, 398 
Purpura, 113 
treatment, 120 
Purulent leptomeningitis from 
otic disease, 501 
rhinitis, 71 
Pynchon's cabinet, 47 
Pyriform arytenoids, 275 
Ragged tonsil, 214 
Recessus epitympanicus, 318 
Recurrent laryngeal nerve, 258 
Reflector of laryngoscope, 17, 18 
method of wearing, 19 
otoscopic, 36 
Reflex nasal neuroses, 106 
Reissner's membrane, 327 
Resection, submucous, for devi- 
ated septum, 138 
Retropharyngeal abscess, 241 
treatment, 242 
Rhinitis, acute, 67 
atrophic, 91 
etiology of, 91 
Gottstein's treatment, 93 
pathology of, 92 
prognosis of, 96 
symptoms of, 93 
treatment of, 93 
chemic, 63 
chronic, simple, 69 
hyperplastic, 75 
hypertrophic, 75 
membranous, 72 
purulent, 71 
syphilitic, 96 
treatment of, 97 
tubercular, 100 
treatment of, 101 
turgescent, 69 
Rhinoliths, 104 
treatment of, 105 
Rhinorrhea, cerebral, 113 
Rhinoscleroma, 102 
Rhinoscopy, 30 
anterior, 30, 32 
posterior, 30, 33 
image in, 35 586 
INDEX 
Rhinoscopy, posterior, obstacles 
.to, 34 
technic of, 30 
Rima glottidis, 27, 256 
Rinne's test for hearing, 335 
Rivini's foramen, 379, 389 
Rodman's operation for bulbous 
enlargement of end of 
nose, 150 
Rods of Corti, 328 
Roe's operation for bulbous en- 
largement of end of 
nose, 150 
Rose cold, 107 
Round window of tympanum, 
320 
Rupture of membrana tympani, 
386 
treatment, 388 
Saccule of labyrinth, 325 
Sacculus laryngis, 257 
Saddle-back nose, 146 
Sajous' saw, 88 
Salt solution, normal, 534 
Salvarsan, 540 
Santorini, cartilages of, 253 
cartilages, 27 
Sarcoma of nose, 121, 124 
Saws, nasal, 88 
nasal, Bosworth's, 88 
Bucklin's, 88 
Hall's, 88 
Sajous', 88 
Scala media, 327, 328 
tympani, 327 
vestibuli, 326, 327 
Scarlatina, otitis media from, 
437 
Scarlet Red, 557 
ointment in atrophic rhinitis, 
95 
Schneiderian membrane, 60 
anesthesia of, 106 
hyperesthesia of, 106 
inflammation of, 65 
catarrhal, acute, 65 
chronic, 65 
croupous, 65 
diphtheritic, 66 
paresthesia of, 106 
pathology, 62 
physiology, 62 
Schwabach's test for hearing, 337 
Scirrhous tonsil, 214 
Scissors, Beckmann's, 85 
Sclerosed mastoid, 457 
Scute of tympanum, 318 
Sedatives, 564 
local, 565 
Seiler's septum knife, 133 
Semicircular canals, function of, 
329 
membranous, 328 
Semon's law, 293 
Sensory neuroses of larynx, 286 
of nose, 106 
Septum knife, Ballenger's, 138 
Freer's, 138 
Seiler's, 133 
nasal, 56, 57. See Nasal sep- 
tum. 
Serum, horse, in nasal hemor- 
rhage, 547 
treatment of diphtheria, 303 
of hemophilia, 120 
Sesamoid cartilage, 56 
Sessile exostoses of external audi- 
tory canal, 370 
Sharpnell's membrane, 316 
in newborn, 455 
Siegle's pneumatic speculum, 39 
Sign, Babinski's, in intracranial 
complications of dis- 
eases of ear, 491 
Kernig's, in intracranial com- 
plications of diseases of 
ear, 491, 492 
Silver nitrate, 539 
in atrophic rhinitis, 95 
Simpson's intranasal tampon, 
116 
Singing voice, 260 
Sinks, 47 
Sinus probe, Skillern's 173 
thrombosis after mastoid opera- 
tion, 504 
from otic disease, 503 
Skillern-Hajek sphenoid punch, 
189 
Skillern's evulsor, 190 
modification of Hajek's opera- 
tion for empyema of 
sphenoidal cells, 189 
sinus probe, 173 
Skin covering nose, 58 
diseases of auricle, 354 
tests for tuberculosis, 557 INDEX 
587 
Skin-grafting after radical mas- 
toid operation, 482 
Ballance's method, 483 
Korner's method, 483 
Pause's method, 482 
Passow's modifica- 
tion, 483 
Thiersch's method, 483 
Smell, loss of sense of, 106 
Smith's paraffin syringe, 147 
Snare, Blake's polypus, 421 
Jarvis', 78 
Martin's tonsil, 218 
Sneezing, definition of, 67 
Snow cold, 107 
Sodium iodid, 540 
Soft spot of antrum of Highmore, 
161 
Soft-rubber tubes, sterilization, 
51 
ulcer syringe, 43 
Sore throat, clergyman's, 227 
Sound, 330 
laryngeal, 40 
sources of, 330 
Spasm of adductor muscles, 288 
of larynx, 287 
Spasmodic abductor paralysis, 
293 
laryngeal cough, 287 
Speculum, Allen's, 32 
Boucheron's, 37 
ear, 36 
for otoscopy, 36 
method of introducing, 37 
Foster's, 140 
Gleason's, 32 
Killian's, 31 
O'Reilly's modification, 31 
nasal, 31 
Siegle's pneumatic, 39 
Sphenoid punch, Skillern-Hajek, 
189 
Sphenoidal cells, empyema of, 
186 
Hajek's operation, 188 
Skillern's modifica- 
tion, 189 
treatment, 187 
Spittoon, swinging, 47 
Splint, Carter's nasal, 146 
Spoke shave, 83 
Spot, soft, of antrum of High- 
more, 161 
Spots, granular, on membrana 
tympani, 384 
Sprays, 533 
Stacke's protector, 474 
Stapedius muscle, 323 
Stapes, 321, 322 
extraction of, 442 
mobilizing of, 442 
Static labyrinth, diseases of, 519 
Sterilization of atomizers, 52 
of glass instruments, 51 
of hard-rubber nozzles, 51 
of instruments, 50 
of nose, 52 
of soft-rubber tubes, 51 
of syringes, 51 
Stethoscope, aural, 341 
Stimulated disharmony, 526 
Stirrup bone of ear, 321, 322 
Stovain as local anesthetic, 537 
Stricture of Eustachian tube, 413. 
See also Eustachian tube, 
stricture of. 
Struycken's forceps, 84 
Stylomastoid artery, 323 
Subacute laryngitis, 263 
treatment, 265 
Subdural abscess from otic dis- 
ease, 496 
Submerged tonsil, 214 
Submucous infiltration of nasal 
septum, 145 
resection for deviated septum, 
I38 
tissue of larynx, inflammation, 
270 
Sullivan's frontal sinus rasps, 173 
Sulphonal, 547 
Suppuration of ethmoid cells, 181 
Suprameatal triangle, 474 
Supravomerine cartilage, 57 
Suspension laryngoscopy, 27-29 
Swinging spittoon, 47 
Syphilis of auricle, 358 
of labyrinth, 517 
of larynx, 271 
otitis media from, 441 
Syphilitic laryngitis, 271 
pharyngitis, 236 
treatment, 237 
rhinitis, 96 
treatment, 97 
Syringe, ear, soft-rubber, 43 
eye, soft-rubber, 43 588 
INDEX 
Syringe, piston-, 40 
Smith's paraffin, 147 
sterilization of, 51 
ulcer, soft-rubber, 43 
with interchangeable nozzles, 
„ 44 
Systemic diseases causing otic 
inflammation, 437 
Tache ceffibrale, 501 
Tampon, Simpson's intranasal, 
116 
Tegmen tympani, 319 
Temporal bone, caries of, 430 
mastoid process of, 325 
necrosis of, 430 
of newborn, 454 
Tensor palati, 324 
tympani, 322 
Tensors of vocal cords, paralysis 
of, 287, 294 
Tests, caloric, for nystagmus, 523 
conjunctival in tuberculosis, 
. 557 
electric, for nystagmus, 524 
finger, for nystagmus, 523 
fistula, for nystagmus, 524 
for hearing, 54, 330. See also 
Hearing, tests for. 
functional, for nystagmus, 522 
skin, for tuberculosis, 557 
Thiersch's method of skin-graft- 
ing, 483 
Thiosinamin, 541 
Thornwaldt's disease, 206 
Throat, clergyman's sore, 227 
Thrombosis, sinus, after mastoid 
operation, 504 
from otic disease, 503 
Thyro-arytenoideus muscle, 255 
Thyroid cartilage, 250 
Thyrotomy, 285 
Timbre, 259, 331 
Tinnitus from otitis media sup- 
purativa chronica, oper- 
ation for, 446 
in otitis media catarrhalis 
chronica, 407 
in stricture of Eustachian tube, 
416 
Tone, 331 
intensity of, 331 
pitch of, 332 
quality of, 331 
Tongue, control of, in laryngo- 
scopy, 23 
examination of, 53 
Tongue-depressor, Bosworth's, 25 
Tonics, 566 
Tonsillar gland, 196 
Tonsillectomy for hypertrophied 
tonsils, 217 
Tonsillitis, acute, 206 
croupous, 206 
follicular, acute, 2 06 
treatment of, 209 
chronic, 210 
treatment of, 210 
phlegmonous, 213 
Tonsillotome, Ermold's, 216 
tonsillotomy with, for hyper- 
trophied tonsils, 215 
Tonsillotomy with tonsillotome 
for hypertrophied ton- 
sils, 215 
Tonsils, 195 
blood-supply of, 197 
buried, 214 
crypts of, 196 
cyst of, 214 
faucial, 195 
functions of, 197 
immunity and, 198 
hard, 214 
hypertrophy of, 214 
chronic, 214 
galvanopuncture in, 215 
soft, 214 
tonsillectomy in, 217 
tonsillotomy with tonsillo- 
tome in, 215 
treatment, 215 
knife, Myles', 211 
lingual, 195 
diseases of, 224 
hypertrophy of, 224 
local anesthesia of, 537 
malignant growths, best way 
of removing, 197 
pharyngeal, 195 
adenoid vegetations of, 199 
hypertrophy of, 199 
punches, Myles', 215 
ragged, 214 
scirrhous, 214 
snare, Martin's, 218 
submerged, 214 
tubal, 195 INDEX 
589 
Toynbee's artificial drum-head 
392 
auscultation-tube, 342 
Tracheobronchoscope, Kahler, 27 
Tracheoscopy, direct, 29 
Tracheotomy, 308 
anesthetic in, 308 
high operation, 308, 310 
instruments for, 309 
low operation, 308, 310 
preparation of patient, 309 
Tracheotomy-tube, 312 
Triangle, Macewen's, 474 
suprameatal, 474 
Troutman's, 499 
Triangular cartilage of nose, 57 
Trichloracetic acid, 542 
in treatment of anterior 
nasal hypertrophies, 81 
Trional, 547 
Troutman's triangle, 499 
Tubal tonsils, 195 
Tubercular laryngitis, 273 
climate for, 544 
differential diagnosis, 275 
treatment, 277 
pharyngitis, 238 
rhinitis, 100 
treatment, 101 
Tuberculosis, conjunctival reac- 
tion in, 557 
cutaneous reaction in, 557 
of pharynx, 238 
otitis media from, 440 
pulmonary, climate for, 544 
skin tests in, 557 
Tumors of larynx,' 280 
treatment, 281 
of nose, 121 
of pharynx, 243 
Tuning-forks, 332, 333 
Turban-shaped epiglottis, 275 
Turbinated bones, 59 
Turbinectomy, 83, 84 
Turbinotomy, 83 
Turgescent rhinitis, 69 
Twitching of nose, 105 
Tympanic plexus, 323 
Tympanum, arteries of, 323 
atrium of, 318 
attic of, 318 
cavity of, 318 
diseases of, 392 
floor of, 319 
Tympanum, inner wall of, 320 
muscles of, 322 
nerves of, 323 
outer wall of, 319 
oval window of, 320 
plexus of, 323 
roof of, 319 
round window of, 320 
scute of, 318 
Typhoid fever, otitis media from, 
439 
Ulcer of pharynx, simple, 235 
treatment of, 236 
syringe, soft-rubber, 43 
Ulceration of uvula, 247 
Urotropin, 556 
Useless cough, 228- 
Utricle of labyrinth, 325 
Uvula, bifid, 247 
deformities of, 247 
diseases of, 246 
elongation of, 248 
inflammation of, treatment, 
247 
ulceration of, 247 
Uvulitis, 246 
pseudomembranous, 246 
Valsalva's method of inflating 
accessory sinuses, 163 
test of patency of Eustachian 
tubes, 341 
Vegetations, adenoid, of pharyn- 
geal tonsil, 199 
Veins of auricle of ear, 315 
of larynx, 257 
Ventricles of larynx, 257 
Ventricular bands of larynx, 256 
Vernix caseosa, 452 
Vertigo in otitis media catarrhalis 
chronica, 408 
laryngeal, 290 
treatment of, 291 
Vestibular apparatus, diseases of, 
5i9 
function of, 329 
nystagmus, 520. See also Nys- 
tagmus, vestibular. 
Vestibule of labyrinth, 325 
Vibration, pendulum, 331 
Vibrations, aerial, 330 
Vincent's angina, 234 
treatment, 235 590 
INDEX 
Vocal cords, 256 
false, 256 
tensors of, paralysis, 287, 
294 
true, 256 
Voice, 258, 259 
falsetto, 259 
in testing hearing, 339 
lozenges, 554 
production, 258 
qualities of, 259 
range of, 259 
singing, 260 
timbre of, 259 
Vomerine cartilage, 57 
crest, 58 
Washes, 533 . 
Watch in testing hearing, 338 
Water-pump for compressed air, 
, 45 
Weber s test for hearing, 334 
Whistle, Edelmann-Galton, 332 
perforation, 388, 422 
Whiting's encephaloscope, 500 
mastoid curette, 466 
Wounds of auricle of ear, 353 
Wrisberg's cartilages, 27, 253 
Xeroform, 563 
Ya ws, 99 
Zinc chlorid, 542 
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463 pages, with 171 original illustrations. Cloth, $2.25 net. 
JUST ISSUED 
Dr. Davis' manual is a concise text-book of exceptional value. Dr. Davis, 
himself a teacher of many years' experience, knows the requirements of such 
a work and has here supplied them. You get anatomy of the normal and ab- 
normal bony pelvis, physiology of impregnation, anatomy of the birth canal 
in pregnancy, growth and development of the embryo. You get a full and clear 
discussion of pregnancy-its diagnosis, physiology, hygiene, pathology. You 
get the causes and treatment of labor, the physiology, conduct, pathology; 
the puerperal period-care of the mother and child ; obstetric surgery, fetal 
pathology, mixed feeding, and medicolegal aspects of obstetric practice. 
Davis' Operative Obstetrics 
Operative Obstetrics. By Edward P. Davis, M. D., Pro- 
fessor of Obstetrics at Jefferson Medical College, Philadelphia. 
Octavo of 483 pages, with 264 illustrations. Cloth, $5.50 net; 
Half Morocco, $7.00 net. 
INCLUDING SURGERY OF NEWBORN 
Dr. Davis' new work on Operative Obstetrics is a most practical one, and 
no expense has been spared to make it the handsomest work on the subject 
as well. Every step in every operation is described minutely, and the technic 
shown by beautiful new illustrations. The section given over to surgery of 
the newborn you will find unusually valuable. It gives you much informa- 
tion you want to know-facts you can use in your work every day. There 
is an excellent chapter on anesthesia in obstetrics. 
The Lancet, London 
" The best and most interesting part of the book is the summary of results given at the 
end of the chapters and compiled from the author's own experience and from the literature." 
3 4 
SAUNDERS' BOOKS ON 
Ashton's 
Practice of Gynecology 
The Practice of Gynecology. By W. Easterly Ashton, 
M.D., LL.D., Professor of Gynecology in the Medico-Chirurgi- 
cal College, Philadelphia. Handsome octavo volume of noo 
pages, containing 1058 original line drawings. Cloth, $6.50 
net; Half Morocco, $8.00 net. 
THE NEW (5th) EDITION 
Among the important new matter may be mentioned the De Keating-Hart 
fulguration treatment, Coley's mixed toxins for sarcoma of the genito-urinary 
organs, the cutireaction of von Pirquet in the diagnosis of tuberculosis, " 606 " 
for syphilis, the hormone theory, the Fowler-Murphy treatment of suppurative 
peritonitis, tincture of iodin in sterilization, and Baldy's new round ligament 
operation for retrodisplacement. Nothing is left to be taken for granted, the 
author not only telling his readers in every instance what should be done, but 
also precisely how to do it. A distinctly original feature of the book is the 
illustrations, numbering 1058 line drawings made especially under the author's 
personal supervision. 
From its first appearance Dr. Ashton's book set a standard in practical 
medical books ; that he has produced a work of unusual value to the medical 
practitioner is shown by the demand for new editions. 
Howard A. Kelly, M. D., 
Professor of Gynecologic Surgery, Johns Hopkins University * 
" It is different from anything that has as yet appeared. The illustrations are particu- 
larly clear and satisfactory. One specially good feature Js the pains with which you 
describe so many details so often left to the imagination. 
Charles B. Penrose, M. D., 
Formerly Professor of Gynecology, University of Pennsylvania. 
" I know of no book that goes so thoroughly and satisfactorily into all the details of 
everything connected with the subject. In this respect your book differs from the others." 
George M. Edebohls, M.D. 
Professor of Diseases of Women, New York Post-Graduate Medical School. 
« I have looked it through and must congratulate you upon having produced a text- 
book most admirably adapted to teach gynecology to those who must get their knowledge, 
even to the minutest and most elementary details, from books." GYNECOLOGY. 
Bandler's 
Medical Gynecology 
Medical Gynecology. By S. Wyllis Bandler, M. D., 
Adjunct Professor of Diseases of Women, New York Post- 
Graduate Medical School and Hospital. Octavo of 790 pages, 
with 150 original illustrations. Cloth, $5.00 net; Half Morocco, 
$6.50 net. 
NEW (3d) EDITION-60 PAGES ON INTERNAL SECRETIONS 
This new work by Dr. Bandler is just the book that the physician en- 
gaged in general practice has long needed. It is truly the practitioner1 s gyne- 
cology-planned for him, written for him, and illustrated for him. There are 
many gynecologic conditions that do not call for operative treatment; yet, 
because of lack of that special knowledge required for their diagnosis and 
treatment, the general practitioner has been unable to treat them intelligently. 
This work gives just the information the practitioner needs. 
American Journal of Obstetrics 
" He has shown good judgment in the selection of his data. He has placed most 
emphasis on diagnostic and-therapeutic aspects. He has presented his facts in a manner 
to be readily grasped by the general practitioner." 
Bandler's Vaginal Celiotomy 
Vaginal Celiotomy. By S. Wyllis Bandler, M. D. Octavo 
of 450 pages, with 148 illustrations. Cloth, $5-°° net- 
SUPERB ILLUSTRATIONS 
The vaginal route, because of its simplicity, ease of execution, absence of 
shock, more certain results, and the opportunity for conservative measures, 
constitutes a field which should appeal to all surgeons, gynecologists, and 
obstetricians. Posterior vaginal celiotomy is of great importance in the re- 
moval of small tubal and ovarian tumors and cysts, and is an important step 
in the performance of vaginal myomectomy, hysterectomy, and hystero- 
myomectomy. Anterior vaginal celiotomy with thorough separation of the 
bladder is the only certain method of correcting cystocele. 
The Lancet, London 
" Dr. Bandler has done good service in writing this book, which gives a very clear 
description of all the operations which may be undertaken through the vagina. He makes 
out a strong case for these operations." 
5 6 
SAUNDERS' BOOKS ON 
Hirst's Obstetrics 
The New (7th) Edition 
A Text-Book of Obstetrics. By Barton Cooke Hirst, 
M. D., Professor of Obstetrics in the University of Pennsylvania. 
Handsome octavo, 1025 pages, with 900 illustrations, 46 in colors. 
Cloth, $5.00 net; Half Morocco, $6.50 net. 
INCLUDING RELATED GYNECOLOGIC OPERATIONS 
Immediately on its publication this work took its place as the leading text- 
book on the subject. Both in this country and abroad it is recognized as the 
most satisfactorily written and clearly illustrated work on obstetrics in the 
language. The illustrations form one of the features of the book. They are 
numerous and the most of them are original. In this edition the book has 
been thoroughly revised. Recognizing the inseparable relation between ob- 
stetrics and certain gynecologic conditions, the author has included all the 
gynecologic operations for complications and consequences of childbirth, 
together with a brief account of the diagnosis and treatment of all the path- 
ologic phenomena peculiar to women. 
British Medical Journal 
" The illustrations in Dr. Hirst's volume are far more numerous and far better exe. 
cuted, and therefore more instructive, than those commonly found in the works of writers 
on obstetrics in our own country." 
Hirst's Diseases of Women 
A Text-Book of Diseases of Women. By Barton Cooke 
Hirst, M. D. Octavo of 745 pages, 701 illustrations, many in 
colors. Cloth, $5.00 net; Half Morocco, $6.50 net. 
SECOND EDITION 
As diagnosis and treatment are of the greatest importance in considering 
diseases of women, particular attention has been devoted to these divisions. 
The palliative treatment, as well as the radical operation, is fully described, 
enabling the general practitioner to treat many of his own patients without 
referring them to a specialist. 
Medical Record, New York 
"Its merits can be appreciated only by a careful perusal. . . Nearly one hundred 
passes are devoted to technic, this chapter being in some respects superior to the descrip- 
tions in other text-books." GYNECOLOGY. 
Kelly and Noble's Gynecology 
and Abdominal Surgery 
Gynecology and Abdominal Surgery. Edited by Howard 
A. Kelly, M. D., Professor of Gynecology in Johns Hopkins 
University; and Charles P. Noble, M.D., formerly Clinical 
Professor of Gynecology in the Woman's Medical College, Phila- 
delphia. Two imperial octavo volumes of 950 pages each, con- 
taining 880 illustrations, mostly original. Per volume : Cloth, 
$8.00 net; Half Morocco, $9.5° net. 
BOTH VOLUMES NOW READY 
WITH 880 ORIGINAL ILLUSTRATIONS BY HERMANN BECKER 
AND MAX BRODEL 
In view of the intimate association of gynecology with abdominal surgery 
the editors have combined these two important subjects in one work. For 
this reason the work will be doubly valuable, for not only the gynecologist and 
general practitioner will find it an exhaustive treatise, but the surgeon also will 
find here the latest technic of the various abdominal operations. It possesses 
a number of valuable features not to be found in any other publication cover- 
ing the same fields. It contains a chapter upon the bacteriology and one upon 
the pathology of gynecology, dealing fully with the scientific basis of gyne- 
cology. In no other work can this information, prepared by specialists, be 
found as separate chapters. There is a large chapter devoted entirely to 
.medical gynecology, written especially for the physician engaged in general 
practice. Heretofore the general practitioner was compelled to search through 
an entire work in order to obtain the information desired. Abdominal sur- 
gery proper, as distinct from gynecology, is fully treated, embracing operations 
upon the stomach, upon the intestines, upon the liver and bile-ducts, upon the 
pancreas and spleen, upon the kidney, ureter, bladder, and the peritoneum. 
Special attention has been given to modern technic. The illustrations are the 
work of Mr. Hermann Becker and Mr. Max Brbdel. 
American Journal of the Medical Sciences 
" It is needless to say that the work has been thoroughly done : the names of the authors 
and editors would guarantee this ; but much may be said in praise of the method of presen- 
tation. and attention mav be called to the inclusion of matter not to be found elsewhere." 
7 SAUNDERS' BOOKS ON 
GET the new 
the best nmencan standard 
Illustrated Dictionary 
The New (7th) Edition, Reset 
The American Illustrated Medical Dictionary. A new 
and complete dictionary of the terms used in Medicine, Surgery, 
Dentistry, Pharmacy, Chemistry, Veterinary Science, Nursing, 
and all kindred branches; with over 100 new and elaborate 
tables and many handsome illustrations. By W. A. Newman 
Dorland, M.D., Editor of " The American Pocket Medical 
Dictionary." Large octavo, 1105 pages, bound in full flexible 
leather. Price, $4.50 net; with thumb index, $5.00 net. 
A KEY TO MEDICAL LITERATURE 
Gives a Maximum Amount of Matter in a Minimum Space 
ENTIRELY RESET-5000 NEW WORDS 
This edition is not a makeshift revision. The editor and a corps of expert 
assistants have been working on it for two years. Result-a thoroughly down- 
to-the-minute dictionary, unequalled for completeness and usefulness by any 
other medical lexicon published. It meets your wants. It gives you all the 
new words, and in dictionary service new words are what you want. Then, it 
has two-score other features that make it really a Medical Encyclopedia. 
PERSONAL OPINIONS 
Howard A. Kelly, M. D., 
Professor of Gynecologic Surgery, Johns Hopkins University, Baltimore. 
" Dr. Dorland's dictionary is admirable. It is so well gotten up and of such conve- 
nient size. No errors have been found in my use of it." 
J. Collins Warren, M.D., LL.D., F.R.C.S. (Hon.) 
Professor of Surgery, Harvard Medical School. 
''I regard it as a valuable aid to my medical literary work. It is very complete and 
of convenient size to handle comfortably. I use it in preference to any other." 
8 DISEASES OF WOMEN. 
Webster's 
Diseases cf Women 
Diseases of Women. By J. Clarence Webster, M. D. 
(Edin.), F. R. C. P. E., Professor of Gynecology and Obstetrics 
in Rnsh Medical College. Octavo of 712 pages, with 372 illus- 
trations. Cloth, $7.00 net; Half Morocco, $8.50 net. 
FOR THE PRACTITIONER 
Dr. Webster has written this work especially for the general practitioner, 
discussing the clinical features of the subject in their widest relations to 
general practice rather than from the standpoint of specialism. The magni- 
ficent illustrations, three hundred and seventy-two in number, are nearly all 
original. Drawn by expert anatomic artists under Dr. Webster's direct super- 
vision, they portray the anatomy of the parts and the steps in the operations 
with rare clearness and exactness. 
Howard A. Kelly, M.D., Professor of Gynecologic Su rgery, Johns Hopkins University. 
" It is undoubtedly one of the best works which has been put on the market within 
recent years, showing from start to finish Dr. Webster's well-known thoroughness. The 
illustrations are also of the highest order." 
Webster's Obstetrics 
A Text=Book of Obstetrics. By J. Clarence Webster, 
M. D. (Edin.), Professor of Obstetrics and Gynecology in Rush 
Medical College. Octavo of 767 pages, illustrated. Cloth, 
$5.00 net; Half Morocco, $6.50 net. 
Medical Record, New York 
The author s remarks on asepsis and antisepsis are admirable, the chapter on eclamp- 
sia is full of good material, and ... the book can be cordially recommended as a safe 
guide." 
9 SAUNDERS' BOOKS ON 
Kelly arid Cullen's 
Myomata of the Uterus 
Myomata of the Uterus. By Howard A. Kelly, M. D., 
Professor of Gynecologic Surgery at Johns Hopkins University; 
and Thomas S. Cullen, M. B., Associate in Gynecology at 
Johns Hopkins University. Large octavo of about 700 pages, 
with 388 original illustrations by August Horn and Hermann 
Becker. Cloth, $7.50 net; Half Morocco, $9.00 net. 
A MASTER WORK 
ILLUSTRATED BY AUGUST HORN AND HERMANN BECKER 
This monumental work, the fruit of over ten years of untiring labors, will 
remain for many years the last word upon the subject. Written by those men 
who have brought, step by step, the operative treatment of uterine myoma to 
such perfection that the mortality is now less than one per cent., it stands out 
as the record of greatest achievement of recent times. 
The illustrations have been made with wonderful accuracy in detail by Mr. 
August Horn and Mr. Hermann Becker, whose superb work is so well known 
that comment is unnecessary. For painstaking accuracy, for attention to every 
detail, and as an example of the practical results accruing from the associa- 
tion of the operating amphitheater with the pathologic laboratory, this work 
will stand as an enduring testimonial. 
Surgery, Gynecology, and Obstetrics 
" It must be considered as the most comprehensive work of the kind yet published. It 
will always be a mine of wealth to future students." 
New York Medical Journal 
" Within the covers of this monograph every form, size, variety, and complication of 
uterine fibroids is discussed. It is a splendid example of the rapid progress of American 
professional thought." 
Bulletin Medical and Chirurgical Faculty of Maryland 
" Few medical works in recent years have come to our notice so complete in detail, so 
well illustrated, so practical, and so far reaching in their teaching to general practitioner, 
specialist, and student alike." 
10 G YNECOL OGY AND OBSTETRICS. 
Penrose's 
Diseases of Women 
Sixth Revised Edition 
A Text=Book of Diseases of Women. By Charles B. 
Penrose, M. D., Ph. D., formerly Professor of Gynecology in 
the University of Pennsylvania; Surgeon to the Gynecean Hos- 
pital, Philadelphia. Octavo volume of 550 pages, with 225 fine 
original illustrations. Cloth $3.75 net. 
ACCURATE 
Regularly every year a new edition of this excellent text-book is called 
for, and it appears to be in as great favor with physicians as with students. 
Indeed, this book has taken its place as the ideal work for the general prac- 
titioner. The author presents the best teaching of modern gynecology, un- 
trammeled by antiquated ideas and methods. In every case the most modern 
and progressive technique is adopted, and the main points are made clear by 
excellent illustrations. 
Howard A. Kelly, M.D., 
Projessor oj Gynecologic Surgery, Johns Hopkins University, Baltimore. 
" I shall value very highly the copy of Penrose's ' Diseases of Women ' received. I 
have already recommended it to my class as the best book." 
Cullen's Uterine Adenomyoma 
Uterine Adenomyoma. By Thomas S. Cullen, M. D., Asso- 
ciate Professor of Gynecology, Johns Hopkins University. Octavo 
of 275 pages, with original illustrations by Hermann Becker and 
August Horn. Cloth, $5.00 net. 
Cullen's Cancer of Uterus 
Cancer of the Uterus. By Thomas S. Cullen, M. B., Asso- 
ciate Professor of Gynecology, Johns Hopkins University. Large 
octavo of 693 pages, with over 300 colored and half-tone text-cuts 
and eleven lithographs. Cloth, $7.50 net; Half Morocco, $8.50 net. 
11 SAUNDERS' BOOKS ON 
Dorland's 
Modern Obstetrics 
Modern Obstetrics : General and Operative. By W. A. 
Newman Dorland, A. M., M. D., Professor of Obstetrics at 
Loyola University, Chicago. Handsome octavo volume of 797 
pages, with 201 illustrations. Cloth, $4.00 net. 
Second Edition, Revised and Greatly Enlarged 
In this edition the book has been entirely rewritten and very greatly 
enlarged. Among the new subjects introduced are the surgical treatment of 
puerperal sepsis, infant mortality, placental transmission of diseases, serum^ 
therapy of puerperal sepsis, etc. 
Journal of the American Medical Association 
" This work deserves commendation, and that it has received what it deserves at the 
hands of the profession is attested by the fact that a second edition is called for within such 
a short time. Especially deserving of praise is the chapter on puerperal sepsis." 
Davis' Obstetric and 
Gynecologic Nursing 
Obstetric and Gynecologic Nursing. By Edward P. 
Davis, A. M., M. D., Professor of Obstetrics in the Jefferson 
Medical College and Philadelphia Polyclinic; Obstetrician and 
Gynecologist, Philadelphia Hospital. i2mo of 480 pages, illus- 
trated. Buckram, $1.75 net. 
NEW (4th) EDITION 
This volume gives a very clear and accurate idea of the manner to meet 
the conditions arising during obstetric and gynecologic nursing. The third 
edition has been thoroughly revised. 
The Lancet, London 
" Not only nurses but even newly qualified medical men, would learn a great deal by 
a perusal of this book. It is written in a clear and pleasant style, and is a work we can 
recommend.* 
12 GYNECOLOGY AND OBSTETRICS 
Garrigues* Diseases of Women Third Edition 
A Text-Book of Diseases of Women. By Henry J. Garrigues, 
A. M., M. D., Gynecologist to St. Mark's Hospital and to the German 
Dispensary, New York City. Handsome octavo, 756 pages, with 367 
engravings and colored plates. Cloth, $4.50 net; Half Morocco, 
$6.00 net. 
Thad. A. Reamy, M. D., Professor of Gynecology, Medical College of Ohio. 
" One of the best text-books for students and practitioners which has been published 
in the English language; it is condensed, clear, and comprehensive. The profound 
learning and great clinical experience of the distinguished author find expression in 
this book." 
Macfarlane's Gynecology for Nurses (2d) Edition 
A Reference Hand-Book of Gynecology for Nurses. By Cath- 
arine Macfarlane, M. D., Gynecologist to the Woman's Hospital of 
Philadelphia. l6mo of 156 pages, with 70 illustrations. Flexible leather, 
$1.25 net. 
A. M. Seabrook, M. D., Woman's Medical College of Philadelphia. 
" It is a most admirable little book, covering in a concise but attractive way the sub- 
ject from the nurse's standpoint." 
American Text-Book of Gynecology Edition 
American Text-Book of Gynecology. Edited by J. M. Baldy, 
M. D. Imperial octavo of 718 pages, with 341 text-illustrations and 
38 plates. Cloth, $6.00 net. 
American Text-Book of Obstetrics second Edition 
The American Text-Book of Obstetrics. In two volumes. 
Edited by Richard C. Norris, M. D. ; Art Editor, Robert L. Dick- 
inson, M. D. Two octavos of about 600 pages each ; nearly 900 illus- 
trations, including 49 colored and half-tone plates. Per volume : Cloth, 
$3.50 net. 
Matthew D. Mann, M. D., 
Professor of Obstetrics and Gynecology, University of Buffalo. 
" I like it exceedingly and have recommended the first volume as a text-book. It 
is certainly a most excellent work. I know of none better." 
13 SA UNDE Ji S' BOOKS ON 
Schaffer and Webster's 
Operative Gynecology 
Atlas and Epitome of Operative Gynecology. By Dr. 
O. Schaffer, of Heidelberg. Edited, with additions, by J. 
Clarence Webster, M. D. (Edin.), F. R. C. P. E., Professor of 
Obstetrics and Gynecology in Rush Medical College, in affili- 
ation with the University of Chicago. 42 colored lithographic 
plates, many text-cuts, a number in colors, and 138 pages of text. 
In Saunders' Hand-Atlas Series. Cloth, $3.00 net. 
Much patient endeavor has been expended by the author, the artist, and 
the lithographer in the preparation of the plates for this Atlas. They are based 
on hundreds of photographs taken from nature, and illustrate most faithfully 
the various surgical situations. Dr. Schaffer has made a specialty of demon- 
strating by illustrations. 
Medical Record, New York 
"The volume should prove most helpful to students and others in grasping details 
usually to be acquired only in the amphitheater itself." 
De Lee's Obstetrics for Nurses 
Obstetrics for Nurses. By Joseph B. De Lee, M. D., 
Professor of Obstetrics in the Northwestern University Medical 
School, Chicago; Lecturer in the Nurses' Training Schools of 
Mercy, Wesley, Provident, Cook County, and Chicago Lying-In 
Hospitals. i2mo of 508 pages, fully illustrated. 
Cloth, $2.50 net. 
NEW (4th) EDITION 
While Dr. DeLee has written his work especially for nurses, the practi- 
tioner will also find it useful and instructive, since the duties of a nurse often 
devolve upon him in the early years of his practice. The illustrations are 
nearly all original and represent photographs taken from actual scenes. The 
text is the result of the author's many years' experience in lecturing to the 
nurses of five different training schools. 
J. Clifton Edgar, M. D<, 
Professor of Obstetrics and Clinical Midwifery, Cornell University, New York. 
" It is far and away the best that has come to my notice, a,nd I shall take great pleasure 
in recommending it to my nurses, and students as well." 
14 GYNECOLOGY AND OBSTETRICS. 
Schaffer arid Edgar'y 
Labor and Operative Obstetrics 
Atlas and Epitome of Labor and Operative Obstetrics. 
By Dr. 0. Schaffer, of Heidelberg. From the Fifth Revised 
and Enlarged German Edition. Edited, with additions, by J. 
Clifton Edgar, M. D., Professor of Obstetrics and Clinical Mid- 
wifery, Cornell University Medical School, New York. With 14 
lithographic plates in colors, 139 other illustrations, and in pages 
of text. Cloth, $2.00 net. In Saunders' Hand-Atlas Series. 
This book presents the act of parturition and the various obstetric opera- 
tions in a series of easily understood illustrations, accompanied by a text 
treating the subject from a practical standpoint. 
American Medicine 
" The method of presenting- obstetric operations is admirable. The drawings, repre- 
senting original work, have the commendable merit of illustrating instead of confusing." 
Schaffer Edgar'y* 
Obstetric Diagnosis and Treatment 
Atlas and Epitome of Obstetric Diagnosis and Treat= 
ment. By Dr. O. Schaffer, of Heidelberg. From the Second 
Revised German Edition. Edited, with additions, by J. Clif- 
ton Edgar, M. D., Professor of Obstetrics and Clinical Mid- 
wifery, Cornell University Medical School, N.Y. With 122 
colored figures on 56 plates, 38 text-cuts, and 315 pages of text. 
Cloth, $3.00 net. In Saunders' Hand-Atlas Series. 
This book treats particularly of obstetric operations, and, besides the wealth 
of beautiful lithographic illustrations, contains an extensive text of great value. 
This text deals with the practical, clinical side of the subject. 
New York Medical Journal 
" The illustrations are admirably executed, as they are in all of these atlases, and the 
text can safely be commended, not only as elucidatory of the plates, but as expounding the 
scientific midwifery of to-day." 
15 SAUNDERS' BOOKS ON GYNECOLOGY AND OBSTETRICS. 
American Pocket Dictionary „ ,Oi.. __ 
New (8th) Edition 
The American Pocket Medical Dictionary. Edited by W. A. 
Newman Dorland, A. M., M.D. With 677 pages. Full leather, 
limp, with gold edges, $1.00 net; with patent thumb index, $1.25 net. 
James W. Holland, M. D., 
Professor of Chemistry and Toxicology, at the Jefferson Medical College, 
Philadelphia. 
" I am struck at once with admiration at the compact size and attractive exterior, 
I can recommend it to our students without reserve." 
Cragin's Gynecology seventh Edition 
Essentials of Gynecology. By Edwin B. Cragin, M. D., Pro- 
fessor of Obstetrics, College of Physicians and Surgeons, New York. 
Crown octavo, 240 pages, 62 illustrations. Cloth, $1.00 net. In 
Saunders' Question-Compend Series. 
Galbraith's Four Epochs of Woman's Life Edition 
The Four Epochs of Woman's Life: A Study in Hygiene. 
Maidenhood, Marriage, Maternity, Menopause. By Anna M. Gal- 
braith, M. D. With an Introductory Note by John H. Musser, 
M. D., University of Pennsylvania. I2mo of 247 pages. Cloth, 
$1.50 net. 
Schaffer and Norris' Gynecology Saunders' Atlases 
Atlas and Epitome of Gynecology. By Dr. O. Schaffer, of 
Heidelberg. Edited, with additions, by Richard C. Norris, A. M., 
M. D., Assistant Professor of Obstetrics, University of Pennsylvania. 
207 colored illustrations on 90 plates, 65 text-cuts, and 272 pages of text. 
Cloth, $3.50 net. 
Ashton's Obstetrics Seventh Edition 
Essentials of Obstetrics. By W. Easterly Ashton, M. D., Pro- 
fessor of Gynecology in the Medico-Chirurgical College, Philadelphia. 
Crown octavo, 252 pages, 109 illustrations. Cloth, $1.00 net. In 
Saunders' Question-Compend Series. 
Southern Practitioner 
"An excellent little volume, containing correct and practical knowledge. An admir- 
able compend, and the best condensation we have seen." 
Barton and Wells' Medical Thesaurus 
A Thesaurus of Medical Words and Phrases. By V ilfred M. 
Barton, M. D., Assistant to Professor of Materia Medica and Thera- 
peutics, Georgetown University, Washington, D. C. ; and Walter A. 
Wells, M. D., Demonstrator of Laryngology, Georgetown University, 
Washington, D. C. I2mo of 534 pages. Flexible leather, $2.50 net; 
with thumb index, $3.00 net. 
16