APPLIED PATHOLOGY IN DISEASES OF 
THE 
NOSE, THROAT, AND EAR Bulla of the Membrana Tympani in Acute Infection of tile Influenzal Type APPLIED PATHOLOGY 
IN DISEASES 
OF THE 
NOSE, THROAT, AND EAR 
BY 
JOSEPH C. BECK, M.D., F.A.C.S. 
Ml 
associate professor of laryngology, rhinology, and otology, 
UNIVERSITY OF ILLINOIS COLLEGE OF MEDICINE; CHIEF 
OF STAFF, OTOLARYNGOLOGY, NORTH CHICAGO 
HOSPITAL, CHICAGO 
WITH 268 ORIGINAL ILLUSTRATIONS 
INCLUDING 4 COLOR PLATES 
ST. LOUIS 
C. V. MOSBY COMPANY 
1923 Copyright, 1923, by C. Y. Mosby Company 
(All Rights Reserved) 
Printed in U. S. A. 
Press of 
C. V. Mosby Company 
St. Louis, Mo. TO 
THE FUTURE OF OTOLARYNGOLOGY 
AND 
TO MY SON 
JOSEPH C. BECK, JR. FOREWORD 
I have long felt the need for such a work as I am herein pre- 
senting, both from my own experience as well as the communica- 
tions from many other otolaryngologists. There is not, even to 
this day, an English text hook that is limited to the Pathology 
of Nose, Throat, and Ear Diseases and their borderline condi- 
tions, but I hope for the early appearance of one. 
The work of Oscar Beck, of Vienna, to he published in the 
form of an atlas ‘‘Atlas der Histopathologie der Nase und ilirer 
Nebenhohlen (Atlas of Histopathology of the Nose and Acces- 
sory Sinuses) will shortly appear in German and I have accepted 
the translation of it into English. The colored illustrations 
which so beautifully demonstrate the pathologic processes will 
enhance the value of this volume. There are many illustrations 
of the same conditions found in my work, only that they are 
plain, not retouched, microphotographs. 
It has further been determined to make this work one on 
applied pathology, in the belief that a greater benefit will be 
derived from applying the pathological entities to etiology, 
symptoms, diagnosis, and prognosis, thereby arriving at a 
rational basis for treatment, exclusive of the strictly surgical 
interventions. In other words, the fundamental object in the 
analysis and management of a case is a definite knowledge of 
the underlying pathological change present. 
It is my desire to limit this work almost exclusively to my 
personal experiences and therefore it should not be considered 
as a text book. There will be many subjects that will not appear 
either because I have had no personal experience pertaining 
thereto, or because I cannot offer any data as to their pathology. 
Particularly is this true in acute conditions wherein it is but 
seldom possible to secure actual pathological specimens, it 
being either surgically contraindicated, or otherwise uncalled 
for. However, by analogy, adhering to the fundamental prin- 
ciples of pathology, one may infer such changes as would natur- 
ally occur, for instance, in acute inflammation elsewhere. 
3 4 
FOREWORD 
Certain gross illustrations, other than those from my own 
cases, have been taken and modified after other investigators 
only when they seemed to serve better than if taken from the 
original, but they always represent and typify case groups and 
conditions found in my own work. I wish, therefore, to ac- 
knowledge the work of Denker, Katz, Preysing, Blumenthal and 
Wittmaack. 
In the study of jDathological changes, I have considered each 
subject as shown grossly in the patient during examination and 
further corroborated by laboratory data, as x-ray, etc., or dur- 
ing operative procedure or treatment; next, the gross specimen 
after removal, if such be the case, with subsequent microscopical 
examination. I have been fortunate in a few instances to have 
secured postmortem specimens. The subjects presented both 
in gross and microscopical sections, as well as in the photo- 
graphs, are selected as typifying groups rather than individual 
cases. In all the laboratory work, experts have collaborated and 
I wish, therefore, to express my appreciation to Drs. Ludwig 
Ilektoen, Maximilian Herzog, W. A. Evans, and Carl Beck. 
More than any other contributory factor in making this work 
possible has been the interest shown by some of my students 
and fellow-workers, and I desire at this time to mention a few 
who figure prominently in the work: Drs. Clara Moore, Theresa 
Lane, W. J. Neuzil, Frank J. Novak, Jeanette Shefferd, Harry 
L. Pollock, as well as my collaborators and former students, 
Drs. Arnold B. Kauffman and Francis L. Lederer. In apprecia- 
tion of their cooperation, I have purposely used the pronoun 
“we” throughout the work. I also wish to express my thanks 
to the artist, Mr. A. B. Streedain, for his cooperation. 
I desire to acknowledge the fact that in the text the reader 
will frequently find that I am at variance with many of the ac- 
cepted principles both in diagnosis and treatment, and I expect 
criticism on this score, but these are my beliefs and I have car- 
ried them out in our practice with satisfactory results. 
It will be noted that there is an absence of much of the bor- 
derline of ear, nose and throat conditions, as well as operative 
surgery, with which work I have been identified, but owing to 
the enormity of the material, these could not be incorporated in 
this volume. Should the demands warrant it, I have promised FOREWORD 
5 
myself tlie writing of such books with the same pleasure as the 
writing of this volume has given me. 
In regard to the absence of radiographic illustrations, I wish 
to state that a great part of my radiographic work has already 
appeared in my “.Radiographic Atlas” published a number of 
years ago by The Laryngoscope, and more modern work will 
appear in a future joint publication on radiography, covering 
subjects especially interesting to otolaryngologists, by Drs. 
Randall, Bigelow, Iglauer, Gerber and myself. CONTENTS 
PART I 
ACUTE DISEASES 
CHAPTER I page 
Acute Diseases of the Nose 17 
Fracture, 17; Furunculosis, 20; Frost-bite, 20; Vestibulitis Acuta, 21; 
Foreign Bodies, 22; Septal Abscess and Hematoma, 23; Epistaxis, 24; 
Acute Rhinitides (Rhinosinuitis), 24; Paranasal Sinus Disease—Acute, 
30; Acute Sinus Disease in Children, 31; Acute Fulminating Sinuitis, 33. 
CHAPTER II 
Acute Diseases of the Pharynx 36 
Epipharyngitis, 36; Retropharyngeal Abscess, 37; Acute Bursitis (Thorn- 
waldt’s Disease), 37; Acute Ostium-Tubitis (Salpingitis), 38. 
CHAPTER III 
Mesopharynx 39 
Mesopharyngitis (Tonsillopharyngitis), 39, Acute Peritonsillar Abscess 
(Quinsy), 42; Acute Tonsillar Abscess, 44; Membranous Pharyngitis, 45; 
Hypopharyngitis, 48; Pharyngeal Bleeding, 50. 
CHAPTER IV 
Acute Diseases of the Larynx 51 
Acute Simple Laryngitis, 51; Acute Laryngitis, Severe Type, 51; Diph- 
theritic Laryngitis, 52; Trauma, 53. 
CHAPTER V 
Acute Diseases of the Trachea 55 
Acute Tracheitis, 55; Foreign Bodies in the Trachea, 55; Injuries, 56; 
Acute Diseases of the Bronchi, 59; Acute Esophagitis, 59. 
CHAPTER VI 
Acute Diseases of the Ear 60 
Otitis Externa, 60; Acute Ostium Tubitis, 66; Acute Otitis Media, 66; 
Acute Mastoiditis, 72. 
CHAPTER VII 
Acute Complications of Mastoiditis 84 
Acute Labyrinthitis, 85; Perisinus Abscess, 86; Sinus Thrombosis, 87; 
Extradural Abscess, 89; Intradural Abscess (Acute Brain Abscess), 90; 
Hernia Cerebri, 91; Meningitis, 91; Acute Facial Paralysis, 93; Acute 
Facial Paralysis Unassociated with Mastoid Disease, 94. 
PART II 
CHRONIC DISEASES 
CHAPTER VIII 
Chronic Diseases of the Nose 96 
External Nose, 96; Rhinophyma, 96; Lupus and Tuberculosis, 96; Lues, 
7 8 
CONTENTS 
98; Rhinoscleroma, 100; Pus Infections—with or without Destruction of 
the Soft Parts, 100; Tumors, 100; Paraffinoma, 105; Vestibulum of the 
Nose, 109; Internal Nose, 109; Nasal Septum, 109; Traumatic Septum, 
115; Lues, 117; Tuberculosis of the Septum, 119; Malignant Disease of 
the Septum, 120; Papilloma of the Septum, 120; Congenital Absence of 
the Septal Cartilage, 122; Closure of the Posterior Choanae, 122; Septum 
in Atrophic Rhinitis, 122; Synechia, 123; Inferior Turbinate, 124; 
Turgescence, 124; Hypertrophy, 125; Atrophy, 134; Atrophic Rhinitis, 
134; Hyperplasia, 138; New Growths of the Inferior Turbinate, 138; 
Lupus or Tuberculosis of the Inferior Turbinate, 139; Syphilis of the 
Inferior Turbinate, 139; Chronic Rhinosinuitis, 139; Pathology of In- 
dividual Structures, 140; Hyperplastic Rhinosinuitis, 149; The Middle 
Turbinate and Sinuses in Atrophic Rhinitis, 155; Sarcoma of the Sinuses, 
157. 
CHAPTER IX 
Nasopharynx and Oropharynx 167 
Chronic Tubitis, 167; Pharyngitis—Lateralis Hypertrophicus, 168; 
Atrophic Pharyngitis, 169; Thornwaldt’s Disease, 170; Syphilis of the 
Pharynx, 171; Tuberculosis of the Pharynx, 174; Tumors of the Pharynx, 
175; Sarcoma of the Tonsil, 177; Carcinoma of the Pharynx, 177; Tonsil 
and Adenoid Diseases, 179; Tuberculosis of the Tonsil, 188; Luetic Tonsil, 
192; Actinomycosis of Tonsil, 192; Hyperkeratosis of the Tonsil, 193; 
Benign Tumors, 194. 
CHAPTER X 
Chronic Diseases of the Larynx 197 
Carcinoma of the Larynx, 197; Tuberculosis of the Larynx, 206; Syphilitic 
Laryngitis, 210; Chronic Simple Laryngitis, 212; Fibrous Polyp, 213; 
Papilloma of the Larynx, 215; Ecchondroma of Larynx, 218; Laryngeal 
Paralyses, 218. 
CHAPTER XI 
Chronic Diseases of the Trachea, Bronchi and Esophagus 221 
Chronic Mucopurulent Tracheitis, 221; Syphilitic Tracheitis, 222; 
Neoplasms of the Trachea, 222; Adenoma of the Trachea, 223; Bronchor- 
rhea, 223; Carcinoma of the Esophagus, 223; Esophageal Diverticulum, 
224; Strictures of the Esophagus, 224. 
CHAPTER XII 
Chronic Diseases of the Ear 227 
Chronic Otitis Externa, 227; Chronic Otitis Media, 243; Chronic Sup- 
purative Tympanomastoiditis, 244; Chronic Nonsecretive Otitis Media, 249; 
Adhesive Otitis Media, 250; Atrophic Otitis Media, 250; Otitis Media 
Residualis of Wittmaack, 251; Chronic Otitis Media Serosa or Seromueosa, 
254; Summary of Pathologic Processes in Chronic Mastoid Disease, 260; 
Chronic Diseases of the Internal Ear, 268. ILLUSTRATIONS 
FLG. PAGE 
Bulla of the membrana tympani in acute infection of the influenzal 
type (Color Plate) Frontispiece 
1. Abscess of the septum; resection for deflection following traumatic hema- 
toma, showing marked cellular infiltration with destruction of cartilage 18 
2. Septal cartilage removed subsequent to hematoma of the septum, showing 
an active chondritis 18 
3 and 4. Compound fracture of the nose 19 
5. Simple fracture of the nose 19 
6. Same case as in Fig. 5 after recovery 19 
7. Frost bite 21 
8. Septal abscess (Color Plate) 22 
9. Notched nose following septal abscess 23 
10. Meeting of the septal and the triangular cartilage with the lateral masses 
at the tip and bridge of the nose 23 
11. Suction apparatus with capillary suction tube 25 
12. Beck’s Irrigation Unit 26 
13. Beck’s postural method of treatment of nose and throat 28 
14. Cameron’s antralamp 32 
15. Brigg’s method of transillumination of antrum 32 
16. Mucous membrane and bone in acute fulminating Sinuitis 34 
17. Acute follicular tonsillopharyngitis, with hyperplasia of the tonsils . . 39 
18. Head traction method (as demonstrated by Lyman) to aid swallowing . 41 
19. Acute peritonsillar abscess with a follicular tonsillitis of the opposite side 42 
20. Incipient peritonsillitis and peritonsillar abseess formation (Color Plate) . 42 
21. Tonsillar abscess with localization and exudate appearing on the surface 
of the tonsil 44 
22. Acute inflammation of the lingual tonsil and base of tongue .... 49 
23. Laryngeal diphtheria 52 
24. Gas burn ulceration 57 
25. Othematoma 61 
26. Trauma of external auditory meatus and canal following self-infliction with 
saturated solution of carbolic acid 65 
27. Tympanic membranes in acute inflammation of the middle ear .... 67 
27. Betrogression of acute middle ear process (Color Plate) 68 
28. Herniation of the tympanic membranes in severe forms of acute otitis 
media suppurativa 69 
29. Nipple perforation 70 
30. Cortex of mastoid in acute mastoiditis, showing necrosis and fistulous tract 73 
31. Thickened periosteum in acute mastoiditis 73 
32. Acute mastoiditis, cell route infection, showing cortex of mastoid and ad- 
joining cells 74 
33. Curettements from the interior of the mastoid in acute mastoiditis, cell 
route infection, showing the lining membrane of the cells thickened 
and infiltrated with leucocytes 74 
9 10 
FIG. PAGE 
34. Acute mastoiditis, cell route invasion 75 
35. Acute mastoiditis, cell route infection 76 
36. Mastoid chip in acute mastoiditis, cell route infection, showing necrosing 
osteitis 76 
37. Acute mastoiditis, cell route invasion 77 
38. Acute mastoiditis, with curettement showing nothing but abscess formation 77 
39. Reparative osteitis in a mastoid chip removed in a reoperative case of 
chronic suppurative otitis media 78 
40. Same as Fig. 39, high power 78 
41. Acute mastoiditis, vascular or osteophlebitic route 80 
42 and 43. Sinus thrombosis 88 
44. Extradural- abscess 89 
45 and 46. Cerebral hernia 92 
47. Rhinophyma (Pound Nose) 98 
48. End result of lupus of lip and both alae nasi showing marked cicatrization 97 
49. Luetic destruction of septum nasi including the columella and center of 
upper lip 98 
50. Gumma of external nose with marked destruction of the interior of the 
nose and the columella 99 
51. End result of deformity and cicatrization in gumma of nose .... 99 
52. Nevus of external nose (scar at tip following boiling water injection) . . 101 
53. Rapidly developing nevus, and result after various methods of treatment 101 
54. Sarcoma of nose producing the typical frog face appearance .... 102 
55. Sarcoma of nose involving the external parts with a fistula formation . . 103 
56. Epithelioma of external nose about the ala 103 
57. Epithelioma of external nose confined to the tip 104 
58. Paraffinoma of external nose showing a scar where attempts were made 
to remove it 106 
59. Masses of paraffinoma removed 106 
60. Paraffinoma of the nose, showing persistent particles of paraffin surrounded 
by fibrous tissue and numerous fat cells 107 
61. Paraffinoma of the nose, showing definite node formation about the paraffin 
particles 107 
62. Paraffinoma of the nose, showing dense fibrous tissue and cellular infiltra- 
tion about fibrous particles 108 
63. Paraffinoma of the nose, showing nodule surrounded by fibrous tissue and 
numerous fat cells 108 
64. Septal spur taken posteriorly near the sphenoid, showing marked rarefaction 
in the bone and the presence of osteoblasts with the deposition of new, 
deeply staining bone in the walls of the larger spaces 110 
65. Gross illustration showing septal ridges at the floor of the nose . . . 110 
66. Large ridge from the premaxilla, showing marked rarefaction .... Ill 
67. Septal ridge showing blood vessels Ill 
68. Septal ridge, showing at the junction of the bone and cartilage large blood 
vessels filled with blood 112 
69. Septal cartilage taken high up anteriorly from a young individual, showing 
marked thickening of the subpericliondrium with great karyokinetic 
figures in the cartilaginous cells at this point 112 
ILLUSTRATIONS ILLUSTRATIONS 
11 
FIG. PAGE 
70. Septal ridge, showing cartilage and bone activity at their junction; rare- 
faction is also clearly demonstrable 113 
71. Septal exostosis, showing areas of rarefaction and dense bone .... 113 
72. Septal ridge, showing rarefaction of bone and great activity of the bone 
and cartilage cells at their junction, and blood vessels filled with blood 114 
73. Traumatic septum; resected cartilage in a traumatic football nose caused 
primarily by an abscess of the septum 115 
74. Septal cartilage, showing round cell infiltration and the great activity of 
the cartilage cells themselves; also cross section of blood vessels . . 116 
75. Same as Fig. 74 (high power) 116 
76. Septal defects, anteriorly and posteriorly, luetic origin 117 
77. Typical saddle or notched nose following gummatous destruction . . . 118 
78. Gumma of the septum 118 
79. Multiple papillomata of the septum 120 
80. Benign papilloma of the nose, showing structural formation with finger- 
like projections 121 
81. Papilloma of the nose showing hornification 121 
82. Lip of wound in atrophic rhinitis, showing hyperplasia of the mucous 
membrane, especially the glands 123 
83. Epithelial hypertrophy of the inferior turbinate with folded-in masses . . 125 
84. Same as Fig. 83, high power, showing epithelial lakes 126 
85. Hypertrophy of the inferior turbinate, showing marked thickening of the 
epithelium with folded-in masses 126 
86. Eschar following cauterization of the inferior turbinate 127 
87. Papillary hypertrophy of the inferior turbinate, showing the epithelial 
hypertrophy 127 
88. Papillary hypertrophy of the inferior turbinate 128 
89. Mulberry hypertrophy of the posterior end of the inferior turbinate . . 128 
90. Posterior end of the inferior turbinate showing ‘ ‘ mulberry hypertrophy ’’ 129 
91. Diffuse papillary hypertrophy of the inferior turbinate 129 
92. Inferior turbinate, showing rarefaction 130 
93. Chronic intumescence of the inferior turbinate, showing predominance of 
connective tissue with round cell infiltration of the surface epithelium 
and almost complete atrophy of the glands, together with new blood 
vessel formation 130 
94. Same as Fig. 93, high power 131 
95. Beck’s conchotribe 132 
96. Crushing of the inferior turbinate (conchotribe) ; section taken on the 
third day showing marked round cell infiltrated masses of necrobiosis 133 
97. Eschar of the inferior turbinate following actual cautery in a case of 
vascular hypertrophy, showing fibrinous organization and papillary 
formation, together with marked leucocytic infiltration 133 
98. Atrophy of the turbinates in atrophic rhinitis 134 
99. Inferior turbinate and early atrophic rhinitis, showing distention of the 
glands 135 
100. Inferior turbinate and early atrophic rhinitis, showing metaplasia of the 
epithelium of the median side and thickening of the antral side . . 135 12 
ILLUSTKATIONS 
FIG. PAGE 
101. Middle turbinate in early atrophic rhinitis, showing metaplasia of the 
epithelium of the median side and thickening of the antral side . . 135 
102. Apparently true myxomatous polypi of the inferior turbinate; showing 
also rarefaction of the bone 138 
103. Chronic hypertrophy of the middle turbinate in chronic suppurative 
sinuitis, showing an increase in the normal tissue elements with 
preservation of the glands 141 
104. Glandular hypertrophy of the middle turbinate, showing besides the in- 
crease in glandular elements a rarefying osteitis 141 
105. Rarefying osteitis of the ethmoids in suppurative sinuitis 143 
106. Ethmoid curettements in chronic suppurative ethmoiditis, showing areas of 
bone necrosis 143 
107. Lining membrane of the frontal sinus in chronic suppurative pansinuitis, 
showing infiltration and thickening, with areas of myxomatous de- 
generation 145 
108. Solitary polyp in the frontal sinus in a case of chronic suppurative 
sinuitis, showing areas of myxomatous degeneration 146 
109. Same as 108 (high power) 146 
110. Pyogenic membrane lining the antrum of Highmore in chronic, suppura- 
tive pansinuitis, showing practically a leucocytic wall 147 
111. Anterior wall of the sphenoid with chronic suppurative pansinuitis, show- 
ing connective tissue fibrosis 147 
112. Pyogenic membrane lining the sphenoid in chronic suppurative sinuitis 148 
113. Tooth with granuloma attached extending to the antrum, removed in case 
of unilateral chronic suppuration of the antrum and ethmoid sinuses 148 
114. Multiple polyp under the middle turbinate in early hyperplastic ethmoiditis 150 
115. Solitary sphenoid polyp 150 
116. Sphenoid polyp 151 
117. Solitary pedunculated fibrous polyp removed from the naso-frontal duct, 
in case of chronic nonsuppurative sinuitis 151 
118. Cystic formation in a nasal polyp in nonsuppurative sinuitis .... 152 
119. Polyp arising from middle turbinate proper 152 
120. Anterior end of the middle turbinate removed in a case of hyperplastic 
ethmoiditis, showing the loss of glandular structure and fibrous changes 153 
121. Middle turbinate in nonsuppurative sinuitis, showing degenerated glands 
and infiltrated mucous membrane 153 
122. Turbina bullosa of the anterior end of the middle turbinate . . . 154 
123. Same as Fig. 122 (sagittal section). Turbina bullosa 154 
124. Cyst of the middle turbinate 155 
125. Ethmoid mass in case of chronic nonsuppurative ethmoiditis, showing no 
differentiation but practically complete myxomatous degeneration and 
some vacuolization 155 
126. Middle turbinate in early atrophic rhinitis, showing metaplasia of the 
epithelium and persistence of mucous glands 156 
127. Nasal polyp, removed in chronic suppurative pansinuitis, showing myxo- 
matous degeneration 156 
128-152. Sarcoma of the antrum treated by surgery, x-ray and radium . . . 157 ILLUSTRATIONS 
13 
FIG. PAGE 
153. Spindle-celled sarcoma of the anterior wall of the antrum of Highmore, 
associated with chronic suppuration 163 
154. Large, small, round, and spindle cell sarcoma of the antrum .... 163 
155. Sarcoma of the nose, showing a highly vascular growth 164 
156. Melanosarcoma, high power 164 
157. Radium exudate in the same case as in Fig. 156. The exudate consists 
chiefly of fibrin and distintegrated cells 165 
158. Lateral pharyngitis (chronic) showing thickened epithelium, bone, 
lymphoid tissue, round-celled infiltration and old connective tissue . . 168 
159. Rubber catheter drawn through nose and out mouth to expose area for 
treatment 169 
160. Healed out luetic cicatrices of the velum palati 172 
161. Pharyngeal stenosis-healed lues 173 
162. Unilateral carcinoma of the tonsil 178 
163. Hyperplasia of tonsils with infection, also adenoid mass 179 
164. Tonsil—hyperplasia of lymphoid tissue, showing but slight dilatation of 
the crypts and absence of cheesy masses in them 182 
165. Adenoids, showing marked increase of lymphoid tissue and very little 
connective tissue 183 
166. Adenoids, showing degeneration of the lining epithelium 183 
167. Tonsil, showing remnants of lymphoid tissue and marked increase in con- 
nective tissue 184 
168. Tonsil in chronic lacunar inflammation, showing dilated crypts filled with 
cheesy masses 184 
169. Tonsil, showing dilated crypts filled with detritus containing cholestrin 
crystals in case of chronic tonsillar infection 185 
170. Same as Fig. 168, high power, showing cheesy masses filling dilated crypts 185 
171. Tonsil, showing trabeculae of fibrous tissue starting at the inner surface 
of the capsule and enclosing masses of degenerated lymphoid tissue; 
also, large number of blood vessels of small lumen present . . . 186 
172. Persistent granulation after removal of adenoids 187 
173. Multiple tonsilloliths 189 
174. Tuberculosis of the tonsil, showing cheesy masses in a dilated crypt . . 189 
175. Tuberculosis of the tonsil, showing numerous tubercles and a dilated, de- 
generated crypt 190 
176. Tuberculosis of the tonsil, with caseation, showing typical tubercles 
formed about the central giant cells 191 
177. Luetic tonsils, showing round cell infiltration and caseous gummata . . 192 
178. Leptothrix 193 
179. Tonsillar crypt filled with bismuth paste, showing the communication of 
the crypts 195 
180. Photomicrograph showing the foreign body giant cells most numerous in 
the region of the bismuth masses 196 
181. Carcinoma of the arytenoids and cords 198 
182. Carcinoma of larynx, extending from the pyriform fossa 198 
183. Carcinoma of the hypopharynx extending into the larynx 199 
184. Carcinoma of the larynx, involving the tongue, showing hard, ragged, 
infiltrated and ulcerated mucous membrane 200 14 
FIG. PAGE 
185. Carcinoma of the larynx 200 
186. Carcinoma of the larynx, showing typical epithelial pearls .... 201 
187. Carcinoma of the larynx showing some typical epithelial pearls . . . 202 
188. Carcinoma of the larynx, showing typical epithelial pearls under high 
power 202 
189. Carcinoma of the larynx, showing marked activity of the malignant 
epithelial cells 203 
190. Carcinoma of the larynx, showing epithelial pearls and a considerable 
number of blood vessels and connective tissue . 203 
191. Carcinoma of the larynx, showing combined activity of the cartilage cells 204 
192. Carcinoma of the larynx, showing “nests” of epithelial cells and older 
connective tissue and uninvaded blood vessels 204 
193. Carcinoma of the larynx, after radiation, showing some round cell in- 
filtration and evidence of chronic inflammatory changes but no active 
malignant cells 205 
194. Interarytenoid tuberculoma simulating papilloma 206 
195. Tuberculous infiltration of the cord and epiglottis 207 
196. Tuberculosis of the larynx, involving the arytenoids and the epiglottis 
which is markedly edematous 207 
197. Tuberculosis of the larynx 208 
198. Tuberculosis of larynx showing typical tubercle formation .... 208 
199. Chronic inflammation of the larynx in case of advanced pulmonary tuber- 
culosis, showing marked round cell infiltration but no tubercle forma- 
tion or giant cells 209 
200. Laryngeal stenosis; luetic origin 211 
201. Singers’ nodules 212 
202. Solitary fibrous polyp of the cord (pedunculated) 213 
203. Laryngeal polyp showing fibrous tissue in various stages and numerous 
capillaries 214 
204. Benign papilloma of the ventricular band 216 
205. Multiple papillomata of the larynx 216 
206. Papillomatous formation about the tracheal fistula 217 
207. Papilloma of the larynx, showing typical papillae formation .... 217 
208. Electrically heated bougie for esophagus with thermostat .... 225 
209. A group of congenital malformations of the ear in the process of recon- 
struction. Pour degrees, complete absence to presence of half of the 
auricle 228 
210-225. Congenital partial absence of auricle, complete absence of middle 
and internal ear right. Polyotia, left. Plastic reconstruction, Gills 
method of tube formation from neck. Septal cartilage implants. 
Twelve separate steps in the operation 229 
226. Congenital macrotia and macrocephalia 233 
227. Congenital deafness, external ear deformity and right facial paresis in 
brothers 233 
228. Congenital verruca (wart) 233 
229. External ear completely torn off in elevator accident 234 
230. Part of external ear bitten off by dog 234 
231A. Artificial ear used in correction of case shown in Pig. 230 .... 234 
ILLUSTRATIONS ILLUSTRATIONS 
15 
FIG. PAGE 
231B. Artificial ear held in place by spectacles 234 
232. Partial destruction of external ear and scars about the face and scalp 235 
233. Practically complete loss of external ear associated with scarring of the 
left side of the face and neck following burn of third degree . . 235 
234. Partial loss and contracture of the external ear and side of the face 
following accidental application of 95 per cent carbolic acid . . 235 
235. Retroauricular fistula following radical mastoid operation 235 
236. Chronic perichondritis 237 
237. Chronic perichondritis 237 
238. Chronic perichondritis with fistula following incision of a subperiosteal 
abscess 237 
239. Chondroma of pinna and external auditory canal 238 
240. Paraffinoma of pinna injected to correct a soft roll ear 239 
241 -A. Epithelioma of pinna and external auditory canal 239 
241-B. Complete destruction of auricle following epithelioma and radium ap- 
plication 239 
242. Schematic outlines of perforations as to prognosis 244 
243. Schematic illustration of multiple perforations 245 
244. Polyp in ear completely filling the external canal in case of chronic sup- 
purative otitis media 245 
245. Incus removed in case of chronic suppurative otitis media, showing an 
osteitis in its long process 245 
246. Ankylosis of the malleus and incus removed in case of chronic sup- 
purative otitis media, showing necrotic areas in both bones . . . 246 
247. Center perforation healed over by thin scar * 246 
248. Thickened margin of central perforation, showing marked injection of the 
lining of the middle ear 246 
249. Beck’s wall plate 248 
250. Marked retraction of the drum with displacement of the ossicles . . . 250 
251. Calcareous deposit in a drum membrane 250 
252. Section through the mastoid of a six-year-old child after latent hyper- 
plastic otitis, showing complete arrest of pneumatization .... 251 
253. Section through the mastoid tip in a two-year-old baby, showing a partly 
pneumaticized mastoid, with the nonpneumaticized portion filled with 
marrow cells and a partly developed cellular network 252 
254. Section through the mastoid in an adult 60 years of age, showing normal 
pneumatization 253 
255. Osteofibrosis and chronic suppurative otitis media showing complete fibrosis 
of the mastoid cells 254 
256. Apparatus for introduction of nascent iodine 256 
257. Schematic drawing for the Pfannenstiel treatment 257 
258. Mercury tube 258 
259. Chronic suppurative otitis media, showing osteofibrosis with fistulae forma- 
tion 261 
260. Otitis media suppurativa chronica (high power), showing necrosis with 
accompanying fibrous reparative process—a chronic osteofibrosis with 
fistulous tract, filled with pus and granulation tissue 261 16 
ILLUSTRATIONS 
FIG. PAGE 
261. Chronic suppurative otitis media, showing osteofibrosis, fistulous tracts 
and cholesteatomatous infiltration 262 
262. Otitis media suppurativa chronica 262 
263. Otitis media suppurativa chronica 263 
264. Otitis media suppurativa chronica, showing tuberculous focus with fistula 263 
265. Sequestral osteitis showing particularly the worm-eaten appearance of 
the edges of the sequestrae 264 
266. Sequestral luetic osteitis 264 
267. Mastoid chip in chronic suppurative otitis media of luetic origin, showing 
an osteofibrosis 266 
268. Epidermal scar of healed radical mastoid cavity, showing the absence of 
any blood vessels or any resemblance to true skin 267 APPLIED PATHOLOGY IN DISEASES OF 
THE NOSE, THROAT AND EAR 
PART I 
ACUTE DISEASES 
CHAPTER I 
ACUTE DISEASES OF THE NOSE 
1. FRACTURE 
Fracture of the nose is now relatively infrequent in this coun- 
try compared with the days preceding prohibition. The cases 
in the Receiving Wards of all public hospitals have been re- 
duced from six to eight a day to two or so a month, and similarly 
in proportion in private practice. The gravity of the condition 
is, of course, in its compound form. The hematoma, with sub- 
sequent infiltration is particularly significant on account of the 
reposition of the displaced and fractured bones, since in many 
cases reduction is impossible until the acute reaction has sub- 
sided. It is to be noted that in addition to the fractured nasal 
bones, there is nearly always associated a bending, displacement 
or fracture of the septum, cartilaginous, osseous or both. The 
immediate attention to such injuries gives the best prognosis 
and cosmetic results. Subsequent attention to these cases, as in 
resecting the cartilage to correct deformity, shows in section, 
a loss of cartilage cells with the formation of connective tissue 
especially in the subperichondrial region and the areas of ab- 
sorbed cartilage (Figs. 1 and 2). 
Case 1.—Compound fracture of nose. Fragments protruding 
externally and internally. Four days’ standing, complicated by 
emphysema, adenitis and subsequent cellulitis and septicopy- 
emia (Fig. 3). Operation: Opened externally and reapposition 
of parts which were held together by silver wire. Rubber tube 
17 18 
APPLIED PATHOLOGY 
Fig. 1.—Abscess of the septum; resection for deflection following traumatic hema 
toma, showing marked cellular infiltration with destruction of cartilage. 
Fig. 2.—Septal cartilage removed subsequent to hematoma of the septum, showing 
an active chondritis. 
intranasal drainage. Further uneventful recovery,—seventeen 
weeks (Fig. 4). 
This case illustrates the most severe pathologic entity of frac- 
tures in which the soft tissues become infected and the bones ACUTE DISEASES OF THE NOSE 
19 
necrotic with subsequent sequestration and extrusion. In con- 
tradistinction is Case 2. 
Case 2.—Simple fracture of nose following “bump against 
door.” Examination showed crepitation, blood suffusion along 
Fig. 3. 
Fig. 4. 
Figs. 3 and 4.—Compound fracture of the nose. 
Fig. 5.—Simple fracture of the nose. 
Fig. 6. —Same case as in Fig. 5 after 
recovery. 
lower lid, septal hematoma. X-ray verities nasal bone severance 
from the nasal spine of the frontal bone. Immediate readaption 
with proper intranasal splinting and external strapping. 
(Method of Lee Cohen.) Recovery in three weeks with good cos- 
metic result. (Figs. 5 and 6.) 20 
APPLIED PATHOLOGY 
2. FURUNCULOSIS 
The most frequent cause of furunculosis lies in the habit of 
pulling out vibrissae and picking the nose, with subsequent fol- 
liculitis. Associated there may be frequently some constitu- 
tional disorder that should not be overlooked. In this respect it 
has been noted that not infrequently a high blood sugar content 
is found without glycosuria. The symptoms are entirely out of 
proportion to the pathologic changes—pain, swelling and dis- 
figurement. Essentially the condition is a cellulitis with subse- 
quent localization; the venous channels are blocked; the outlets 
of the follicles are sealed up by crusts. The intensity of the 
pain is explained by lack of loose areolar tissue at the site of 
infection. The course as a rule is uneventful. Recovery with- 
out deformity but frequent recurrence is to be noted. The treat- 
ment par excellence is the avoidance of manipulation as squeez- 
ing, cutting, picking and neither excess heat nor cold. The best 
results are obtained with warm compresses and an excess of 
petrolatum in the vestibule. We have also used with good re- 
sults Crede’s ointment locally or 10 per cent iclithyol ointment 
instead of the petrolatum. In rare instances this process be- 
comes grave and fatal cases have been seen, especially in ane- 
mia, diabetes and malnutrition, and particularly where surgical 
intervention has been practiced; here the thrombus extends to 
the superior longitudinal sinus through the foramen cecum. 
The complications are perichondritis with deformity and ery- 
sipelas. 
3. FROST-BITE 
This condition affecting the nose is comparatively rare in con- 
tradistinction to frost-bite of the ear. The most important 
symptom for diagnosis is the blanching of the skin with a sharp 
line of demarcation above the alae on either side. 
Case 1.—Cab driver, alcoholic, suffering from acne rosacea. 
Shows the characteristic white blanching of alae and the lower 
portion of the tip of the nose (Fig. 7). Complained of loss of 
sensation followed by excruciating pain radiating to temples. 
Treatment: Snow applications of no avail. Necrosis of blanched 
parts and subsequent slow healing with cicatrization. 
Case 2.—Ordinary case of mild severity, showing blanching ACUTE DISEASES OF THE NOSE 
21 
(constriction of superficial vessels) followed by loss of sensa- 
tion. Rubbing with snow and moist cold compresses were fol- 
Fig. 7.—Frost bite. Note sharp line of demarcation. 
lowed by intense pain (secondary engorgement). Leeches ap- 
plied with almost immediate relief. Slow recovery with atrophy 
of skin which became thin, parchment-like. 
4. VESTIBULITIS ACUTA 
Invariably associated with, or immediately following acute 
rliinosinuitis there is some vestibular inflammation present, 
usually on the inner alar surfaces and the contiguous portion of 
the vestibule to the upper lip. Occasionally, the septal denuda- 
tion, associated with the above-mentioned rliinosinuitis, extends 
to the dermal surface of the vestibule, at times in the most an- 
terior-superior portion of the vestibule, where the vibrissae are 
the most numerous; caking of accumulated and dried mucus will 
irritate the skin and occasionally lead to what is much more 
frequent in chronic vestibulitis, viz., fissure formation. The 
upper lip is commonly affected in this small excoriation contigu- 
ous to the vestibule. The treatment, of course, must be directed 
toward the etiological factor, viz., the rliinosinuitis, by neutral- 22 
APPLIED PATHOLOGY 
izing the excessive alkalinity of the secretion as well as influ- 
encing the action of the bacterial content. This management is 
described in the subsequent chapters. Treatment of the vestib- 
ulitis per se is most satisfactorily carried out by the use of 
ammoniated mercury ointment (2 per cent) freely applied within 
the vestibule. 
5. FOREIGN BODIES 
Foreign bodies in the nose are found most frequently in chil- 
dren; wads of paper, small buttons, small pebbles, and marbles 
are among the commonest forms. In the adult, the formation of 
concretions by accretions of various salts from the mucous secre- 
tions, particularly magnesium phosphate, is the most frequent 
foreign body, and at that, it is comparatively rare. We have 
had a case in which a rhinolith of the magnesium phosphate 
variety was of such size as to make its removal impossible either 
anteriorly or posteriorly through the nose. However, by apply- 
ing strong acetic acid we were able to so alter its composition 
as to make crushing and piece-meal removal possible. The re- 
sultant destruction within the nasal cavity from pressure, was a 
defect in the lateral wall and a perforation in the posterior part 
of the septum. 
Parts of instruments broken off during surgical operations, 
particularly knives and chisels, are found with sufficient fre- 
quency to record them. Gauze and cotton left in the nose fol- 
lowing treatment or operation, have also been observed. The 
x-ray is of great value in diagnosis. The symptoms resulting 
from all foreign bodies consist in the main of unilateral, thick 
foul discharge, bleeding, especially when associated with ulcera- 
tion, and nasal obstruction. Vestibulitis invariably accomjmnies 
foreign bodies. 
Treatment.—Removal of the foreign body is the only proce- 
dure to be considered, and each case is an entity in itself. In 
children, it is best to remove the foreign body under general 
anesthesia, although, if it is located anteriorly it may be re- 
moved without an anesthetic; in adults, removal is best accom- 
plished under local anesthesia. Metallic substances have in 
many instances been removed by aid of the Haab magnet, al- 
though in several cases it was necessary to remove some of the 
overlying bony structures. Fig. 8.—Septal abscess. ACUTE DISEASES OF THE NOSE 
23 
While foreign bodies should be considered under the heading 
of acute conditions, if they are retained over a period of time, 
they cause chronic disease, or eventually lead to a foreign body 
tumor. 
6. SEPTAL ABSCESS AND HEMATOMA 
Septal abscess usually follows a fall or direct trauma of the 
tip of the nose. We have seen one case in a child of nine of 
what apparently must be called an idiopathic septal abscess, 
there being no history of trauma. Examination shows a bilat- 
eral occlusion and when the tip is lifted, two smooth, rounded 
masses are revealed extending from the septum laterally and 
Fig. 9.—Notched nose fol- 
lowing septal abscess. 
Fig. 10.—Meeting of the septal and the tri- 
angular cartilage with the lateral masses at 
the tip and bridge of the nose. 
filling the entire nares (Fig 8). This is doughy to the touch 
and not particularly tender. If the hematoma remains unin- 
fected, which is rare, absorption will follow with probable pres- 
sure atrophy of the cartilage with the resultant corresponding 
kink or notch nose (Fig. 9). This is caused by complete absorp- 
tion of the triangular septal cartilage at its important support- 
ing triangle. (Fig. 10.) 
When there is abscess formation, there may be a rise of tem- 
perature and pain radiating to the root of the nose and the tem- 
ples. Usually there is a submaxillary adenitis. The treatment 24 
APPLIED PATHOLOGY 
of both hematoma and abscess is immediate evacuation under 
strict aseptic conditions with firm packing on both sides. Drain- 
age can be obtained irrespective of the packing by the insertion 
of a few strands of silkworm gut into the depth of the wound. 
(The treatment of deformities has been taken up in the Chapter 
hv Dr. J .C. Beck in Loeb’s “Operative Surgery of the Nose, 
Throat and Ear.”) 
7. EPISTAXIS 
Epistaxis is rather a symptom than a disease. One of the 
commonest causes is a nose-picker’s ulcer of the septum. In 
children it is associated with exanthemata and in former years 
it was the great prodromal symptom of typhoid fever. It is also 
found in blood dyscrasias, such as anemias, hemophilia and 
cardiovascular diseases, characterized by high arterial tension, 
but in the largest number of cases it is associated with opera- 
tion. The commonest site is at the locus of Kieselbacli in the 
anterior inferior portion of the cartilaginous septum. In most 
instances these conditions are chronic and will be discussed 
later. Immediate treatment is directed toward the bleeding- 
points by sufficient packing with Bernay splints or post-nasal 
tampon and subsequent use of caustics, such as full strength 
silver nitrate, chromic and trichloracetic acid and at times actual 
cautery. In cases where bleeding persists, submucous resection 
becomes necessary. 
8. ACUTE RHINITXDES (RHINOSINUITIS) 
Acute rhinitis should he thought of as a rhinosinuitis. 
Whether one or the other is primary is a problem. The patho- 
logic changes in this disease must be studied in the various 
stages. 
1. At the onset the mucous membranes, if they could be meas- 
ured, would be much thinner than normal owing to the narrow- 
ing of the vessels. On inspection, a corresponding ischemia is 
to be noted. This period lasts but a short time and is most fre- 
quently associated with irritation of the nerves characterized by 
dryness and repeated sneezing. ACUTE DISEASES OF THE XOSE 
25 
2. The first stage is followed by vascular dilatation, in which 
there is a swelling of the mucous membranes with the outpour- 
ing of a watery serous discharge, nonirritating at first. This 
stage again is fleeting and of short duration. 
3. Leucocytic infiltration, as well as the outpouring of lymph 
and the increase of alkaline content of the transudate follows. 
The swelling of the mucosa becomes greater and is accompanied 
by round-cell infiltration. There is often superficial rhexis and, 
at times, slight bleeding. This stage is likewise of short dura- 
tion. 
4. Pus formation with a marked increase of mucin, giving the 
mucopurulent character to the discharge, succeeds the leuco- 
Fig. 11.—Suction apparatus with capillary suction tube. 
cytic infiltration. At this period we advise the patient to try 
not to blow his nose if possible. If the secretion is very thick, 
capillary suction may be used to great advantage (Fig. 11). As 
little manipulation as possible is advisable. The common olive 
tip suction is not to be recommended because of the increased 
possibility of drawing in the mucous membrane and thus ob- 
structing the outlet of the paranasal sinuses. 
The purulent period is of the longest duration because of ob- 
struction to the outlets of the paranasal sinuses and secondary 
or other changes in the sinuses from closure, increased secretion, 
greater swelling of the membranes or increased bacterial activ- 
ity. There may likewise be even putrefaction or actual necrosis. 
It is desirable as soon as the sensation of a “heavy feeling” 
over the sinuses is noticed, to shrink the mucous membranes in 26 
APPLIED PATHOLOGY 
the region of the sinus outlets with a small pledget of cotton, 
moistened with either a weak cocaine solution or apothesin solu- 
tion to which a few drops of adrenalin may be added. Adrenalin 
alone, over a longer period of time, is to be avoided because of 
Fig. 12.—Beck’s irrigation unit. 
the marked secondary dilatation of the blood vessels which pro- 
duces further engorgement of the mucous membranes. Rasping 
the secretions back into the throat is to be preferred to frequent 
blowing of the nose, even though this method may not be es- 
thetic. Capillary suction under direct inspection can be used to ACUTE DISEASES OF THE NOSE 
27 
advantage but again we advise strongly against the bulb suc- 
tion tips. The use of mild alkaline antiseptics or normal saline 
solution may be employed by the aid of cannula irrigation under 
direct ocular inspection. We employ the apparatus as shown 
in Fig. 12, which consists, in the main, of a thermos bottle fed 
by compressed air. Cannulas of various sizes and shapes as 
they may be required in irrigation of the nose, throat or ear are 
also shown. Solutions which we have found valuable in these 
conditions are silvol or neosilvol (5 to 20 per cent solutions) in- 
troduced preferably by Beck’s postural method (Fig. 13). It is 
to be emphasized here that for the most part, these conditions 
are self-limited and as little as possible manipulation is to be 
practiced. The general treatment must not be neglected, i. e., 
intake of fluids, free catharsis, etc. 
As a general rule, if there has not been too much interference 
or too many complications, the patient recovers from his marked 
discomfort within a limited period. There is a gradual resolu- 
tion and the discharge becomes thicker, scantier, and the vesti- 
bule tends to crusting, at which time the patient is apt to pick 
the nose and add the complication of a possible vestibulitis with 
fissure formation. At this time, one frequently finds in the ef- 
fort to dislodge the thick secretions, blood-streaked mucus and 
often the beginning of a chronic septal ulceration. Coincident- 
ally, there is increased space in the nose associated with im- 
provement in the general symptoms and feeling of well-being. 
This usually occurs about the second week. 
Complications: 
1. Acute Sinuitis, one or all sinuses. 
2. Tubotympanitis—by extension. 
3. Acute tonsillitis. 
4. Pharyngolaryngitis. 
5. Tracheitis. 
It is known that the symptoms of infection may begin in the 
lower respiratory passages and extend upwards. 
If the process tends to become subacute, local treatment to the 28 
APPLIED PATHOLOGY 
Fig. 13.—Beck’s postural method of treatment of nose and throat. acute diseases of the xose 
29 
nasal mucous membranes of tlie coal tar products, as ichthyol, 
and various emollients, as petrolatum, are of great benefit. 
As far as the microscopic changes are concerned, the initial 
stage will rarely be studied because of its transient duration 
and we can only infer here the absence of inflammatory prod- 
ucts. The most important change is the marked vascular dila- 
tation, many of the vessels being literally choked up with leu- 
cocytes. In many places active diapedesis and marked leuco- 
cytic infiltration can be observed. The superficial epithelium in 
many places is denuded. The marked hyperactivity of the 
mucous glands manifests itself in distention and the columnar 
cells show great activity,—the granules staining deeply. 
In the later stage, the round-cell infiltration becomes more 
marked and in many instances there are hemorrhagic areas. 
The glands are reduced in size. Pus corpuscles can be seen in 
great numbers on the surface; and in tissues stained for bacteria, 
the prevailing microorganisms, with corresponding disappear- 
ance of the usual nasal flora, can be seen. 
The mucous membranes lining the sinuses differ only in the 
glandular changes, as they are sparingly distributed, but on the 
other hand, since the membrane serves as periosteum to the 
nasal accessory sinuses, there are observed areas of definite 
superficial osteitis in addition. In very virulent infections, there 
is an actual necrosis in addition to the osteitis, the engorgement 
and increased number of osteoblasts especially in the first layers 
of the lacunae. Not infrequently there are definite areas of 
superficial bony necrosis which in most instances tends toward 
resolution. (Gerber.) We ourselves have not studied these 
changes, but accept the work of authorities. 
Bacteriology.—Without entering into either the literature or 
references to this subject, we prefer to take the old basis of 
authorities for our classification of the acute and chronic flora 
of the nasal cavities. The most prevalent organism in the acute 
cases is the staphylococcus, predominating in the ordinary 
“cold.” Even in the majority of the exanthemata in children 
this is true, and only in the epidemics or pandemics of “La 
Grippe” is the influenzal bacillus found together with the pneu- 
mococcus or streptococcus. The question of transmutation of 30 
APPLIED PATHOLOGY 
bacteria (Bosenow) found in acute processes is not accepted, 
but one frequently observes an acute rliinosinuitis in which the 
influenza bacillus is present early but is later supplanted en- 
tirely by the pneumococcus and then even later by the staphy- 
lococcus and streptococcus. Barely diphtheritic organisms have 
been found in acute cases (without membrane or exudate). 
Spirochetes are likewise rarely found. 
PARANASAL SINUS DISEASE—ACUTE 
Acute paranasal sinus disease as a sequence to tlie acute 
rliinitides is comparatively infrequent, as by far the majority of 
“colds” clear up, although latent infection may remain in the 
sinuses making predisposition to further attacks quite likely. 
When it does occur we find the involvement more frequently 
unilateral, and if bilateral, one side is more active than the other. 
As to the sinuses involved, the anterior group is known to be 
involved much more frequently than the posterior group. In 
the former, in order of frequency of involvement comes the 
antrum, the ethmoid and then the frontal. Primarily the an- 
trum may not he most frequently involved, but secondarily to 
frontal and ethmoid infection as well as to dental infection. In 
the posterior group comes in order of frequency, the posterior 
ethmoid and sphenoid sinuses. 
Acute sinus disease is found apart from complicating, or as a 
sequence to, rhinosinuitis, associated with the following condi- 
tions: 
1. Influenza, epidemic as well as pandemic form. 
2. Bronchitis. 
3. Bronchopneumonia. 
4. Acute exanthemata, especially in children. 
5. Secondary to nasal operations, especially where packing 
was done. 
6. Secondary to dental disease (antrum infection). 
Pathology.—As in rhinosinuitis, there are various stages of 
involvement in both the mucous membrane and the bone. There ACUTE DISEASES OF THE XOSE 
31 
is first a venous engorgement, followed immediately by a trans- 
udation, depending on the severity, leading to small rliexis. 
Then within a very short time, twenty-four hours or so, free 
fluid is found in the cavities. The fluid itself is slightly cloudy, 
of watery consistency, and chemically of a strong alkaline re- 
action. Bacteriologically, this fluid is scant in organisms, except 
in cases of antrum infections associated with dental disease, 
when organisms are present in great numbers. 1 lowever, many 
leucocytes are invariably found. If a puncture of the antrum 
be made within forty-eight hours, for example, the fluid is 
thicker in consistency, and a marked increase in bacteria, par- 
ticularly the staphylococcus, is to be noted. There is a rapid 
change in the mucosa with tremendous swelling about the ostia 
and in the mucous membrane of the ethmoid labyrinth, (as has 
been shown when opened through the external route). Complete 
closure of a cavity has been noted due to the excessive swelling 
of the mucous membrane. 
If the case progresses without drainage being established, 
there is a, rapid change to marked round-cell infiltration in the 
subepithelial layers of the mucous membrane, together with ac- 
tive congestion by arterial dilatation which gives rise to the 
throbbing sensation so often mentioned by the patient. Should 
the organisms be hemolytic in type, streptococcus or pneumo- 
coccus, Group III type, we notice frequent small ulcerations 
and the bone may show a definite osteitis. At this point we 
might mention that it is our opinion that a sinus once affected 
by an infective process never undergoes complete resolution; 
especially is this true of the ethmoid labyrinth where predispo- 
sition to repeated attacks is so often seen. 
ACUTE SINUS DISEASE IN CHILDREN 
There is conclusive evidence from recent studies that acute 
sinns disease in children, especially antrum and ethmoid in- 
volvement, is much more frequently present than heretofore be- 
lieved. The continued “running nose” in infants and children 
and the excessive discharge continuing longer than the usual 
acute rhinosinuitis, is sufficient to lead one to suspect the pres- 32 
APPLIED PATHOLOGY 
ence of a subacute sinus involvement. The symptom of indef- 
inite pressure about the face is very commonly complained of 
by older children and indicated frequently by even the younger. 
Upon intranasal inspection, the inflammation of the nasal 
mucous membrane is not sufficient to explain this excessive dis- 
charge. The persistent engorgement of the conjunctiva, espe- 
cially on the nasal side, is an additional finding of considerable 
aid in arriving at a diagnosis. The application of adrenalin to 
Fig. 14. 
Fig. 15.—Brigg’s method of transillumination of antrum, 
the upper straits of the nose frequently discloses secretions con- 
fined to the lateral wall of the nose. The nasopharyngoscope is 
of considerable value to demonstrate the affection involving the 
ethmoid. A puncture into the antrum and then suction through 
the trocar will often demonstrate the secretion. The x-ray will 
often demonstrate the involvement, especially in unilateral an- 
trum disease. The small cold lamp can he used nicely in trans- 
illumination, especially when introduced against the infraorbital 
margin and directed into the oral cavity (Figs. 14 and 15). 
The pathologic changes are quite different in acute sinuitis 
than when the condition is acutely engrafted upon a chronic 
process; i. e., acute exacerbation of a chronic jn’ocess, which ACUTE DISEASES OF THE NOSE 
33 
condition frequently comes to operation. This subject will be 
taken up with the chronic conditions. Definite bony and mem- 
branous changes have been demonstrated. 
ACUTE FULMINATING SINUITIS 
Gross Pathology.—There is marked swelling and edema of all 
the mucous membranes of the nasal cavity, especially about the 
anterior end of the middle turbinate and the adjacent lateral 
wall of the nose. The sinuses, frontal, antrum or ethmoid, show 
the following changes: the overlying skin and periosteum are 
edematous and acutely infiltrated; the bone bleeds freely and as 
soon as the cavity is opened a flow of secretion escapes under 
tension. The mucous membrane lining of the cavity is mark- 
edly thickened and edematous; it bulges through the opening 
and bleeds very freely and appears to be lifted off the under- 
lying bone. 
Microscopic examination shows marked thickening of the sub- 
epithelial structures. There is marked engorgement and there 
are some thrombotic vessels. The underlying bone shows an 
acute osteitis and in places may show definite bony necrosis. 
(Fig. 16.) This is of particular importance in relation to sec- 
ondary orbital and cranial infections. 
Application.—From the pathology present, it can be seen that 
this condition should always be attacked surgically through the 
external route. In the antrum, sublabially; the ethmoid, trans- 
orbitally; and the frontals, likewise externally. In the posterior 
group we have no record of operations in the fulminating type. 
For the technic of the various operative procedures, the reader 
is referred to the many texts on this subject, as Loeb’s, etc. 
Prevention.—After reviewing the changes taking place in 
the nose and paranasal sinuses, we must particularly emphasize 
the correction of anatomical malformations of the interior struc- 
ture of the nose, i. e., deflected septums, especially the type as- 
sociated with marked thickening of the tuberculum septi. At- 
tention, too, must be directed toward middle turbinate enlarge- 
ments which produce irritation from pressure and contact, or 
enlargements from previous sinus disease. 
To our dental and oral hygiene should be added nasal hygiene, 34 
APPLIED PATHOLOGY 
particularly as preventive measures during epidemics of respi- 
ratory infections. Nasal irrigations of the sinuses should only 
be done by the experienced rhinologist. The use of oral and 
nasal masks during the virulent epidemic influenza has undoubt- 
edly proved itself of value. 
Fig. 16.—Mucous membrane and bone in acute fulminating sinuitis. 
Irritation from manipulation during the acute rhinitides 
should be avoided. The general condition of the patient must 
of course be brought up to the highest point of resistance. 
Antrum 
Treatment.—The treatment differs in no marked respect 
from that given in the consideration of the acute rhinitides,— 
treatment that is rationally based on the pathology present. 
However, if we would have definite proof of tension within the 
antrum, the passing of a Pierce cannula into the natural opening 
of the sinus after cocainization is indicated. The head is then 
bent down and after suction is applied, irrigation again followed 
by suction should be carried out. We here caution against the 
blowing of air into the sinus under any consideration either for 
diagnostic or therapeutic purposes. We do not advise puncture 
under the inferior turbinate in acute processes unless puncture 35 
ACUTE DISEASES OF THE NOSE 
through the natural opening cannot be done, although we are 
aware of the fact that this method is practiced by the majority 
of rliinologists. 
Frontals 
In the frontal sinus, under no circumstances do we consider 
the passage of sounds or cannulae in acute conditions, because 
we have seen, in consultation, severe complications and even 
fatalities from such procedures. If a more radical procedure 
should be necessary, we much prefer the adoption of a safer 
procedure. The sinus is entered through a small external open- 
ing. However, infraction of the middle turbinate for the pur- 
pose of securing better drainage is a perfectly safe procedure. 
Many rliinologists remove the anterior end of the middle tur- 
binate for this purpose, but we do not recommend it. 
Ethmoids 
Surgical intervention in the ethmoid labyrinth during acute 
processes is had practice, holding with it the danger of exten- 
sion to the cribriform plate and perineural lymph spaces of the 
olfactory filaments. These cells, if the condition is of the ful- 
minating type, can be attacked through the transorbital route. 
Posterior Ethmoid and Sphenoid 
Surgical interference in tliis posterior group during an acute 
process either for irrigation or sounding does not conform to 
our principles of treatment, and from our experience we strongly 
advise against it. CHAPTER II 
ACUTE DISEASES OF THE PHARYNX 
Distinct clinical entities are rarely confined to one portion of 
the pharynx; thus acute conditions involving the epi-, meso- or 
hypo-pharynx are usually confluent. 
EPIPHARYNGITIS 
A distinct entity involving the epipharynx has been for a long 
time recognized clinically and spoken of by the German pedi- 
atricians as “Kinderdriisenfieber.” This condition is character- 
ized by a complete lockage of the postnasal space with an acute 
swelling of the adenoid tissue and is accompanied by a cervical 
adenitis. The angular glands of the neck are like small packets 
and suboccipital adenitis is usually present. The middle ear, 
with or without subsequent discharge, seldom escapes. The 
condition gives rise in infants and children to a most persistent 
recurrence of septic temperature, with a rapidly developing sec- 
ondary anemia, sweats and emaciation, and even, when uncom- 
plicated, is of considerable duration. 
The pathologic change in the adenoid tissue is but a simple 
hyperplasia and suppuration is almost unheard of. Hanoch has 
shown that the organism involved is usually a filtrable virus. 
Such adenoids removed surgically by mistake are accompanied 
with a comparatively small amount of bleeding. The remaining 
mucous membrane on the oropharynx appears thickened but 
smooth, and is not markedly injected. 
Treatment.—Supportive measures, with little or no local treat- 
ment, have, in our experience, produced the most satisfactory 
results. Hexamethylenamine given internally, entirely on an em- 
pirical basis, has been very satisfactory and has been found to 
be almost specific in this inflammatory process. Local instilla- 
tion of silvol preparations through the nose and Crede’s oint- 
ment applied externally to the involved glands lias perhaps the 
greatest number of advocates. Where surgery has been em- ACUTE DISEASES OF THE PHARYNX 
37 
ployed we have observed no particularly brilliant results, and 
in some cases the toxemia has continued to be intense and a 
rapidly developing emaciation has ensued. 
In adults, an acute lacunar adenoiditis is not infrequently 
seen, although it more often is associated with a lateral pharyn- 
gitis. This condition is found particularly where there is a 
compensatory hypertrophy of the posterior pharyngeal lymph- 
oid tissue subsequent to previous tonsillectomy. 
RETROPHARYNGEAL ABSCESS 
Retropharyngeal abscess is observed most frequently in in- 
fants and children and not uncommonly incorrectly diagnosed 
diphtheria. The gross changes observed in the pharynx show a 
thickening of all the mucous membranes about the pharynx, 
together with a noticeable hypersecretion. The mucous mem- 
branes are not very much injected at first and invariably one 
side of the pharynx appears more swollen than the other, and 
on palpation a distinct boggy mass is felt. Within a short time, 
twenty-four hours or so, the sensation of bogginess gives way 
to a feeling of lack of resistance rather than definite fluctuation. 
Incision is usually very gratifying and is accompanied with 
comparatively little bleeding. The use of the suction tube 
immediately after incision is quite advantageous. The path- 
ology of these conditions is an infection of the retropharyngeal 
lymphatic glands, which break down very quickly, and the in- 
vading organism is usually the staphylococcus. Recovery as a 
rule is uneventful without further attention, and recurrences 
are rare, but do occasionally occur, especially if drainage is 
insufficient either because of the size of the opening or the inci- 
sion having been made straight rather than oblique. The 
oblique incision has the advantage of actually cutting some of 
the muscle fibers and thus preventing too early complete closure 
of the wound by the constrictor muscle fibers. 
ACUTE BURSITIS (THORNWALDT’S DISEASE) 
Occasionally in the case of Thornwaldt’s disease, an acute bur- 
sitis, involving the retropharyngeal bursa, is observed. The 
mucous membrane having become invaginated and the opening 38 
APPLIED PATHOLOGY 
closed, retention is apt to ensue. On examination a smooth, 
bulging mass is found in the upper vault of the pharynx where 
the adenoid tissue is located. The mass appears to fluctuate on 
palpation and very often an attempt to make a diagnosis digit- 
ally effects a cure by squeezing out the retained fluid. Dys- 
phagia is a persistent and obstinate feature of this condition. 
The differential diagnosis is concerned chiefly with upper Pott’s 
disease. The treatment consists mainly of emptying the bursa 
by downward incision. 
ACUTE OSTIUM-TUBITIS (SALPINGITIS) 
Salpingitis, although usually taken up in connection with dis- 
eases of the ear, is often confined to the lips of the tube or 
extends only as far as the isthmus. It is very seldom an 
entity in itself, but usually is found associated with a rhinitis or 
tonsillopharyngitis. 
One finds on examination with the mirror that both lips of 
the tube are very red and swollen so that the usual recess open- 
ing is practically obliterated. In a later stage the glairy mucus 
at the opening can be seen. With a well-retracted soft palate, 
in cases where this process is secondary to a lateral pharyn- 
gitis, the direct extension of the inflammatory process along the 
lateral walls of the pharynx up to the posterior lip of the tubal 
orifice and the fossa of Rosenmiiller can be seen. Not infre- 
quently definite adhesions in the fossa are observed, which are 
the remains of atrophied lymphoid tissue together with inflam- 
matory products. Where there is much thickening, the exist- 
ence of a definite perichondritis can be assumed. If palpated, 
the stiffened posterior lip of the tube is felt and very often ad- 
hesions in Rosenmuller’s fossa give way. 
Treatment.—Mild astringents applied intranasally by drop- 
ping in the medication with the head well back and slightly 
tilted to the side will reach the parts. We have used in our 
practice, with satisfactory results, solutions of zinc sulphate and 
silvol. Later, direct applications of 2 to 5 per cent silver nitrate 
solution to the ostium tubae may be used. It is to be noted that 
in these conditions, although no middle ear symptoms may be 
present and the acute process has subsided, catheterization 
should nevertheless be instituted. CHAPTER III 
MESOPHARYNX 
MESOPHARYNGITIS (TONSILLOPHARYNGITIS) 
Mesopharyngitis is most frequently found as an entity con- 
fined to the mesopharynx. The inflammatory process, as a rule, 
involves the tonsillar ring and the base of the tongue. Inflam- 
mation of the tonsil without involvement of the pillars is rare. 
Usually the entire Waldeyer ring becomes affected when lympli- 
Fig. 17.—Acute follicular tonsillopliaryngitis, with hyperplasia of the tonsils. 
oid tissue is the seat of the trouble, but a localized acute inflam- 
mation of the tonsil, pillars, and uvula is the rule. 
The gross changes observed are an injection of the whole 
area, one side more than the other, soon followed by swelling 
of the pillars and tonsils, also more marked on one side than the 
other. The extent of the coagulation necrosis in the lacunae, 
spoken of as the “white spots” of tonsillitis (Fig. 17), depends 
on the virulence of the invading organism. This in turn leads 
to a greater swelling of the tonsil because of the accumulation 40 
APPLIED PATHOLOGY 
iii the crypts and hyperemia of the pillars. The uvula becomes 
less mobile and elongated because of the edema and subsequent 
stretching of the mucous membrane. Associated with this in- 
flammatory process is a peritonsillitis and a pharyngeal myo- 
sitis, which accounts for the predominating symptom, pain on 
swallowing, especially of small amounts of saliva or fluids. 
Should the peritonsillitis assume borderline manifestations of a 
peritonsillar abscess, then the uvula and the plica supratonsil- 
laris show the first signs of edema. This is likely to occur in 
cases where the sinus supratonsillaris of Killian is present, the 
large superior crypt becoming hidden by the supratonsillar fold. 
The receding of this process or progress to a peritonsillar ab- 
scess, depends upon previous attacks and the presence of a 
sinus supratonsillaris. In the majority of cases, however, ap- 
parent resolution takes place and the first symptom of difficulty 
in swallowing disappears because of undoubted relaxation of 
the muscles. The white, flaky material correspondingly dis- 
appears. The histopathology in these cases can only be thought 
of in analogy with inflammation elsewhere. 
Treatment.—The symptom of pain as well as the discomfort 
of dryness is best overcome by the use of warm solutions as 
gargles, particularly the milder astringents containing a small 
amount of salicylic acid or wintergreen. As in rhinitis, so here, 
not too frequent flushing of the throat is advisable because in 
the secretions covering the inflamed mucous membranes are 
contained the immune bodies of Nature’s defensive forces. 
Rough handling, as in frequent swabbing and probing, is to be 
avoided. The value of external apjfiications of warm, moist 
compresses cannot be overestimated. This is best accomplished 
by the use of cotton pads the width of the neck, moistened in 
tepid water, the excess squeezed out, and wrapped around the 
neck. Another similar compress may be placed under the chin 
and brought over the ears and after covering with oiled silk 
still another dry cotton pad is placed and retained by a four- 
tailed bandage. This type of compress retains the heat for a 
very long time and is soothing. 
Because of the painful swallowing and the importance of 
plenty of fluids, the use of the head traction method during the 
effort of swallowing liquids can be very successfully applied. MESOPHARYNX 
41 
With the patient sitting up, the one applying traction places his 
hands over the ears with the tips of the fingers directed toward 
the temples, the palms over the ears, the thenar and hyperthenar 
eminence over the mastoid. Traction is then directed upwards. 
(Fig. 18.) The internal administration of salicylates, elimina- 
tion and attention to general hygiene should be instituted. The 
use of urotropin is advised against because of the already pres- 
ent irritation of the renal epithelium in these cases, apart from 
Fig. 18.—Head traction method (as demonstrated by Lyman) to aid swallowing 
the possible chemical irritation of the formalin. In the abating 
period of acute tonsillitis, direct irrigation with a fine stream 
of a mild antiseptic solution against the tonsillar surface, fol- 
lowed by capillary suction of the small crypts by means of a 
small trumpet-end capillary tube may be used advantageously 
(Fig. 11). This should be followed by application of a 2 to 5 
per cent silver nitrate solution. The types of gargles recom- 
mended are those of oxidizing nature, as potassium chlorate and 
potassium permanganate. 
In the treatment of peritonsillitis bordering on peritonsillar 42 
APPLIEI) PAT 11OLOGY 
abscess formation, great caution is to be observed in the danger 
of the unnecessary procedure of incision, especially incision into 
the tonsillar tissue. The best treatment for this unilateral swell- 
ing and infiltration is the constant application of heat by the use 
of small amounts of hot water repeatedly to be held in the throat 
as long as possible. Warm water irrigations may likewise be 
used. 
ACUTE PERITONSILLAR ABSCESS (QUINSY) 
Development of the preceding conditions into peritonsillar 
abscess formation is due to the extension of the process into the 
loose peritonsillar tissue. In the majority of cases this occurs 
in the superior and external part of the tonsillar fossa, but the 
posterior inferior portion is also more or less infiltrated. This 
Fig. 19.—Acute peritonsillar abscess with a follicular tonsillitis of the opposite side. 
latter area particularly blocks the venous return, giving rise 
to edema about the uvula which occasionally reaches great pro- 
portions. As the case progresses, extension laterally may ensue, 
with infiltration of the pterygoid muscles, giving rise at the 
height of the process to “lockjaw.” 
The tonsil itself in most cases is practically hidden by the 
swelling of the pillars, but when seen, since this is usually the Fig. 20.—Incipient peritonsillitis and peritonsillar abscess formation. MESOPHAUYXX 
43 
sequence of acute tonsillitis, the lacunae are filled up with exu- 
dative material (Fig. 19). Abscess formation is noted usually 
within forty-eight hours in the region of the superior external 
portion of the palatoglossal fold. On palpation two points are 
observed, softness and tenderness (Fig. 20). The posterior 
pillar when markedly enlarged should always be suspected of 
containing a sinking abscess, and is of great importance in the 
prognosis of a possible mediastinitis developing. In the event 
of the lower anterior pillar becoming very much swollen, in- 
cluding the base of the tongue, a graver prognosis of the pos- 
sibility of a Ludwig’s angina must be considered. When in this 
connection swelling occurs in the anterior thyroid region, it is 
almost certain that a sinking abscess has passed along the stylo- 
hyoid muscle and ligament, and acute thyroiditis is the impend- 
ing danger. 
Two other unusual locations for the possible rupture of a peri- 
tonsillar abscess are into the pterygoid fossa and into the tonsil 
itself. In the event of its occurrence in the former site the per- 
sistent inability to relieve the lockjaw, together with the char- 
acteristic neck swelling near the scalenae, simulating a Bezold’s 
mastoid, is observed. In the event of its rupture into the tonsil 
itself, pus is seen oozing out of the crypts. This is not to be 
confused with an acute tonsillar abscess. 
In recent years attempt has been made to curtail the course 
of this condition by obtaining drainage by removal of the tonsil. 
Although contrary to the well-established surgical principle of 
operating in acute conditions, the result lias been uneventful as 
far as serious consequences are concerned. This method of pro- 
cedure is not popular. Tonsils removed in this condition leave 
an operative terrain of muscle exposure—the fascia and apo- 
neurosis coming along with the tonsillar capsule. Dissection 
in these cases is comparatively easy and is not accompanied by 
any greater bleeding than usual. Cross sections of tonsils thus 
removed show nowhere any evidence of abscess formation, and 
cut with greater ease than the ordinary tonsil removed for 
chronic disease. Microscopic examination shows an acute in- 
flammatory process. 
Treatment.—The treatment follows along the same lines as 44 
APPLIED PATHOLOGY 
that given above, with the addition of promoting suppurating 
or eventual resolution by heat, external and within the oral 
cavity. As soon as localization is determined, free incision 
should be made in line with the arcus palatinus, being certain 
not to cut into or through the tonsillar capsule. Other methods 
of producing drainage, such as direct opening into the superior 
tonsillar fossa by use of a scissors or artery forceps, are quite 
satisfactory. A particularly gratifying gargle in these cases is 
composed of warm tea and seltzer, equal parts. Head traction 
is likewise of value in relieving the pain of swallowing (see Fig. 
18). The accumulation of secretions in the mouth is best re- 
moved by suction. Warm saline irrigations with the head held 
forward are effective. 
ACUTE TONSILLAR ABSCESS 
Acute tonsillar abscess is quite rare and found almost exclu- 
sively in the adult. It must always be considered a grave dis- 
Fig. 21.—Tonsillar abscess with localization and exudate appearing on the surface 
of the tonsil. 
ease. The patient is very septic and not infrequently the tem- 
perature rises to 105° F. The process is confined to the tonsil 
itself, and the surrounding tissues are not greatly involved. 
The tonsil is large, deeply injected, particularly over the site of MESOPHAEXNX 
45 
the abscess, is hard to the touch and not painful. It is usually 
unilateral, although we have had one case with bilateral involve- 
ment. We have observed three cases, two being fatal, one of 
which was incised and the other not. The third case, with re- 
covery, was treated by enucleation of the tonsil. The invading 
organism was streptococcus viridans. In this latter case the 
patient gave a history of two previous attacks of Vincent’s 
angina. We have seen one additional case in consultation, in 
which the tonsillar abscess undoubtedly followed, and was 
caused by, an unnecessary incision in an acute tonsillitis (Fig. 
21). 
MEMBRANOUS PHARYNGITIS 
Tlie term membranous pharyngitis is a general one and in- 
cludes any of the following: 
1. Diphtheria. 
2. Vincent’s angina. 
3. Lues. 
4. Locally induced (escharotics, operations, 
x-ray and radium). 
5. Pseudomembranous. 
6. Streptococcic sore throat. 
Each condition has its definite pathological as well as bac- 
teriological differentiation, although clinically they may look 
alike. 
Diphtheria 
Diphtheritic tonsillopharyngitis, while a disease within the 
realm of the laryngologist, is really more in the domain of 
the pediatrician or the internist. The membrane is located 
principally on the tonsil and extends to the velum. It is 
adherent to the surface, and bleeding follows its removal. 
The color depends on the duration; it is at first white and later 
may become grayisli-white or a dirty black. The membrane is 
fibrinous in character with a tremendous leucocytic infiltration 
and contains much free blood. The organisms are easily demon- 
strable in stained specimens, and cultures and smears are def- 
initely diagnostic. The treatment is only too well known; that 46 
APPLIED PATHOLOGY 
is, the early use of antitoxin or toxin-antitoxin mixtures. The 
inefficiency of local medication is well recognized, and if at- 
tempted, only the mildest of antiseptic solutions should be used 
and great caution should be exercised in their application. In 
the immediate postdiplitheritic throat a 2 to 5 per cent silver 
nitrate solution can be applied over the raw area with a camel’s 
hair brush. 
Vincent’s Angina 
Iii Vincent’s angina there is a massive dirty grayish-white 
exudate in and about the tonsil, the favorite location being at 
the palatoglossal fold. The exudate lasts hut a short time be- 
fore it sloughs away, taking with it part of the tissue itself, 
leaving a crater-like ulceration. This in turn becomes covered 
with a similar membrane and the same change goes on, which 
may ultimately destroy most of the tonsillar tissue if left un- 
treated. In one case of a bilateral infection we have observed 
an almost complete tonsillar destruction. Attempt to remove 
the membrane is futile, and scraping with a dull curet is likewise 
inefficient. The membrane contains little fibrin but many leu- 
cocytes and symbiotic organisms, the spirillum of Vincent and 
Bacillus fusiformis. 
The variance of subjective symptoms, both local and general, 
is quite noteworthy. We have seen cases with extensive involve- 
ment of both tonsillar areas without the patient’s being con- 
scious of any throat disturbance; on the other hand, we have 
seen cases wherein but a small plaque was present on the tonsil- 
lar surface, associated with tremendous dysphagia and gland- 
ular enlargement. As a rule, however, the general symptoms 
are not associated with any marked degrees of sepsis and the 
average case is without very marked local or systemic symp- 
toms. 
Treatment.—The treatment, apart from the general systemic 
attention, is directed towards the invading organism, either 
through local or general means. Among the most satisfactory 
methods is the use of neoarsplienamine, either intravenously or 
applied locally in a concentrated aqueous solution or both. 
Other methods of treatment that have proved satisfactory are: 47 
MESOPHARYXX 
Tryptofiavin (14 per cent solution) as a spray to the affected 
tonsil several times a day, and the use of the same solution as a 
gargle with 20 drops to a glass of water. Locally 10 per cent 
solution of salicylic acid in equal parts of alcohol and glycerine, 
or pyoktanin in 1 per cent solution, applied until an intense 
blue color is produced, combining with the latter a gargle of 
potassium chlorate solution, used every two hours. Methylene 
blue has also been used locally to advantage. 
Lues 
While luetic manifestations in the main are included in the 
chronic diseases, acute primary as well as secondary manifesta- 
tions are not infrequently found. The “plaques mucouse” is 
very frequently mistaken for both of the above-mentioned con- 
ditions. It is characterized by the absolute inability to remove 
the membrane by stripping or even with the curet. Examina- 
tion can be made only by actual excision of the part, which 
when properly stained will show the Spirocheta pallida, when 
observed with the dark-field illumination. The serum can be 
obtained by pressure or with a curet and likewise contains the 
spirochete, which fact is important, particularly in those cases 
which have a coexisting Vincent’s angina. In the luetic plaques 
we find lesions of the tongue, cheek, posterior pharyngeal wall 
and soft palate. Treatment is, of course, directed towards anti- 
luetic measures while locally strict oral hygiene must be main- 
tained. Potassium chlorate gargle is quite effective. 
Locally Induced Membranous Pharyngitis 
Any variety of conditions may produce a membranous phar- 
yngitis. Thus we find a definite membrane or exudate in post- 
operative conditions, after the use of escharotics, and particu- 
larly after exposure to the x-ray or radium application. 
Clinically these cases appear very similar and differential diag- 
nosis can usually be made by means of a careful history. The 
treatment is individual, depending upon the history, but the 
point to be borne in mind is to desist from removal of the mem- 
brane. 48 
APPLIED PATHOLOGY 
Pseudomembranous Pharyngitis 
Pseudomembranous pharyngitis is quite rare in this country 
and is found principally where rhinoscleroma exists. One case 
we have observed, in a Swedish-American child brought up in 
the very best of environment. The second case was observed 
in an adult with wood alcohol poisoning, but unattended by 
subjective throat symptoms and in this case was seen a milky 
white exudate extending from the nose into the pharynx, with 
no associated inflammation. The membrane can be stripped off 
very easily and breaks up into a cheesy appearing mass, leaving 
an apparently normal mucous membrane. Microscopic examina- 
tion shows it to be practically structureless and a poorly stain- 
ing homogeneous mass. The membrane tends to recur within 
twenty-four hours but never as thick as the first time. The 
most effective gargle we have found to consist of equal parts of 
peroxide, witch hazel, listerine and alcohol, which are diluted in 
turn with an equal part of water. 
Streptococcic Sore Throat 
Streptococcic sore throat is not always associated with mem- 
branous formation. As a rule, it is not a local condition per se, 
but rather a local manifestation of a constitutional disturbance, 
as in scarlet fever, influenza, etc. 
HYPOPHARYNGITIS 
Any of the preceding conditions may, of course, be found in 
the hypopharynx. However, we may lind more or less localized 
involvement of the base of the tongue, pyriform fossa, epiglottis 
or mouth of the esophagus. 
1. Base of the Tongue.—At the base of the tongue the lingual 
tonsil is found undergoing acute inflammation, usually as an 
extension from the mesopharynx and associated with a tonsil- 
litis. Examination shows the swelling appearing to All up the 
vallecula and pushing the epiglottis away from the tongue. 
There is an associated inflammation at the base of the tongue 
proper, which manifests itself clinically by marked resistance in MESOPHARYNX 
49 
any attempt to depress the tongue (Fig. 22). The epiglottis 
shows a peculiar, stiffened appearance. Treatment is concerned 
with rest of the part, obtained by giving rectal feedings for 
forty-eight hours. Hot mouth fillings (not gargles) are sooth- 
ing. If there is an abscess formation superficial incisions are 
usually sufficient. As a rule, it is necessary to subsequently 
remove the lingual tonsil. 
2. Edema in the Pyriform Fossa.—Edema in this locality, 
with or without associated edema of the epiglottis often simu- 
Fig. 22.—Acute inflammation of the lingual tonsil and base of tongue 
lates malignancy. It is always secondary to tonsillitis after 
recession of the acute symptoms and the neck is usually swollen 
and tender on the involved side. Treatment consists of watch- 
ful waiting and the application of heat externally. 
3. Epiglottis.—Acute conditions involving the epiglottis are 
discussed in connection with the larynx. 
4. Mouth of the Esophagus.—An acute esophagitis in this lo- 
cality is usually traumatic, following the careless ingestion of 
foods, excessive stretching secondary to other trauma, such as 
burns, x-ray or radium. Treatment here, too, consists chiefly in 
rest of the part. 50 
APPLIED PATHOLOGY 
PHARYNGEAL BLEEDING 
While the most frequent bleeding occurs after operative inter- 
ference, particularly enucleation of the tonsils and adenoids or 
severe ulcerative processes, there is one particular hypophar- 
yngeal condition that produces the most annoying pharyngeal 
bleeding and that is varices at the base of the tongue or from 
the lingual tonsil. This latter condition is usually associated 
with cardiovascular and renal disease. It suffices to say, how- 
ever, that the bleeding vessel, if it be an artery, must be grasped 
and ligated. If however, it occurs at a later period after opera- 
tion, say a day or so, or if associated with severe ulcerative 
processes, then a thorough disinfection of the parts, usually by 
a formalin solution (5%) and, if necessary, the eventual use of 
a compression clamp and such remedies as horse serum, throm- 
boplastin, calcium lactate and pituitrin are indicated. CHAPTER IV 
ACUTE DISEASES OF THE LARYNX 
ACUTE SIMPLE LARYNGITIS 
In acute simple laryngitis the ventricular bands are at first 
injected and somewhat swollen. This is almost immediately 
followed by hyperemia of the cords, usually posteriorly. The 
edema of the vocal processes prevents the approximation of the 
cords and hoarseness results. The epiglottis invariably is with- 
out change and as a rule, resolution takes place within several 
days, but if maltreated, irritated or abused by the use of the 
voice, the process may go on and assume the pathological 
changes of the next type. 
ACUTE LARYNGITIS, SEVERE TYPE 
In the severe type of infection every structure from the epi- 
glottis to the trachea is in a state of violent inflammation. The 
ventricular bands are not involved to the extent of the cords, 
but the inflammation undoubtedly extends to the joints and 
muscles because of the associated pain on any effort of move- 
ment, such as speaking, in addition to the complete aphonia. 
There is an associated laryngeal cough, which is painful, and 
swallowing likewise is attended with marked discomfort. This 
condition does not resolve quickly but tends to last several 
weeks and is frequently complicated by a typical tracheitis, with 
a mucopurulent and blood-streaked expectoration. 
Treatment.—Complete rest of the voice, neither extremes of 
heat nor cold in foods and drinks, inhalations of medicated 
vapors, the free use of instillations of warmed oils and liquid 
petrolatum, and warm, moist compresses externally, are very 
gratifying. We would here emphasize the avoidance of topical 
application of the silver preparations. When the acute process 
has abated, mild astringents, as weak solutions of silver nitrate 
or zinc sulphate, may be applied either by means of the laryngeal 
51 52 
APPLIED PATHOLOGY 
spray or direct instillation. It is most important that this proc- 
ess be allowed to undergo complete resolution, for if the voice 
is used strenuously either in speaking or singing before this 
occurs, a chronic indurative laryngitis is very apt to follow. 
DIPHTHERITIC LARYNGITIS 
Although diphtheritic laryngitis is a laryngeal condition, it 
is considered more in the realm of the pediatrician or the gen- 
eral practitioner. In laryngotracheal diphtheria, usually occur- 
ring in infants and children, the appearance of increasing 
Fig. 23.—Laryngeal diphtheria. 
hoarseness, fever and obstructed respiration, inspiratory or ex- 
piratory, should be sufficient for a laryngoscopic examination to 
confirm the diagnosis. The appearance of the larynx is quite 
characteristic, in addition to the above-mentioned laryngoscopic 
procedure one is also enabled to make a culture and smear di- 
rectly from the larynx. 
Examination reveals the characteristic catarrhal inflammation 
of the fauces, and the appearance of a white or grayisli-white 
membrane in the larynx, perhaps extending into the trachea. 
The important feature of this membrane is that it does not form 
an integral connection with the mucous surface—it is not incor- 53 
ACUTE DISEASES OF THE LARYNX 
porated nor does it penetrate into the mucous membrane, as in 
marked contradistinction to the membrane in tonsillopliaryngeal 
diphtheria with membrane formation. The former type of mem- 
brane appears on mucous surfaces that are lined with columnar 
epithelial cells and the surrounding mucous surfaces are swol- 
len, red, and inflamed, and often covered with a mucopurulent 
secretion (Fig. 23). 
The treatment is, of course, antitoxin, but herein we caution 
the use of too large a dosage in diphtheritic laryngitis whereby 
too rapid sloughing of the membrane may occur and result in 
unlooked-for obstruction, necessitating an immediate intubation 
or tracheotomy. The actual removal of the membrane after 
passage of the laryngoscope or bronchoscope or the production 
by its passage of sufficient irritation so that the cast is coughed 
up and expelled has proved its value in the pioneer work of the 
late Henry L. Lynali, of New York. Intubation or tracheotomy 
may at any time be necessary in this condition. 
TRAUMA 
1. Foreign Bodies.—Foreign bodies in the larynx, until re- 
moved or displaced, produce an early inflammatory reaction of 
injection and swelling of the tissues. They usually lodge be- 
tween the ventricular bands and the cords. Following dislodge- 
ment or removal we may expect resolution unless too severe a 
trauma has occurred, in which case ulceration is very apt to be 
superinduced. 
2. Cut Throat.—In cut throat a smooth or jagged surface is 
produced which becomes rapidly infected. Treatment depends 
upon the nature and extent of the injury. 
3. Strangulation is usually associated with a fracture of the 
thyroid cartilage and the tremendous secondary edema is an 
outstanding feature. 
4. Gunshot Wounds.—The injury is dependent upon the mis- 
sile and the location, shrapnel wounds being the most destruc- 
tive. 
5. Chemicals.—Either as a manifestation of an occupational 
disease, as in the inhalation of arsenic, or accidental during 
treatment of the upper air passages, the larynx may be involved. 54 
APPLIED PATHOLOGY 
In all these conditions attention is called to the secondary 
changes of adhesive bands and cicatricial stenosis. The treat- 
ment depends upon the individual case and any laryngeal con- 
dition must be watched for the possible development of second- 
ary edema requiring tracheotomy. It is, therefore, good prac- 
tice to do a tranquil tracheotomy in order to give the parts a 
chance to heal. However, intubation for the same condition is 
not to be overlooked. 
6. Burns.—As the result of cautery, by the electrocoagulation 
method or the galvanocautery, also reactions (sometimes called 
burns) of radium or x-ray, lead to severe symptoms that may 
later become chronic. The treatment is wholly expectant. CHAPTER V 
ACUTE DISEASES OF THE TRACHEA 
ACUTE TRACHEITIS 
Acute tracheitis is usually found in association with acute in- 
flammatory processes involving the respiratory tract by virtue 
of continuity of structure. In severe cases breathing and cough- 
ing are both painful. By the aid of the bronchoscope the 
mucous membranes, especially in the posterior portion, are seen 
to be very much thickened and actually in folds. They are 
highly injected and the mucous glands become hyperactive and 
soon throw out masses of mucus, which relieves the acute irri- 
tative symptoms. Within a short time the tenacious mucus 
becomes mucopurulent and begins to shed in masses, usually in 
the morning. There are superficial ulcerations which account 
for the blood-streaked expectoration and at times the bleeding 
may be considerable but it is usually mixed with much mucus. 
The musical rales heard during an attack are due to air tun- 
neling through the thick, mucous secretions which span the 
trachea. Resolution takes place only to a degree and a patient 
once having tracheitis is almost sure to have a yearly recur- 
rence, but not always of the same severity. 
Treatment.—Absolute rest, expectorant mixtures, Dover’s 
powders in good sized doses, steam and benzoin inhalations, are 
extremely soothing as soon as the very acute condition has sub- 
sided. Unless the blood-streaked expectoration appears, ammo- 
niated mixtures to stimulate excretion are indicated. Almost 
specific is a change of climate, particularly to the mountains of 
North Carolina or the pine regions of Florida. Direct applica- 
tion of medicaments to the trachea to dissolve the mucus and 
subsequent removal (washing and suction), followed by mild 
astringents, are nicely borne. The free use of petrolatum, by 
either direct or indirect intratracheal injection, is quite soothing. 
FOREIGN BODIES IN THE TRACHEA 
Foreign bodies lodging in the trachea are either too large to 
pass beyond or are caught by irregular projections of the for- 
55 56 
APPLIED PATHOLOGY 
eign body. The lesion is an irritative one like that produced in 
the larynx. Treatment consists of removal and as a rule little 
after-treatment is necessary. 
INJURIES 
1. Cut Throat.—Cut throat in this region is really a transverse 
tracheotomy. The injury is never of the trachea alone but in- 
volves the neighboring structures, particularly the thyroid 
gland and large neck vessels. Bleeding is severe and frequently 
fatal, drowning the individual in his own blood. Should the 
tracheal opening be small and the patient seen early so that the 
bleeding may be controlled, then a primary closure is usually 
successful. 
2. Missiles.—As in the case of the larynx, shrapnel wounds are 
the most destructive. 
3. Burns.—Radium and x-ray burns in this region are not 
uncommon. 
4. Gas.—During the war, the treatment of gas burns of the 
respiratory tract was one of the most important and arduous 
duties of the nose, throat and ear service. Mustard gas par- 
ticularly, depending on the degree of concentration and the time 
of exposure, produced intense inflammation of the respiratory 
tract. Practically the entire tract was affected to varying de- 
grees and the esophagus likewise rarely escaped. The vestibule 
of the nose very frequently showed more marked involvement 
than did the remaining intranasal structures. 
The pathology of gas burns has been excellently described by 
Lafayette Page, and his treatment can be by analogy applied in 
occupational gas injuries of the respiratory tract. He reports 
that “The pathology of gas burns is similar to that of an escha- 
rotic chemical applied to the tissues. If gas sufficient to pro- 
duce serious effects is inhaled, there results an extreme engorge- 
ment of all the vessels and capillaries of the lungs, followed by 
the outpouring of a serous exudate from the injured bronchial 
and alveolar linings. 
“Necrosis of the bronchial walls and lung tissue resulted in a 
varying degree from exposure to the gas. These areas were, of 57 
ACUTE DISEASES OF THE TRACHEA 
course, promptly invaded by whatever bacteria were present in 
the respiratory tract, resulting in ragged, foul ulcerations of the 
larynx, trachea and bronchi, and in multiple abscesses of the 
lung. 
Fig. 24.—Gas burn ulceration. (After Lafayette Page.) 
“Examination.—In the milder forms of mustard-phosgen poi- 
soning, we found the nasal, laryngeal and bronchial mucosa red, 
dry or edematous, in the early stages. The general appearance 
was not unlike an ordinary laryngitis or bronchitis. After a 
short time, the membranes began to pour out large quantities 58 
APPLIED PATHOLOGY 
of mucus. In many of these cases of mild gassing, the patients 
recovered in a few days, and, in those patients who had been 
exposed to a high degree of gas concentration, the mucosa 
showed an intense hyperemia and dryness at first, followed later 
by flooding of the air passages with the frothy mucus, often 
mixed with blood. After two or three days, the burned areas 
were covered with a fibrinous membrane. These patches were 
found in the vestibule of the nose, on the turbinates and, in 
some instances, extending into the accessory sinuses (Fig. 24). 
The mouth and pharynx seemed to show resistance to the caus- 
tic action of the gases, owing, probably, to the character of the 
epithelial lining; while the larynx, especially the arytenoid 
region, seemed to be particularly vulnerable. Burns were often 
found to be deep, with infiltration and edema about the vocal 
bands, causing aphonia, which occasionally persisted for weeks 
and months. The tracheal lining was usually burned in irregu- 
lar jDatches and in many cases the entire lining of the trachea, 
.extending into the small bronchi, was involved. Edema of the 
lungs was always present to a greater or less extent when there 
had been exposure to the mixture of mustard and phosgen in 
any high degree of concentration. Bronchopneumonia with 
multiple abscesses was not infrequently present. 
“Treatment.—Intratracheal medication of guaiacol, menthol 
and camphor, 5 per cent of each in liquid petrolatum, is clearly 
indicated in all forms of inflammation of the lower respiratory 
tract resulting from the caustic action of poison gases. It should 
be used as early as possible after gassing, for the purpose of 
relieving the first symptoms of pain and asphyxia and reducing 
the extent of secondary infection, by facilitating drain a,ge of 
the trachea and bronchi and rendering the passages as sterile 
as possible, through the antiseptic properties of the oil solutions. 
“This method of treatment shortens the process of suppura- 
tion in the secondary stage by aiding the lung reflexes, in expel- 
ling the necrotic membranes and products of inflammation, and 
in healing the ulcerated surfaces, thus relieving the strain on 
the nerve centers and checking the cough and spasmodic efforts 
to expel the debris; and thus improving oxidation, diminishing 
toxic absorption and affording rest to the whole organism. 
“Through shortening the healing process, the permanent 59 
ACUTE DISEASES OF THE TRACHEA 
damage to the pulmonary mechanism is lessened, and there is 
less surface denuded of epithelium, less scar formation, less peri- 
bronchial thickening and, consequently, less tendency to chronic 
bronchitis and predisposition to tuberculosis infection.” 
ACUTE DISEASES OF THE BRONCHI 
Acute bronchitis when associated with an acute laryngo- 
tracheitis is not in the domain of the laryngologist. In an acute 
suppurative process following foreign body in the bronchus, 
direct treatment with the bronchoscope is of considerable as- 
sistance. Foreign bodies in the bronchi are in the special field 
of the bronclioscopist, hence, we shall not consider this subject 
from the pathological viewpoint. For the borderline patho- 
logical conditions in the mediastinum and lung the reader is 
referred to the excellent monographs by Jackson and others. 
ACUTE ESOPHAGITIS 
Tliis subject is dealt with in the consideration of strictures of 
the esophagus under chronic diseases, wherein the various etio- 
logic factors are considered. It is well, however, to emphasize 
the fact of the ease with which the esophagus is traumatized and 
secondarily infected. The most delicate mucous membrane of 
the entire gastrointestinal tract and one that stands the least 
amount of insult is found here. During the war it was noted 
that the gases, while they irritated the nose, mouth, pharynx, 
larynx and trachea, would produce marked changes in the 
mucosa of the esophagus. The sensation, however, appears to 
be less than in the above-mentioned locations and one may 
manipulate the esophagus without anesthetization. The well- 
known toleration to thermic insults, particularly food, empha- 
sizes this point. CHAPTER VI 
ACUTE DISEASES OF THE EAR 
OTITIS EXTERNA 
(a) Pinna. 
(b) External Auditory Canal. 
1. Frost-bites.—For this subject we refer the reader to the 
same condition of the external nose. 
2. Othematoma.—Othematoma is of both spontaneous and 
traumatic origin, the former being very rare but we have ob- 
served this condition in one case of intense cholangeitis accom- 
panied by marked jaundice and in another case unaccounted 
for. The much more common form is the post-traumatic, occur- 
ring in the amateur boxer and prize-fighter. The most frequent 
location is between the rim and the concha (Fig. 25), although 
the subcutaneous extravasation does at times extend into the 
concha and almost occludes the meatus. On palpation the feel- 
ing is at first doughy and later of a firmer consistency. If not 
interfered with and not infected, the process goes to the chronic 
form of the so-called “tin or cauliflower ear” which is described 
under the chapter of chronic ear conditions. Treatment of this 
acute form consists in controlling further bleeding by compres- 
sion or elastic bandage, the entire pinna being encased in cotton 
moistened in hot aluminum acetate. To assist absolution of the 
blood clot Crede or ichthyol ointment is applied externally. 
Under no circumstances should the ear be incised because in- 
fection under the strictest aseptic precautions has not been 
avoided. This mistake has caused most of the deformed ears 
of boxers since it has been the common practice in the ring 
to cut the ear immediately after the hematoma forms. 
3. Acute Perichondritis and Abscess.—Both of these patho- 
logical conditions can and do develop following othematoma. 
Especially is this true if a puncture or incision is made into it. 
(a) Pinna 
60 ACUTE DISEASES OF THE EAR 
61 
Perichondritis, primary, is comparatively rare and usually of 
traumatic origin or occurs in sequence to a severe frost-bite. 
Acute perichondritis in most instances is observed in mas- 
toid operation due to rough manipulation of instruments, 
especially retractors, followed by secondary infection. The 
mildness of the subjective symptoms, namely, pain, is entirely 
out of proportion to the severity of the ultimate result—fre- 
Fig. 25.—Othematoma. 
quently complete deformity of the external ear from septic ab- 
sorption of the cartilage. In perichondritis, the overlying skin 
is somewhat red and swollen and slightly tender to the touch. 
As soon as the abscess forms, which is most frequently located 
between the cartilage and perichondrium, a fluctuating mass is 
felt. Absorption, systematically, from such an abscess is very 
slight, therefore, the general reaction is also slight. Regional 
adenopathy may be present. Aspiration of the contents of the 62 
APPLIED PATHOLOGY 
abscess for diagnosis reveals in most instances a serosangnineous 
fluid which microscopically shows leucocytes in great abundance 
and culturally the type of invading organism may be found. 
Perhaps nowhere in the body is the indication for active inter- 
ference so urgent as in abscess of the pinna, owing to the danger 
of cartilage absorption. 
Treatment.—In perichondritis without fluid formation, the 
support of the auricle by a wet aluminum acetate compress and 
a light bandage, usually suffices. When, however, the fluid 
forms and this becomes infected, the indication is to open 
widely by a crucial incision over the most prominent part of the 
SAvelling, turning out all of the material, swabbing the cavity 
with tincture of iodine and readapting the skin and perichon- 
drium to the cartilage. These should be held in contact by 
dental-compound splints placed in front and back of the auricle, 
conforming the splints to the natural shape of it, by applying 
the compound after softening in hot water, further surrounding 
with cotton, and applying a fairly firm bandage. 
4. Burns.—One of the most frequent causes of burns is the 
use of the hot-water bag, the patient falling asleep while lying 
on it, thus producing a first degree burn with occasional vesicle 
formation. Occupational injuries or those produced by fire are 
next in frequency. These are of more severe type, even to the 
extent of complete destruction. The end results of such injuries 
will be considered under chronic diseases of the external ear. 
Treatment.—The mild forms of burns usually respond well to 
such emollients as stearate of zinc ointment. In the more severe 
types where pain may be an important symptom, a sterile mix- 
ure of lime water and linseed oil, thoroughly mixed, and cotton 
saturated in the mixture applied locally has proved very effica- 
cious. Other treatment is directed toward the etiologic factor 
and extent of the trauma. 
5. Dermatitis.—Various forms of acute inflammation of the 
skin of the auricle usually occur secondarily or are associated 
with similar processes about the external auditory canal or the 
face. In the course of an acute otitis media suppurativa, in 
which the discharge is highly alkaline, and of a streptococcic 
variety, we find very often the concha and lobule in the state 
of acute dermatitis. In connection with the mastoid operation A CUTE DISEASES OE THE EAR 
63 
not infrequently an erysipeloid condition may be observed. 
The true erysipelas we have observed a number of times, pri- 
mary about the auricle, and it must be distinguished from the 
chemical dermatitis, secondary to the use of iodoform medica- 
tion. 
Treatment of these various types mentioned consists mainly 
of the treatment of the cause, but the accepted lotions and oint- 
ments advised by dermatologists have given us the best results. 
(b) Auditory Canal—External 
1. Otitis Externa Furunculosa is tlie most frequent type of 
acute disease met with in the external canal, unless it he the 
ceruminal plug which can scarcely be designated as a disease. 
The furuncle is the result of the infection of one of the sebaceous 
glands close to the external auditory meatus where they are in 
greatest abundance. Such an infectious process is promoted by 
the mechanical irritation in response to the first symptom, that 
of itching. If examination is made during this early period, one 
may find at the site of the infected gland a small dark point 
surrounded by a light reddish area. The connective tissue sur- 
rounding the gland is very rapidly converted into acute inflam- 
mation, giving the usual edematous swelling which is so ex- 
tremely painful owing to the traction on the periosteum. The 
coagulation necrosis in furuncle formation is usually brought 
about within twelve hours, showing the white-pointing of the 
abscess. Any surgical interference, such as puncture, before 
this point appears, leads to severe complications. The multiple 
infections of these sebaceous glands, which occur by one rup- 
tured abscess infecting the other, constitute one of the most 
characteristic conditions of this disease. The cardinal diag- 
nostic point, besides those observed by inspection, is the pain 
produced on lifting the auricle. The hearing is seldom, if ever, 
affected. The glands at the angle of the jaw, as well as the 
retroauricular glands, are at times enlarged and tender, leading 
in some instances to a faulty diagnosis of mastoiditis. The 
differential diagnosis from boils in the canal, associated with 
diabetes, is important to remember. 
Treatment.—The initial stage described above is very impor- 
tant for early diagnosis and will be productive of an abortive 64 
APPLIED PATHOLOGY 
cure. A cotton wad, rolled firmly, of a size slightly larger than 
that of a normal external canal, is dipped into pure alcohol and 
inserted into the canal. Every fifteen minutes thereafter, for an 
hour or two, this cotton is resaturated by means of a medicine 
dropper. One will be gratified, in many instances, to find the 
process aborted in twenty-four hours. When the furuncle has 
formed, but before it is ripe, one may promote either resolution 
or abscess formation by the use of hot Billroth solution dress- 
ing. This solution consists of lead acetate (1), alum (10), and 
water (100) parts, the lead and alum being added to the water 
while boiling. The solution must be shaken before using be- 
cause of sedimentation. A strip of narrow gauze is saturated 
in the solution and the canal is packed. Thin layers of cotton 
are also saturated in this solution and packed in front and back 
of the auricle and mastoid. This is covered by a piece of oil 
silk, a large dry pad, a bandage. If necessary the procedure is 
repeated until the resolution or abscess formation occurs. Lying 
on a hot water bag will aid the action of this moist dressing. 
If resolution lias taken place, an ointment, sterile vaseline, is 
applied over the macerated area. If an abscess has developed, 
an incision is made, but cutting into the periosteum should be 
avoided unless one is certain that it, too, is involved. After 
incision care must be exercised to avoid spreading the pus, 
thei'efore mopping or swabbing should not be practiced, but 
the wound should be let alone with only a light dressing. 
Lying on a hot water bag will promote further discharge, so 
that on the following day by gentle pressure the so-called 
“core” or coagulated necrotic mass can usually be expressed. 
The after-treatment consists of the use of mild ointments, such 
as ammoniated mercury (2 per cent) or sterile vaseline. 
2. Otitis Externa Diffusa is most frequently observed second- 
arily to a chronic middle ear disease, although in recent years 
in communities where beach-bathing has become very popular 
in the hot summer days, many cases of acute otitis externa, 
diffusa have been observed. The cause in this latter condition 
is believed to be maceration of the skin from dehydration with 
secondary infection, possibly from manipulation. The disease 
is popularly termed “tank ear,” the belief being that the water 
is contaminated by the masses of bathers. Treatment consists ACUTE DISEASES OF THE EAR 
65 
of a moist dressing as already described and later insertion of 
a strip of gauze saturated in 10 per cent iclitliyol in glycerine. 
3. Otitis Externa Traumatica.—Probably the most frequent 
cause of trauma of the external canal lies in the faulty attempt 
at removal of ceruminal plugs. The use of hair pins, tooth 
picks, pencils, and the specially devised ear spoons for laymen’s 
use, in attempting to remove detritus or dry particles of ceru- 
men is responsible for this affection. Attempt to incise the 
drum head without the aid of the head mirror or by those not 
skilled in this work is another cause. Instillations of caustics 
and irritants may also produce such a condition. A unique case 
of severe trauma is that of a man who poured pure carbolic 
acid into both liis ears in an attempt to avoid being drafted into 
the service during the late war. The resultant injury to the 
Fig. 26.—Trauma of external auditory meatus and canal following self-infliction 
with saturated solution of carbolic acid. 
canal can be imagined. Fig. 26 shows the resultant trauma of 
the external meatus and the concha six weeks after the injury. 
His hearing was practically normal, although the drum was con- 
siderably destroyed. Treatment is principally by disinfection 
to avoid secondary infection and individual as to cause. 
4. Foreign Bodies in the ear are found most frequently in 
children, and pebbles and sand are the commonest objects intro- 
duced; older children insert little balls of paper. One of the 
most unique forms of foreign body was observed by us in the 
case of a man aged thirty-five, who was being treated for an 
uncontrollable salivation. In our routine examination we dis- 
covered a dark object in the fundus of each ear, not unlike a 
ceruminal plug. After several days of attempted removal by 66 
APPLIED PATHOLOGY 
washing, mechanical procedures, etc., we discovered a smooth 
round object, which slipped away from forceps. Finally, we 
were successful in rolling out, by the aid of a fine hook, a small 
cherry pit; the same was done on the opposite side. The patient 
was as greatly surprised as we were, as he could not remember 
ever having inserted these. It is also interesting to note that 
there were never any symptoms produced from the ears. The 
excessive salivation cleared up entirely following this removal. 
The explanation was a parotid irritation. The treatment of 
foreign bodies in the ears consists in their removal by washing 
or mechanical procedure. 
5. Animal Foreign Bodies.—Small flies and bed-bugs are the 
commonest types found which invade the external canal. Per- 
sonal experience with one such case will teach a great lesson, 
for the agony produced by the movements of such a living 
thing, especially when it moves across the drum membrane, can- 
not be described. Inspection will reveal the culprit and its 
destruction is the most important thought at the time, prefer- 
ably by introducing a drop of chloroform and then washing it 
out. The immediate relief is so gratifying that one will con- 
gratulate himself upon the result. We have never seen a patient 
who has had such an experience who has not afterwards shown 
evidence of neurosis as though he had suffered from a great 
■shock. 
ACUTE OSTIUM TUBITIS 
Acute ostium tubitis has been discussed under the acute dis- 
eases of the pharynx. 
ACUTE OTITIS MEDIA 
In acute otitis media the most frequent affection is of the 
milder form, in which the inflammatory process extending from 
the tube to the middle ear consists of engorgement and swelling 
of the mucous membrane of the tube and the modified mucous 
or serous membrane of the middle ear. The greatest oppor- 
tunity for swelling of this modified mucous membrane is in that 
portion lining the membrana tympani because of its resiliency, 
and particularly that lining Shrapnejl’s portion (Fig. 27 A). ACUTE DISEASES OF THE EAR 
67 
.Fig. 27.—Tympanic membranes in acute inflammation of the middle ear. A. 
Normal tympanic membrane. B. Earliest manifestation of acute inflammation of 
middle ear. C. Further progress in the acute inflammation of the tympanic mem- 
brane. D. Marked enlargement of the tympanic membrane with bulging. E. More 
advanced process with excessive bulging and exudate showing through. F. Marked 
injection of the tympanic membrane and the middle ear cavity filled with pus, but 
no bulging. (After Preysing.) 68 
APPLIED PATHOLOGY 
The anatomical configuration of the membrana tympani plays an 
important role in the pathologic changes that occur. Owing to 
the close proximity of the upper and posterior portion of the 
promontory of the cochlea to the junction of Shrapnell’s mem- 
brane with the membrana tensa and the extreme tympanic limit 
of the external wall of the aditus, the tympanic cavity in an 
acute process is divided into two distinct parts when the swollen 
membranes covering the above regions come in contact. This 
contact will in most instances cause retention to develop in the 
upper portion of the middle ear; i. e., the attic and inner portion 
of the aditus, giving rise to swelling of the drum in its upper 
posterior portion (Figs. 27 B and C). If the process is one of 
greater virulence, so that the inflammatory reactionary changes 
are accompanied by transudation and symptoms of tension de- 
velop, in which case the entire drum shows marked engorge- 
ment, together with the above-mentioned swelling of the upper 
posterior part, actually bulging (Figs. 27 1) and E). In these 
virulent processes the inflammatory changes extend entirely 
throughout the mastoid cellular system. At this juncture is the 
turning point as to whether an acute otitis media resolves, with 
or without treatment, requires interference or progresses fur- 
ther (Fig. 27 F). Interference depends equally as much on the 
general systemic reaction as on local manifestations. The x- 
ray picture, so frequently employed to indicate the degree of 
pathologic change, is not to be relied upon, since every acute 
case will show cloudiness of the mastoid cells. Besides, one 
must not forget that the mastoid might have had a previous 
infection or may be of the type referred to by Wittmaack as an 
incomplete or arrested pnemnatisized mastoid. 
Should interference be necessary, which is the free incision 
of the drum, then the ensuing pathologic change is the marked 
relaxation of the inflamed membrane with the accompanying 
pulsation of the hyperemic vessels and the outpouring of large 
quantities of serosanguineous fluid mixed with varying amounts 
of mucus. The fluid obtained after incision of the drum mem- 
brane, depends usually on the type of the invading organism, 
so that in the hemolytic streptococcic infection it will be prin- 
cipally serosanguineous, while in the pneumococcic or influenzal 
pr streptococcus mucosus infection, the fluid will be thicker in Fig. 27. 
(g) Retrogression of acute middle ear process showing a line of the nevau of 
exudate. 
(h) Same as the above after catheterization, with scattered bubbles showing 
through the membrane. ACUTE DISEASES OF THE EAR 
69 
consistency because of the additional mucus from the nose and 
tube. 
The discharge is rapidly changed in character. The blood 
soon disappears except in the hemolytic streptococcic or the 
epidemic influenzal infection, when the bloody discharge is of 
considerable duration. This point is important in judging the 
pathologic process that is going on. The change in the dis- 
charge is due to a secondary infection that occurs from the 
canal, which is unavoidable, as well as through changes that 
may take place in the invading organisms, according to the 
transmutation theory advanced by Rosenow. We have obtained 
Fig. 28.—Herniation of the tympanic membranes in severe forms of acute otitis 
media suppurativa. (After Preysing.) 
cultures from the ear, immediately after incision, of typical 
hemolytic streptococci, and on the following day have obtained 
pure cultures of pneumococci. 
The changes in the opening of the drum are of the utmost im- 
portance and in the main are due to the changes going on in the 
middle ear. So marked is the relaxation of the drum in some 
of these cases as to produce complete eversion of the lips of the 
incision, and the swollen membrane herniates (Figs. 28 A to E). 
Owing to the closure of the perforation, on account of ever- 
sion and subsequent retention, combined with further relaxation 70 
APPLIED PATHOLOGY 
of the tympanic membrane, the nipple formation with occasion- 
ally but a minute opening in the center becomes very noticeable 
(Fig. 29). The lack of understanding of this pathologic change 
has led to the therapeutic abuse of repeated reincisions of this 
portion with no result other than the stirring up of an already 
acute process into a more violent one, and early mastoid destruc- 
tion. We have observed one case in which an incision had been 
repeated fourteen times in thirty-six hours, because of failure 
to recognize this type of nrpple perforation. While it is true 
that reopening a perforation which is insufficient is a distinct 
indication, yet it is comparatively rare that it is necessary. 
Fig. 29.—Nipple perforation. 
A frequent additional finding is the presence of blisters on the 
drum extending to the external canal (frontispiece). This is 
found particularly in influenzal and virulent streptococcic infec- 
tions. The blebs contain a serous or serosanguineous fluid and 
the presence of the invading organism can readily be demon- 
strated. There is usually marked pain in this condition and 
many a fairly normal tympanic cavity is complicated by the 
opening of the blister into the tympanic cavity because it is 
mistaken for a true bulging of the drum. The puncturing of 
the blisters is invariably sufficient to relieve the condition. 
Treatment.—The principles of treatment of uncomplicated 
acute otitis media, before perforation takes place, are based on 
the earliest ventilation of the middle ear cavity. Attention to ACUTE DISEASES OF THE EAE 
71 
the nasopharynx and to the opening of the tube is of the utmost 
importance. Depletion, both by local and general measures, 
should be adopted. One of our most efficacious measures is the 
use of moist dressings by loosely filling the external canal 
with gauze saturated in warm Billroth solution as already de- 
scribed under otitis externa. This is left on for from two to four 
hours or more and repeated. The pain can be controlled by 
pyramidon or the salicylate mixtures. It is important to re- 
member from the aforesaid pathology when resolution has taken 
place that there are contact points both in the tube and the 
middle ear that should be prevented from organization by early 
inflation. However, nothing is more disastrous than inflation 
while the process is still acute. 
As to the management of cases where either a spontaneous or 
operative perforation of the drum has taken place, treatment 
depends upon the capillary dry gauze wick drainage introduced 
to the perforation and placed loosely in the canal. Nowhere 
else in the body have we a natural drainage tube where gauze 
may be used as a, drain such as exists in the external canal. 
Early, when the discharge is profuse it may be necessary to re- 
place the drain several times a day. Acute cases should, there- 
fore, be hospitalized. In infants when this treatment is not 
practical, capillary suction is preferred, and can be well carried 
out in the home (Fig. 11). 
We seldom use irrigation unless it is necessary to get rid of 
unusually thick or viscid discharge, and then only the mildest 
of syringing, using hypotonic solutions. We are of the opinion 
that the usual continuous boric acid irrigation produces some 
damage to the vitality of the cells. 
In the event of the presence of a nipple perforation, the most 
satisfactory means of treatment js to fill the canal with the fol- 
lowing solution, which is allowed to remain for one hour, and 
which is repeated every two hours for a day. 
Tincture of iodin, Ttf 15 
Phenol TTL 15 
Alcohol drams 4 
Distilled water to oz. 1 
In the interim, gauze wick drainage is carried on, being cer- 
tain that the gauze wick comes in contact with the perforation. 72 
APPLIED PATHOLOGY 
Should the nipple be very large and retention marked, it may be 
practically excised by the aid of Hartman’s ear punch forceps, 
but under no circumstances should another portion of the drum 
be incised. 
ACUTE MASTOIDITIS 
Analogous to tlie condition in the nose which is spoken of as 
a rhinosinuitis, a similar combined condition exists in the middle 
ear, a tubo-tympano-mastoiditis, so that in every case where the 
symptoms of tension are manifest the complete mastoid chain 
will be affected, at least the roentgenogram will show evidence 
of ray obstruction or cloudiness. The changes in the modified 
mucous membrane of the mastoid cells, as well as in the bony 
partitions, depend almost entirely upon the type of infection. 
This is particularly evidenced when the causative organism is 
the Streptococcus mucosus capsulatus or the Streptococcus hem- 
olyticus, associated with the influenzal bacillus. It is of great 
practical value to know that these changes within the mastoid 
may go on to extensive destruction without symptoms of pain 
referable to the mastoid. This absence of pain has deceived 
many an otologist who has failed to recognize indications for an 
early operation which would undoubtedly have saved the pa- 
tient from horrible complications. 
Pathologic changes occurring during an attack of mastoid 
disease are determined by several factors, including the anatomy 
of the temporal bone involved, the causative organism, as men- 
tioned above, the secondary infection, the resistance of the pa- 
tient, as well as the treatment instituted. We are able to divide 
this process into three great classes, depending primarily upon 
the method of its extension, i e.: 
1. Cell route, or confluent type, in which all the cells are prac- 
tically simultaneously affected. The swelling of the lining mem- 
brane breaks down the bony partitions, resulting in a coalescing 
mastoiditis. 
2. Vascular route, or the osteophlebitic mastoiditis of Griin- 
ert, in which the blockage of the veins with the concomitant 
bony changes is conspicuous, but with little or no exudate 
within the cells themselves, except it be a specific hemorrhagic 
type. ACUTE DISEASES OF TTIE EAR 
73 
3. Acute exacerbation of a chronic mastoiditis, which will be 
taken up under chronic diseases. 
Cell Route Infection 
Gross Changes.—In this type an external fistula is usually 
found over the antrum or near the tip (Fig. 30) with consider- 
Fig. 30.—Cortex of mastoid in acute mastoiditis, showing necrosis and fistulous tract. 
Fig. 31.—Thickened periosteum in acute mastoiditis. 
able infiltration of tlie periosteum (Fig. 31). The bone bleeds 
easily and at times appears darker, due to the edematous and 
engorged membranes under the thin cortex. As soon as the 
latter is removed, a fair quantity of pus escapes, usually 
under tension, depending on the presence or absence of a fistula 74 
APPLIED PATHOLOGY 
Fig. 32.—Acute mastoiditis, cell route infection, showing cortex of mastoid and 
adjoining cells. These cells are noticed to be coalescing and are filled with pus and 
edematous lining membrane. The cortex itself shows little evidence of any destruc- 
tive process, but the underlying bone is necrotic although a small portion is fairly 
well preserved yet much inflamed. 
Fig. 33.—Curettements from the interior of the mastoid in acute mastoiditis, 
cell route infection, showing the lining membrane of the cells thickened and in- 
filtrated with leucocytes. The bone is necrobiotic, probably beyond possibility of 
repair. ACUTE DISEASES OF THE EAR 
75 
and the type of microorganism present. The bleeding* is usually 
free and the lining* membrane may protrude through the open- 
ing made, which may give the impression that the sinus has 
been exposed. The intercellular septa are usually broken down 
either over the antral region or the tip, and at times over both 
regions. This emphasizes the necessity of a complete exentera- 
tion. Not infrequently the lateral sinus, digastric fossa or the 
dura, are exposed. 
Histopathology.—The early changes are those of simple in- 
flammation. The blood vessels of the lining* mucous membrane 
are dilated; the membrane thickened, edematous and infiltrated 
Fig. 34.—Acute mastoiditis, cell route invasion. Practically every cell is filled 
with edematous membrane and pus. There is cloudy swelling of the bone but no 
necrosis. The intercellular septae are preserved. 
with leucocytes. The exudation, at first serous, later purulent, 
into the cells, together with the swollen membrane, usually ob- 
literates the cell (Fig. 32). 
The lining* membrane may be detached from the bony walls 
and the bone become necrotic (Fig. 33); the bony inner surface 
of the cells eroded in all directions eccentrically—the cavities 
thus become enlarged, coalescing* and filling* with pus (Figs. 
34 and 35). Multinuclear giant cells are seen. As the process 
extends the periosteum shows signs of acute inflammation, while 76 
APPLIED PATHOLOGY 
Fig. 35.—Acute mastoiditis, cell route infection. Practically the same changes 
as in Fig. 34, only more advanced in the coalescence of cells filled with pyogenic 
material. 
Fig. 36.—Mastoid chip in acute mastoiditis, cell route infection, showing necrosing 
osteitis. 
the changes in the bone may go on to further destruction or re- 
pair (Fig. 36). In the former case, the membrane being de- 
stroyed and the nutrition of the bone being impaired, pieces of 
bone are cast off as sequestra, leaving in reality an abscess 77 
ACUTE DISEASES OF THE EAR 
Fig. 37.—Acute mastoiditis, ceil route invasion. Bone necrosis markedly advanced 
and abscess formation is noted. Only a sliver of bone is left here and there. 
Fig. 38.—Acute mastoiditis, with curettement showing nothing but abscess formation 
cavity with only a sliver of bone here and there (Figs. 37 and 
38). During the reparative process as soon as drainage is ac- 
complished, new hone formation takes place, the osteoblasts 
being at the extreme periphery of the involved area (Figs. 39 
and 40). A sclerotic area, then, replaces the former air cells. 78 
APPLIED PATHOLOGY 
Fig. 39.—Reparative osteitis in a mastoid chip removed in a reoperative case 
of chronic suppurative otitis media. At the margin are seen fairly healthy trabeculae 
of bone from which young osteogenic structures loosely arranged with a large 
number of small capillary vessels are in evidence. The new bone formation is from 
the cortical region rather than from the interior of the mastoid, terrain. 
Fig. 40.—Same as Fig. 39, only high power. 
It is to be noted tliat the dura itself and the bony walls of the 
sinus, usually are more resistant to the spread of the infectious 
process. It is also to be noted that necrotic bone present is ACUTE DISEASES OF THE EAR 
79 
dissolved with greater difficulty and much more slowly than 
other tissues, and acts as a foreign body. This is also true of 
bone dust if the burr is used, or chips of bone if the chisel is 
employed which, if allowed to remain in the operative territory 
retard recovery because of the slow dissolving action of the 
endothelial leucocytes (foreign body, giant cells or osteoclasts). 
In our clinic, where the burr is used almost exclusively, after 
the mastoid cells are exenterated if any evidence of bone dust 
remains, the wound is washed out with normal saline solution 
(gravity method). Furthermore, in the repair of bone the 
fibroblasts (which produce the osteoid material) are derived, 
we believe, from the periosteum. This fact is made use of in 
the closure of the mastoid wound when the periosteum is 
brought together, having been at the beginning of the operation 
reflected carefully. The healing process is also assisted by the 
placing of the drain through a posterior stab wound instead of 
through the mastoid wound proper. 
Vascular Route Infection 
In this type we hud the tissues overlying the cortex very little 
changed and so we are less apt to find on external examination 
any redness or edema over the mastoid. The tissues bleed very 
little and have otherwise a fairly normal appearance. On 
opening the mastoid we find the hone, however, very red 
and there is little or no pus escaping. The cells are fairly well 
preserved and their lining membrane is not very edematous, in 
contradistinction to the cell route type of infection. The pre- 
served intercellular septa on close inspection show the marked 
engorgement spoken of above. Only in the later stage in which 
a possible secondary infection takes place, can one find any 
exposures of the lateral sinus, although the same may be ex- 
posed to the infection. In this regard we find it advisable not 
to expose the sinus unless definite indications clinically make it 
advisable, as this in itself may light up an infection about or 
within the sinus wall, which otherwise may be dormant. It is 
this form of mastoiditis which has the greatest percentage of 
perisinus abscesses and sinus thrombosis developing, owing to 
extension within the venous channels. The same is true as re- 
gards the erosion of the other vital areas, such as the dura of 80 
aPpliEt) pathoi .oov 
the cerebrum or cerebellum, the labyrinth, the facial canal, or 
the digastric fossa. 
Histopathology.-—The cells are seen well preserved and empty. 
The bone is highly inflamed and minute necrotic areas all 
through the section are in evidence. Thrombi in the venous 
Fig. 41.—Acute mastoiditis, vascular or osteophlebitic route. The cells are well 
preserved and empty. The bone is highly inflamed, with minute, necrotic spots 
throughout the section. Some of the vessels are definitely thrombotic. 
channels can be distinguished at times (Fig. 41). In strepto- 
coccic infections the mastoid cells frequently contain serosan- 
guineous fluid. 
Application 
Cell Route Type.—The knowledge of the pathologic changes is 
of great value, particularly in regard to prognosis and the 
future course of the reparative process. If we examine either 
grossly or microscopically chips of bone and determine the type 
to be of the confluent variety, the chances are favorable for a 
comparatively short course. AVe must, however, take into con- 
sideration the general condition of the patient and the preexist- 
ing anatomical formation of the mastoid as to its complete, par- 
tial or arrested pneumatization, in addition to the fact that the 
operative and postoperative procedures were technically correct. ACUTE DISEASES OF THE EAR 
81 
The earlier the cell route type case is operated upon the 
quicker is the recovery, the more prompt is restoration of hear- 
ing and the less marked is the destruction. In many cases the 
aural discharge will completely cease before the end of the fifth 
day and drainage from the mastoid wound can be removed 
without any further treatment. The question of operation must 
also be considered if only for the future preservation of hearing. 
Vascular Route Type.—The value of the knowledge of the 
pathology in this type lies particularly in the correlation of 
symptoms to the degree of changes taking place. The x-ray 
may show, even in markedly affected mastoids, practically nor- 
mal cell nests with the cellular outlines well preserved. Again, 
there may be little mastoid tenderness, the hearing well pre- 
served, but marked general symptoms. If one is fortunate 
enough to open the drum in these cases under the strictest 
aseptic conditions and obtain a pure culture of Streptococcus 
mucosus capsulatus or Streptococcus hemolyticus, then corrob- 
orating blood cultures will convince one of the necessity for an 
early operation. It is to he noted, however, that one may fre- 
quently find a positive blood culture in this type of mastoiditis 
without a sinus thrombosis being present. It is also to be noted 
that in this type of mastoiditis one not infrequently finds upon 
examination a fairly normal drum. 
Atypical Types of Acute Mastoiditis 
Periostitis with or without Subperiosteal Abscess.—In infants 
and children periostitis and cellulitis, with or without abscess 
formation, is not infrequent. It is well recognized as brought 
out by Luc that a dehiscence or nonunion exists at the squamo- 
mastoidal suture, with direct continuity to the middle ear. This 
may exist without either a perforation or any symptoms from 
the middle ear. It must he borne in mind that the conception 
that the mastoid of an infant contains no mastoid cells, is erro- 
neous. Wilde’s incision in these cases is not sufficient. The cor- 
tex should he opened and a complete exenteration performed 
irrespective of the gross appearance of the cortex on its first ex- 
posure. Some of these fissures or dehiscences in the mastoid 
may extend well over the attic and at times pus will burrow 
anteriorly towards the glenoid fossa, with corresponding swell- 82 
APPLIED PATHOLOGY 
ing in the preparotid region. This is most significant, as the 
mastoid in these cases should be opened at the earliest possible 
moment to prevent the occurrence of an ankylosis of the man- 
dibular joint. 
Squamozygomatic Mastoiditis.—This term is applied in cases 
where large cells extend into the squamous and zygomatic por- 
tions of the temporal bone and often to the greater wing of the 
sphenoid. Aside from the symptom of swelling over the zygoma 
without tenderness elsewhere, and restricted, painful motion of 
the jaw, the tic douloureux is the most significant feature. De- 
lay in operative procedure may mean an extension of the de- 
structive processes to the subdural space along the anterior por- 
tion of the temporal bone and the resulting appearance of a semi- 
Gradenigo syndrome (abducens paralysis and trigeminal irri- 
tation). 
Koerner Cell Infection.—When these cells are particularly 
large and extensive, and involve the cells in the petrous portion 
surrounding the vestibule, cochlea, bulb and dura about the 
Gasserian ganglion and the sixth nerve, a complete Gradenigo 
syndrome with jugular bulb labyrinthine symptoms may develop. 
Bezold’s Mastoid.—This term is applied to that type of mas- 
toiditis in which there is a fistula from the internal and anterior 
portion of the mastoid tip, anterior to the digastric fissure, to- 
gether with a sinking abscess formation. This dissecting abscess 
may extend into the posterior mediastinum. Aside from the 
swelling in the upper posterior triangle between the tip of the 
mastoid and the angle of the jaw, is the early development of a 
peripheral facial paralysis. The pain is usually referred to the 
lower teeth and radiates towards the temple, being due to pres- 
sure on the auriculotemporal and inferior dental branch of the 
fifth nerve. 
We must here keep in mind a pseudo-Bezold mastoid that is 
produced during an operative procedure and is the result of 
cutting the fibers of the sternomastoid at their origin which al- 
lows the infection to spread into the neck. Here, too, might be 
mentioned a similar process due to cutting of the fibers of the 
temporal muscle and the deep temporal vein which might pro- 
duce symptoms about the eyelids mistaken for a cavernous sinus 
thrombosis. ACUTE DISEASES OE THE EAR 
83 
Differential Diagnosis.—Herpes zoster oticus and spheno- 
palatine irritation may both produce symptoms of marked 
otalgia simulating a mastoid involvement. A secondary cellu- 
litis from an otitis externa, as found in the bather’s ‘‘tank ear,” 
in which there is pain and swelling over the mastoid and tragus, 
likewise may simulate a mastoid involvement. A broken down 
retroauricular gland, frequently found in infants and children 
is not infrequently confused with a mastoiditis. CHAPTER VII 
ACUTE COMPLICATIONS OF MASTOIDITIS 
The complications of acute mastoiditis are, as a rule, practi- 
cally preventable and the intimate knowledge of the before men- 
tioned pathology should enable one to minimize the possibility 
of their occurrence. For example, knowing that the osteo- 
phlebitic type of mastoiditis predisposes to sinus thrombosis 
and that by reckless or unnecessary exposure of the sinus a 
thrombus may actually be produced, unusual care should there- 
fore be taken not to expose it. Likewise, it should be borne in 
mind that a mastoiditis of this type if insufficiently operated 
upon, or not operated early enough, a sinus thrombosis is apt to 
develop. One must, therefore, be on guard for the earliest ap- 
pearance of any symptoms indicating its onset. Many times be- 
fore the actual toxic reaction, septic temperature and chills, one 
can by repeated blood cultures anticipate much trouble. On the 
other hand, we must suspect in the cell route type of infection, 
where the coalescing osteal changes are marked, with destruc- 
tion of any part of the tegmen, the possibility of a dissecting ex- 
tradural abscess. The bacteriologic findings are likewise of 
importance in the assumption of the usual pathologic changes 
associated with the various types of organisms, but neither the 
bacteriologic nor the blood cultural studies are yet of positive 
practical value. The acute complications usually found are: 
1. Acute labyrinthitis, serous or purulent. 
2. Perisinus abscess. 
3. Sinus thrombosis. 
4. Extradural abscess. 
5. Intradural abscess. 
(j. Meningitis. 
7. Chronic mastoiditis. 
8. Facial paralysis. / 
84 ACUTE COMPLICATIONS OF MASTOIDITIS 
85 
ACUTE LABYRINTHITIS 
Labyrinthitis complicating an acnte mastoiditis usually fol- 
lows the osteophlebitic type and rarely the cell route type of 
infection, wherein the middle ear and antrum are markedly dis- 
tended, producing by pressure disturbance transmitted through 
the round or oval window. 
Localized serous labyrinthitis is produced when there is an 
osteitis in the region of the horizontal semicircular canal or 
Trautmann’s triangle. An irritation therefore results and a 
labyrinthitis is manifested clinically by vertigo, etc. Functional 
tests, however, show a normal labyrinthine response. The intra- 
labyrinthine fluid is undoubtedly increased in pressure by virtue 
of the associated engorgement. There doubtless is by this time 
an already existing neuritis. The future course depends to a 
certain extent on the invading organism. The process may go 
on to a suppurative or a diffuse labyrinthitis. 
Mass Labyrinthitis (acute, suppurative, diffuse labyrinthitis). 
The line of demarcation between a suppurative labyrinthitis per 
se and a meningitis is so line that at times it is very difficult to 
distinguish between them. We can assume that there is present 
at least a localized basilar meningitis associated with every case 
of suppurative labyrinthitis. There is usually also associated 
with this condition an acute suppuration within the aqueduct of 
Fallopius, with a resulting facial paralysis. 
Both branches of the auditory nerve undergo changes, but the 
vestibular nerve is much more resistant and will often recover 
from inflammatory changes when the cochlear branch will not. 
Acute exacerbation of a chronic localized labyrinthitis. A 
flare-up of this type is not unlike that described under localized 
labyrinthitis. 
Application.—Recognizing the changes as they occur in an 
acute localized labyrinthitis one can understand that the func- 
tional tests are practically normal, except that they may respond 
more quickly. There is no spontaneous nystagmus present and 
there is no change in reaction to the caloric or turning tests 
other than this. However, when there is a marked increase of 
fluid, resulting in disturbed tonus, spontaneous nystagmus may 
occur. The stormier the symptoms the more rapid is the in- 86 
APPLIED PATHOLOGY 
crease in pressure and the toxicity of the fluid, with the likeli- 
hood of a resulting suppurating labyrinthitis. We can also 
assume a more destructive lesion by judging the rapidity with 
which the spontaneous nystagmus appears and disappears, and 
the rapid development of the spontaneous compensatory nys- 
tagmus on the healthy side, which ordinarily develops slowly. 
When this does occur, even in the face of acute symptoms, an 
immediate operation is indicated, especially if an early irritative 
symptom of meningitis appears—photophobia. 
The all-important aim is■ to obtain resolution with a function- 
ing labyrinth and to prevent the development of a meningitis. 
In a localized process with irritation and a serous labyrinthitis 
the absolute rest of the entire body, particularly the head, is 
essential. Under no circumstances should any operation be per- 
formed whereby the least *1 shaking up ’ ’ will occur, as the dan- 
ger of meningitis developing is imminent. We have, however, 
on two occasions performed a simple drainage (by the burr) of 
the antrum when the primary culture obtained after incision of 
the drum showed the presence of the hemolytic streptococcus. 
Both of these patients recovered and the mastoid operation was 
completed several months after the acute symptoms subsided. 
The hearing in one case was markedly impaired on the involved 
side and in the other case was almost completely gone. We 
need but mention here the contraindication of lumbar puncture 
in that it might start up a diffuse process. 
In the suppurative type operative procedure should not be 
delayed awaiting the appearance of symptoms of meningitis. 
PERISINUS ABSCESS 
If during the course of an acute mastoiditis, whether operated 
upon or not, the patient has a sudden rise of temperature, with 
or without chills (usually without), a leucocytic increase, a sen- 
sation of pressure and increased tension, rather than osteal pain, 
the possibility of a perisinus abscess formation should he 
thought of. Suspicion should he immediately followed hy ex- 
ploratory proof. The pus accumulates in the outer and lower 
portions of the sinus—that portion in close contiguity with the ACUTE COMPLICATIONS OF MASTOIDITIS 
87 
mastoid, and usually before it reaches the knee of the sigmoid 
because there the sinus is freer. 
One of the niceties in pathologic diagnosis at this time is to 
state whether or not a sinus should be explored. Our custom 
during the last ten years when an abscess is present and con- 
sists of not more than ten or fifteen drops of pus, especially if 
the organism is not the hemolytic streptococcus, has been not to 
open the sinus or even to handle it, but to drain the abscess and 
wait for at least twenty-four hours before doing anything fur- 
ther. Of course very free drainage of the mastoid cavity should 
be obtained, the sinus fully exposed, and the mastoid wound left 
open. We believe that any manipulation of the sinus at this 
time might increase the progress of a developing thrombosis. 
In several of the cases we have had under observation we are 
convinced that because of the failure of early mastoid operation 
in the above condition a true parietal thrombosis has developed. 
SINUS THROMBOSIS 
The change that takes place is usually by continuity in the 
osteophlebitic type of mastoiditis. The adventitia of the sinus 
is rapidly permeated by the bacterial invaders and the subse- 
quent inflammatory change extends into the intima with the 
development of a thrombus on one side of the sinus towards the 
bulb or torcula, usually towards the bulb. Starting in one or 
the other direction the progress is all in that direction. How- 
ever, the entire circumference of the sinus wall sooner or later 
takes part in this phlebitis. The complete obstruction of the 
sinus does not take place for a number of days, which accounts 
for the repeated showers clinically characterized by symptoms 
of chills, fever and sweats. Nothing is known to enhance or 
prevent the loosening up of the thrombus or particles of it, ex- 
cept the classical operation or spontaneous arrest of the process. 
Some observers have reported cases rapidly progressing, but 
which cleared up with absolute rest and no operative interfer- 
ence. A case has been described in which subsequent retunnel- 
ing of the thrombosed sinus was observed several years after. 
The longer the process is permitted to exist, the more fre- 
quent are the showers, owing to liquefaction of the thrombus, 88 
APPLIED PATHOLOGY 
especially when the hemolytic streptococcus is the invading 
organism. The various changes that may take place are: 
1. Spontaneous arrest with resolution. 
2. Continuous progress towards the jugular bulb, 
torcula, or beyond to the superior longitudinal, 
occipital or cavernous sinuses. 
3. Liquefaction, including the sinus wall and rup- 
ture intracranially with hemorrhage. 
Fig. 42. 
Fig. 4.°). 
Externally, rupture with hemorrhage between the bone and 
the sinus has never been observed by us. The associated patli- 89 
ACUTE COMPLICATIONS OF MASTOIDITIS 
ology, aside from perisinus abscess, is a localized meningitis, 
with or without abscess; adenitis and cellulitis of the neck, and 
myositis, particularly of the sternomastoid muscle. In one of 
our cases in which resection of the jugular vein was done, a sec- 
ondary dilatation of the carotid artery with a fusiform aneu- 
rysm was observed, and it was a question whether the phle- 
bitis or traumatism during the resection was the cause. Vagus 
irritation has been observed; secondary neuritis following the 
phlebitis and its resulting symptomatology is an aid in diag- 
nosis. 
Based upon the pathologic findings it is clear that even 
though further spread be shut off by ligation or resection of the 
neck veins, and the blocking off of the sinus torculawards, the 
sinus should be opened, the clot removed (Figs. 42 and 43) and 
the parts drained in order to prevent spreading of the infection 
into the cranial cavity by contiguity. In this way the possi- 
bility of a brain abscess or cerebritis developing is minimized. 
EXTRADURAL ABSCESS 
Perisinus abscess is the simplest form of an extradural ah 
scess. The most frequent location, however, is in the temporo 
Fig. 44. 
sphenoidal lobe following tegmental necrosis—the pus traveling 
forward and inward, dissecting up the dura (Fig. 44). There 
is an associated pachymeningitis and an early involvement of 90 
APPLIED PATHOLOGY 
the arachnoid which accounts for the irritative symptoms and 
the cellular changes in the spinal fluid. The hone, aside from 
the atrium of infection, is not much changed. The longer the 
duration of the abscess, and it may exist unrecognized for years, 
the more dense becomes the surrounding dura from a fibrosis. 
The concomitant pathological changes are dependent upon the 
location of the abscess. Thus there may be involvement of the 
fifth and sixth cranial nerves or if the abscess is located pos- 
teriorly, especially close to the tip of the petrous portion of the 
temporal hone, one may encounter changes within the circle of 
Willis, as described in Brieger’s classical case. The next most 
frequent location is towards the cerebellum by virtue of the 
paths of least resistance. The cerebellar dura in the posterior 
fossa is much more difficult to dissect up and consequently an 
intradural or true abscess is most frequently met with in this 
location. 
The amount of pus will play an important role in the symp- 
tomatology. It is important to note that absorption is com- 
paratively slight and therefore the temperature is not an im- 
portant factor. The possibility of the coexistence of an extra- 
dural abscess in the middle and posterior fossa, producing 
Gradenigo’s syndrome, must be recognized. This condition 
must then be differentiated from the involvement of Ivoerner’s 
cells in atypical mastoiditis, as described previously. The 
presence of intracranial irritative and pressure symptoms will 
aid in the differential diagnosis. We have observed one unusual 
case of an extradural abscess in the temporosphenoidal region 
in which necrosis of the thin, squamous portion of the temporal 
bone took place, with the subsequent burrowing of the pus under 
the temporal muscle and the zygoma. 
INTRADURAL ABSCESS (ACUTE BRAIN ABSCESS) 
While brain abscess is much more frequently found in con- 
sequence of chronic suppuration of the ear, it does occur follow- 
ing immediately in the wake of an acute mastoiditis. This 
occurs especially if the mastoid operation has been delayed and 
extension is by the vascular route. The usual onset of this 
change is the presence of severe symptoms of cerebral involve- ACUTE COMPLICATIONS OF MASTOIDITIS 
91 
ment with the rapid dissolution of this tissue—so rapid is this 
that Nature’s defensive forces of encapsulation rarely occur. 
However, in less virulent cases the brain tissue may fortify 
itself against further invasion by the formation of a pseudo- 
capsule, and the knowledge of the presence of this barrier is of 
the utmost importance in that in operative interference it 
should not he destroyed. It is therefore a good, practical de- 
duction to wait a limited time for the formation of this barrier 
before operating, provided the symptoms of dissolution or de- 
struction are not too severe or fulminating. It would be well, 
then, to delay with caution another twenty-four hours or more 
before drainage, provided the mastoid wound has previously 
been opened. 
Acute abscess following mastoiditis is very frequently mul- 
tiple and is one of the greatest difficulties in operative cure, so 
that one may drain one abscess while another may go on to 
further destruction unrecognized. The cerebritis is of the mas- 
sive form, contrary to the superficial type associated with 
meningitis, and the destruction is more by pressure than through 
the extension of the infectious process through the vascular or 
lymphatic routes. The passing of strips of iodoform gauze be- 
tween the meninges and brain to form a cofferdam, and thus 
prevent further inward destruction, is of value. 
HERNIA CEREBRI 
In the drainage of large brain abscesses in which large dural 
incisions are necessary or where the dura becomes infected and 
subsequently destroyed, there develops, at times, this most dis- 
agreeable complication. At first only a small protrusion of the 
cerebral tissue is noted (Fig. 45), and if the proper treatment is 
not instituted or is impossible to carry out, the hernia becomes 
more pronounced (Fig. 46) with eventual cerebrospinal fistula 
formation. The best results have been obtained by ventricular 
puncture through a sterile field, or by spinal puncture. Gentle 
compression bandages are applied to the wound. 
MENINGITIS 
Witli all of the above complications there is always an asso- 
ciated meningitis, localized, be it a pachymeningitis or lepto- 92 
APPLIED PATHOLOGY 
meningitis. The pia and arachnoid are agglutinated to the dura 
and are injected. A true meningitis of otitic origin occurs most 
frequently by the process extending through the labyrinth and 
internal auditory meatus. In the beginning the infectious proc- 
ess travels along the auditory and facial nerve sheaths and con- 
Fig. 45. 
Fig. 46. 
tiguous parts. In this process the arachnoid takes on the great- 
est activity of inflammatory reaction, which is quickly followed 
by an increase in fluid production, which in turn, as the organ- 
isms are present, spreads diffusely. 
The headache, which is the cardinal subjective symptom, is ACUTE COMPLICATIONS OF MASTOIDITIS 
93 
not caused so much by the infection of the meninges as by pres- 
sure. The location of this pain is in no way a criterion of the 
location of the diseased process, and pain by contre-coup as in 
brain tumor, is well recognized. A rapidly diffuse form of men- 
ingitis does occur, but is comparatively rare. It is principally 
dependent upon the type of the invading organism and its viru- 
lence. The invasion of the pia, which dips down into the sulci, 
which do not drain very freely into the arachnoid space, is, per- 
haps, the most important factor in the fatality from this disease. 
Another factor is the involvement within the confines of the 
circle of Willis which is anatomically impossible to drain. The 
plastic exudate that occurs in meningitis is another hindrance 
to drainage. The extension of the process along the cranial 
nerves and spinal cord marks the case practically as hopeless, 
even if a recovery is made from the meningitis. 
The study of the cerebrospinal fluid, its changes physically, 
chemically, cytologically and bacteriologically, is one of the most 
practical indices we have in diagnosis. The viable bacterial 
content especially of virulent organisms is the most important 
prognostic finding, which if present, gives usually a fatal out- 
look. The presence of organisms in the spinal fluid that are 
found only on direct smear and do not grow on culturing does 
not necessarily give a fatal prognosis. The pressure of the 
spinal fluid is of some consecpience and is of importance insofar 
as its influence on nutrition of the brain is concerned. Other 
tests are more of scientific interest than of practical importance. 
Any type of acute meningitis, no matter how slight, if the arach- 
noid is irritated, will immediately respond and the spinal fluid 
will show cytological changes, even though the fluid appear nor- 
mal in color and pressure. 
It is only necessary to mention the various conditions that 
may be confused with a meningitis of this origin, viz., lethargic 
encephalitis, tuberculous meningitis and typhoid fever, any of 
which may have a coexisting otitis media and thus give a pic- 
ture similar to that described above. 
ACUTE FACIAL PARALYSIS 
Acute facial paralysis is far more frequent in relation to acute 
mastoiditis because of anatomical reasons. There are frequently 94 
APPLIED PATHOLOGY 
dehiscences in the fallopian canal. In infants and children the 
mastoid tip cells are in close proximity to the nerve. In Bezold's 
mastoiditis the abscess lies in close proximity to the nerve. 
Facial paralysis coming on during the course of an acute 
mastoiditis without labyrinthine symptoms means the extension 
of the osteitis to the facial canal, with a resulting perineural 
inflammation and neuritis. Edema and pressure within the canal 
are very apt to result in the rapid degeneration of the nerve, 
and therefore the earliest possible unloading of the mastoid as 
far as the aditus, even to completing a radical mastoid opera- 
tion, we consider good practice. 
Acute traumatic facial paralysis may be the result of surgical 
intervention. This may be true particularly when the simple 
mastoid operation is performed in children, where the nerve lies 
close to the surface and the incision extends too far below or to 
the front of the tip of the mastoid. Again, this may occur in 
the over-extensive exenteration towards the anterior-inferior 
portion. By far the greatest number of cases have resulted 
since the radical mastoid operation has been in vogue and a 
great many temporary facial paralyses have been caused by the 
very instrument devised for its protection (Stacke’s protector), 
which is now practically obsolete. 
If the nerve is actually cut during operation, the facial paral- 
ysis develops immediately. If it develops later and gradually 
after the operation, it is either an inflammatory reaction involv- 
ing the nerve, or the result of pressure, or granulation tissue 
formed about the nerve. 
ACUTE FACIAL PARALYSIS UNASSOCIATED WITH 
MASTOID DISEASE 
Iii order to arrive at a rational basis for differential diagnosis, 
it would lie well to mention here several other conditions giving- 
rise to the development of an acute facial paralysis, apart from 
the frequent “Bell’s palsy.” 
Traumatic.—Trauma has played an important part in the pro- 
duction of facial paralysis, particularly during the war when 
various types of missiles produced marked destruction in the 
face, and as a rule part of the nerve was actually torn away. 
In fracture of the base oi the skull through the petrous portion ACUTE COMPLICATIONS OF MASTOIDITIS 
95 
of the temporal bone, facial paralysis accompanied by labyrin- 
thine destruction was not infrequent. In most of the latter 
cases meningitis with fatality developed. 
Infectious Diseases.—Many of the infectious diseases, partic- 
ularly mumps and measles and occasionally diphtheria, are asso- 
ciated with a bilateral facial paralysis more or less acutely 
developing. Except in the latter case it is an infectious neuritis, 
and in this, a toxic neuritis. 
Miscellaneous.—Congenital lesions and various brain lesions 
incidental to birth, as following forceps delivery, might be men- 
tioned. We have seen several unusual cases develop due to 
varied causes. In one case following a sublabial antrum opera- 
tion in which there was long continued retraction of the cheek 
towards the upper and outer portion of the face, there resulted 
a temporary facial paralysis. In another case at the conclusion 
of a radical mastoid operation trichloracetic acid was carried 
into the eustachian tube and some of the caustic undoubtedly 
came in contact with an exposed facial canal, with a resultant 
temporary facial paralysis. In another case a complete facial 
paralysis developed after the use of 100 mg. of radium properly 
screened, placed below the lobule of the auricle for the treatment 
of a tumor. The paralysis persisted for two weeks before there 
were any signs of improvement. 
Application.—When the variability of etiological factors is 
realized, each case is an entity as to its management. Suffice it 
to say that unless the facial nerve has actually been cut through 
and a portion removed one may expect recovery, even though 
it may be protracted. An important fact to remember is that in 
this watchful waiting for recovery, when the nerve is restored 
to function it may be of no avail if the muscles supplied by this 
nerve have not previously been stimulated by galvanic or deep 
sinusoidal current in order to retain their tonus and nutrition. 
The thorough knowledge of the reaction of degeneration is the 
final word for prognosis or as to the indication for nerve anas- 
tomosis. When one applies the cathode to the parotid region 
at 5 to 15 milliamperes of current and then fails to produce the 
characteristic vermicular contraction of the muscle fibers sup- 
plied by the facial nerve, an unfavorable prognosis must be 
given, both as to recovery and the effectiveness of nerve anas- 
tomosis. PART II 
CHRONIC DISEASES 
CHAPTER VIII 
CHRONIC DISEASES OF TITE NOSE 
It is much less difficult to obtain pathologic material in 
chronic than in acute conditions inasmuch as the greater per- 
centage of the chronic conditions met with are amenable only 
to surgery. It is surprising how very little use has been made 
of this fact in the study of pathology of the nose, throat and 
ear, simply because it is assumed that most of the material that 
can be obtained is of the “common garden” variety. This is 
perhaps true but it is only the correlation of the gross and micro- 
scopic findings with the specific case that is of value, both as 
to its course and the treatment that may be indicated. 
EXTERNAL NOSE 
1. Rhinophyma 
Rhinophyma may vary from a slight arterial and venous en- 
gorgement, thickening of the epithelium and some atheromatous 
changes, to that of marked hypertrophy of the skin and verru- 
cous formation. The blood vessels become markedly dilated, 
giving the nose a bulbous appearance (Fig. 47). This condition 
has been called “pound nose,” or elephantiasis. Microscopical 
examination shows hypertrophic changes of all the layers of the 
skin, together with marked hyperplasia of the sebaceous glands. 
Treatment.—In the milder cases the use of surgical diathermy, 
radium and the galvanic needle will be of considerable benefit. 
The technic of these procedures can be found in the various spe- 
cial books on electrotlierapeusis and radiology. In most of the 
cases operation, that is, decortication and skin plastic must be 
resorted to. 
2. Lupus and Tuberculosis 
Neither lupus nor tuberculosis is at all uncommon, although 
lupus is the one most frequently observed. This latter condition 
96 CHRONIC DISEASES OE THE NOSE 
97 
is usually found on the alae and begins as the characteristic 
apple-jelly tubercle which soon breaks down and another one or 
more form in its vicinity, while the earlier ones ulcerate and 
subsequently cicatrize (Fig. 48). This process will go on until 
Fig. 47.—Rhinophyma (Pound Nose) 
Fig. 48-^4. 
Fig. 48-B. 
Fig. 48.—End result of lupus of lip and both alae nasi showing marked cicatrization. 
the greater part of the external nose is involved unless active 
treatment is instituted. It is to he noted that other diseases such 
as lupus erythematosus must be differentiated, hut they are of 
dermatological importance and not in the scope of this work. 98 
APPLIED PATHOLOGY 
The microscopic findings are typical of the tubercle, with many 
giant cells present. The treatment is principally electrothera- 
peusis, the Finsen light, fulguration or surgical diathermy. 
X-ray and radium have also given excellent results. Surgical 
removal of the nodules by curettage and subsequent active cau- 
terization will give curative results, but the resultant cicatriza- 
tion is greater than when the former methods are employed. 
3. Lues 
In lues it is usually the gummatous stage that is seen. Sev- 
eral of the nasal structures as well as those of the palate are 
simultaneously involved. The columella usually undergoes the 
Fig. 49.—Luetic destruction of septum nasi including the columella and center of 
upper lip. 
most marked destruction (Fig. 49). At first there occurs a great 
deal of swelling, the skin showing a deep red color (Figs. 50 and 
51); it is usually not painful to touch or pressure. Later on 
the entire mass breaks down and a deep sulcus results. Necrotic 
masses are seen at the bottom of the ulceration. After the final 
sloughing the border of the ulceration is sharply defined. The 
resultant cicatrization is made up of very dense scar tissue 
(Fig. 51). Microscopically the usual picture of a gumma is 
found. The Wassermann reaction, of course, in these cases is 
usually found to be positive. 
Treatment.—Treatment consists, naturally, in very vigorous 
antiluetic measures, although at times the best results are ob- CHI! ONTO DISEASES OF THE HOSE 
99 
tained by limiting the treatment at this stage to the arsplien- 
amine preparations. At other times the combined treatment 
with mercury and the iodides appears to give the best results. 
Fig. 50.—Gumma of external nose with marked destruction of the interior of the 
nose and the columella. 
Fig. 51.—End result of deformity and cicatrization in gumma of nose. 
Locally cleansing methods should be employed and ammoniated 
mercury ointment, 5 per cent, freely used, has been found ad- 
vantageous. 100 
APPLIED PATHOLOGY 
4. Rhinoscleroma 
In connection with a typical rliinoscleroma of the interior of 
the nose and throat we have had a case of this pathologic entity 
involving the external portion of the nose. The skin of the 
entire external nose feels indurated and has a diffuse, light red 
color. The microscopic changes as well as the treatment will be 
taken up with the same subject in the throat. 
5. Pus Infections—with or without Destruction of the Soft Parts 
Pus infections may be manifold since each case will have a dif- 
ferent etiological factor. Many are the result of fracture, be- 
coming either primarily or secondarily infected. During the 
World War we observed many cases of chronic infection of the 
external nose with or without the presence of foreign bodies or 
necrosis of the cartilage or bones. The staphylococci were the 
most frequent organisms found in these pyogenic infections. 
Treatment.—Treatment consists of a very thorough cleansing 
of the parts, the removal of all foreign substances as well as any 
sequestra of bone or cartilage, and the removal of the skin ad- 
joining any fistulous tracts. The wound is allowed to heal 
openly. 
As the result of any of the above-mentioned conditions affect- 
ing the external nose, the deformity may be considerable and 
require further correction. For this plastic work the reader is 
referred to my chapter on Plastic Surgery in Loeb’s text book 
on “Operative Surgery of the Ear, Nose and Throat.” 
6. Tumors 
Nevus is a very frequent neoplasm of the external nose and is 
either a true nevus or telangiectasis. These present themselves 
principally in infants and at that time are very small. They 
develop rapidly and may finally involve half of the face. The 
skin is somewhat stretched and has a light bluish appearance. 
The tumor feels spongy and springs back after compression. 
When localized at the tip of the nose it may encroach upon the 
size of the nostrils. The progress of growth is shown in the 
change of the skin to a deeper red color and finally elevation 
above the uninvolved portion (Fig. 52). Microscopically there CHRONIC DISEASES OF THE NOSE 
101 
is shown at first only slightly dilated veins and a fair preserva- 
tion of the connective tissue stroma, hut as the process pro- 
gresses one finds practically a disappearance of the connective 
tissue and only large, thin-walled hlood vessels (veins). In 
some instances there is found much free hlood between the 
vessels. 
Fig. 52.—Nevus of external nose (scar at tip following boiling water injection) 
Fig. 53.—A. Rapidly developing nevus (three weeks) from a small blue spot on 
the upper eye lid. 
B. Various methods of treatments employed. The forehead, temple, and scalp, 
carbon dioxide snow; upper and lower eye lids, radium; cheek and upper lip, 
boiling hot water injections; marginal below the ear and lower jaw, subcutaneous 
silk ligatures. 102 
APPLIED PATHOLOGY 
Treatment.—The treatment depends upon the stage and ex- 
tent of the process. In the earliest cases surgical diathermy and 
radium are very efficacious, but when the veins are already 
markedly dilated and the skin transformed in the angiomatous 
process, the use of carbon dioxide snow gives the best results. 
The latter may also be used in combination with diathermy and 
radium. Injections of boiling hot water have also been found to 
be of advantage. Peripheral ligation of the vessels may arrest 
progress, but the deformity and cicatrization resulting is a great 
disadvantage. X-ray has not proved of much value in our hands 
in this condition; the same is true in regard to the use of the 
electric cautery, igni puncture, or the galvanic electrolytic 
needle. We have had one case in which these various methods 
have been used (Figs. 53 A and B). 
Fig. 54.—Sarcoma of nose producing the typical frog face appearance 
Sarcoma is usually secondary by direct extension or contin- 
uity of structure. It is comparatively rare in frequency as com- 
pared with involvement of the interior of the nose. The most 
frequent change is the spreading of the nasal bones in conjunc- 
tion with the involvement of the ethmoid labyrinth, giving the 
patient the characteristic “frog-face” appearance (Fig. 54). 
When the tissues of the external nose have become sarcomatous, 
the nose exhibits a very red appearance, except at one point, 
usually at the bridge, where it is pale, and the growth often 
breaks down at this point to form a fistula (Fig. 55). Palpa- 
tion frequently reveals crepitus due to the necrosis of the nasal 
bones from pressure. Microscopic examination will show the CHRONIC DISEASES OF THE NOSE 
103 
prevalent type of cells. Most of our cases showed mixed and 
small spindle cells, although we have had two cases of inelano- 
sarcoma involving the external nose. These sections will he 
Fig. 55.—Sarcoma of nose involving the external parts with a fistula formation 
shown in connection with sarcoma involving the interior of the 
nose. 
Epithelioma occurs very frequently, and strange to say it 
remains for a long period in a quiescent stage as a very super- 
ficial lesion. The lesion at first is a small elevation of hornified 
Fig. 56.—Epithelioma of external nose about the ala. 
epithelium resembling a wart and in some cases is multiple. Its 
location is usually on the side of the nose or ala (Fig. 56), al- 
though we have had one case in which the primary lesion 104 
APPLIED PATHOLOGY 
occurred on the tip of the nose (Fig. 57). In due time the can- 
cer cells penetrate below the basement membrane and soon after 
the regional lymph glands become involved. The masses soon 
ulcerate and are open to secondary infection. In the case we 
have mentioned occurring at the tip of the nose the growth pro- 
truded externally to the size of a walnut rather than growing 
inwards, as is usually the case. Microscopically the typical 
Fig. 57.—Epithelioma of external nose confined to the tip. 
epithelial cells showing mitotic figures and epithelial pearls are 
to he seen. 
Treatment.—The treatment is to remove or destroy the growth 
at its very earliest appearance. This can he accomplished with 
either the knife, the cautery, x-ray, radium, surgical diathermy 
or a combination of these procedures. In the specific case we 
have mentioned x-ray and radium appeared to stimulate the 
growth rather than to destroy it. The dosage used in this case, 
unfortunately, was not available. CHRONIC DISEASES OF THE NOSE 
105 
Papilloma usually affects the interior of the nose but we have 
had two cases which developed on the columella, so they really 
belong in this category. A small, rounded elevation was ob- 
served. In one of our cases it was sessile, in the other, distinctly 
pedunculated. The surface is very irregular and bleeds easily. 
Microscopically, it has a typical papillomatous appearance with 
considerable hornification of the surface epithelium. In our two 
cases the amount of connective tissue and round cell infiltration, 
together with the vascular supply, was at variance. 
Treatment—The treatment consists in the early surgical re- 
moval, best obtained by the use of a cold wire snare followed by 
deep cauterization of the growth by the galvanocautery point. 
Radium, x-ray, carbon dioxide snow, or surgical diathermy may 
be substituted. We have in one instance excised the small 
growth by sharp dissection and subsequently applied a skin 
graft which healed very promptly and has shown no recurrence 
to this date. 
7. Paraffinoma 
Paraffinoma usually results from improper technic of injecting 
paraffin, although there are cases on record in which the correct 
technic was employed. The cases which have come under our 
observation have all been injected by charlatans or advertising 
quacks, and in one case, by the patient herself. Up to a number 
of years ago we injected quite a number of deficiencies about 
the nose and face with paraffin and did not have a paraffinoma 
as the result in any case. This method is now obsolete and we 
do not any longer employ or recommend its use. 
The symptom from such a condition, aside from the uncosmetic 
appearance (Pig. 58) is severe pain of a neuralgic character. 
The skin, which is invariably involved in this process, is pas- 
sively congested, giving a bluisli-red appearance and on palpa- 
tion, the mass or masses (Fig. 59) seem to be adherent to the 
underlying structures. The paraffin is diffusely infiltrated 
throughout the subcutaneous tissue. 
Microscopic examination reveals particles of paraffin sub- 
divided by trabeculae of newly formed connective tissue making 
a mesh work. Newly formed blood vessels, which remain of 
small calibre, are plentiful. The usual foreign body reaction, 106 
APPLIED PATHOLOGY 
Fig. 58.—Paraffinoma of external nose showing a scar where attempts were made 
to remove it. 
Fig. 59.—Masses of paraffinoma removed. These are very hard to the touch. CHRONIC DISEASES OF THE XOSE 
107 
Fig. 60.—Paraffinoma of the nose, showing persistent particles of paraffin surrounded 
by fibrous tissue and numerous fat cells. 
Fig. 61.—Paraffinoma of the nose, showing definite node formation about the paraf- 
fin particles. 
attended by round-cell infiltration and numerous multinuclear 
giant cells, is also present, especially in the region of the paraffin 
globules (Figs. 60, 61, 62, and 63). 
Treatment.—Treatment is mainly surgical and consists in the 108 
APPLIED PATHOLOGY 
Fig. 62.—Paraffinoma of the nose, showing dense fibrous tissue and cellular in- 
filtration about fibrous particles. The specimen, resembles, and is often mistaken 
for, a spindle cell sarcoma. 
Fig. 63.—Paraffinoma of the nose, showing nodule surrounded by fibrous tissue and 
numerous fat cells. 
removal of all the masses, including the skin, although one may 
attempt to remove them subcutaneously. 
Recurrences are very frequent and this has given rise to the 
belief that paraffinomas become malignant but we have never 
found evidence of this microscopically. CHRONIC DISEASES OF THE NOSE 
109 
Vestibulum of the Nose 
Chronic Vestibulitis is one of the most distressing and unsatis- 
factory conditions to manage. The chief difficulty lies in the 
failure to recognize the etiologic factor. There is usually found 
crust formation at the base of the vibrissae, which gives the 
patient a constant desire to remove them. This adds to the 
irritation, and a dermatitis, spreading to the tip as well as the 
ala of the nose, results. After soaking and carefully removing 
these crusts one often finds fissures anteriorly as well as pos- 
teriorly in the vestibule. There may be associated a rhino- 
sinuitis, which may be the causative factor in producing the 
irritation. Not infrequently definite abscess formation or fu- 
runcles may occur on the tip of the nose. Diabetes as an etio- 
logical factor should not be overlooked. 
Treatment.—The very liberal use of 5 per cent ammoniated 
mercury ointment, both night and morning, gives considerable 
relief. X-ray or medical diathermy has been used but with no 
particularly gratifying results. Attention must be directed to 
the nasal accessory sinuses and to the general health of the pa- 
tient. The fissures should be cauterized very carefully with a 
20 per cent silver nitrate solution daily for three or four days. 
INTERNAL NOSE 
1. Nasal Septum 
A. Deviations may be classified pathologically into (a) car- 
tilaginous; (b) bony; (c) mixed. Deviations have usually super- 
imposed upon them spurs or crests, the deviation being chiefly 
confined to the cartilaginous portions. The ridges begin in the 
inferior meatus and run along the floor of the nose backwards 
and upwards. Spurs are most frequently found posteriorly, 
opposite the end of the middle turbinated body (Fig. 64). The 
type of deviations may vary in shape from a simple bowing to 
an S-shaped twist. Many times the anterior part of the devia- 
tion may protrude from the nostril, simulating a dislocation* 
thus occluding both nostrils. In many instances there is a com- 
bined bony and cartilaginous ridge near the floor of the nose, 
probably arising from the premaxillary bone (Figs. 65, 66, 67 110 
APPLIEI) PATHOLOGY 
and 68) and joining the septal cartilage. It is important here 
to remember the anatomical configuration of the perichondrium 
and periosteum as it passes from one side of the nose to the 
other. There also occurs a bilateral thickening of the septal 
Fig. 64.—Septal spur taken posteriorly near the sphenoid, showing marked rare- 
faction in the bone and the presence of osteoblasts with the deposition of new, 
deeply staining bone in the walls of the larger spaces. 
Cartilage 
Perichondrium 
Mucous membrane 
-Bone 
Fig. 65.—Gross illustration showing septal ridges at the floor of the nose. 
cartilage in its anterior and upper portion known as the tuber- 
culum septi (Fig. 69). 
The mucous membrane of the septum, especially over the 
crests and spurs, shows frequent evidence of ulceration. It is CHRONIC DISEASES OF THE NOSE 
111 
also more adherent to the underlying cartilage or bone. In the 
most anterior deviations where a crest or ridge is present one 
Fig. 66.—Large ridge from the premaxilla, showing marked rarefaction, 
Fig. 67.—Septal ridge showing blood vessels. (Low power.) 
frequently finds the mucous membrane entirely destroyed and 
the cartilage exposed. At times even the cartilage itself is de- 
stroyed, leaving only a thin layer of mucoperichondrium on the 112 
APPLIED PATHOLOGY 
opposite side. This condition is frequently the result of the con- 
stant removal of crusts. 
Micropathology.—In numerous sections of deflected septa and 
Fig. 68.—Septal ridge, showing at the junction of the bone and cartilage large 
blood vessels filled with blood. (High power.) 
Fig. 69.—Septal cartilage taken high up anteriorly from a young individual, 
showing marked thickening of the subperichondrium with great karyokinetic figures 
in the cartilaginous cells at this point. (Only a colored reproduction by a master 
artist’s hand could show the above mentioned findings so clearly demonstrated under 
the microscope.) CHRONIC DISEASES OF THE NOSE 
113 
ridges, excluding those of traumatic origin, there is seen definite 
change in the bone and cartilage. In the bone are areas of rare- 
Fig. 70.—Septal ridge, showing cartilage and bone activity at their junction; rare- 
faction is also clearly demonstrable. 
Fig. 71.—Septal exostosis, showing areas of rarefaction and dense bone. 
faction or spongification (Fig. 70), a softening of the bone, with 
other areas which are apparently later changes where the bone 
is dense and sclerotic (Fig. 71). The process is apparently not 114 
APPLIED PATJIOLOGY 
unlike that described by Siebenmann in the early stages of oto- 
sclerosis. First there is a dilatation of the bony canals with 
increased vascularity. Next there is a lacunar absorption, re- 
sulting in the formation of rarefied areas. Later, new, deeply 
staining bone is deposited in the walls of these large spaces. 
The septal cartilage shows round cell infiltration and great 
activity of the cartilage cells themselves, together with the 
definite presence of blood vessels at times (Fig. 72). Similar 
bony changes are found in osteomalacia, rickets, and physio- 
logically in the first few months of pregnancy. It might be 
Fig. 72.—Septal ridge, showing rarefaction of bone and great activity of the bone 
and cartilage cells at their junction, and blood vessels tilled with blood. 
suggested at this point, as to the relationship of septal devia- 
tions to the bony and cartilaginous changes found in deficiency 
diseases, particularly where the fat soluble A vitamin and the 
calcium content of the blood are lowered, that the septum dur- 
ing this pathological process may yield to external pressure. 
The mucous membrane over certain septal deflections and the 
tuberculum septi is at times very markedly hypertrophied. 
There is a marked increase in the blood vessels and specimens 
show many dilated veins. Those changes found here are not 
unlike those present in the mucous membrane of the inferior 
turbinate in its intumescent state. The presence of this patho- CHRONIC DISEASES OF THE NOSE 
115 
logic condition frequently gives rise to the clinical symptom on 
the part of the patient to constantly try to force air from the 
postnasal space forward in expulsive jerks. 
Treatment.—Insofar as preventive measures are concerned 
relative to deflected septa, but little can be suggested. The 
avoidance of trauma, of course, is important. In addition, care 
should be taken during the growing period that the diet be not 
deficient either in the vitamin content or inorganic salts (par- 
ticularly calcium), which factors are essential to the normal 
growth and development of bone. IVhen the deflection has oc- 
curred, surgical removal is indicated. It is important to note 
that complete resections should not be done under the age of 
sixteen, previous to which time full growth has not occurred 
and following resection deformity is apt to result. Graduated 
resections of the cartilaginous septum may be necessary in the 
young. 
2. Traumatic Septum 
A different picture is shown in resected cartilage to correct 
the deformity following cases of hematoma, or abscess of the 
Fig. 73.—Traumatic septum; resected cartilage in a traumatic football nose 
caused primarily by an abscess of the septum. The perichondrium is very much 
thickened and an organized blood clot is shown within a large vein. The cartilage 
cells in many places are shriveled. (Lower power.) 116 
APPLIED PATHOLOGY 
septum. There is loss of cartilage cells with the formation of 
connective tissue, especially in the subperichondrial region and 
Fig. 74.—Septal cartilage, showing round cell infiltration and the great activity of 
the cartilage cells themselves; also cross section of blood vessels. 
Fig. 75.—Same as Fig. 74. (High power.) Blood vessel in the cartilage is clearly 
shown. 
the areas of absorbed cartilage. The hyalin degeneration is 
evidenced in the homogeneous appearance (Figs. 73, 74, and 75). CHRONIC DISEASES OF THE NOSE 
117 
3. Lues 
The characteristic picture of the gummatous stage involving 
the septum is a bilateral swelling usually extending from the tip 
of the nose back and downwards onto the floor of the nose. It 
is brawny, indurated, and not painful. The hard palate in oral 
examination shows an associated swelling and redness. The 
external nose may also be involved. As the process progresses 
the gumma breaks down, usually at the junction of the cartilage 
of the septum with the bone at the floor of the nose. Ulceration 
Fig. 76.—Septal defects, anteriorly and posteriorly, luetic origin, 
and subsequent sloughing then appears and continues until re- 
peated sequestration occurs. As a result of this destruction 
there will be seen perforations of the septum (Fig. 76) and not 
infrequently perforations of the hard palate into the mouth. 
The edges of these perforations, at first granulating, soon heal 
over fairly smooth and are sharply defined. If the process in- 
volves the septum and the lateral cartilages towards the bridge 
of the nose, a typical saddle or notched nose (Fig. 77 A and B) 
may result. 118 
APPLIED PATHOLOGY 
Fig. 77.—Typical saddle or notched nosia following gummatous destruction, 
Fig. 78.—Gumma of the septum. A. Luetic exudate (low power). B. Same (high 
power). C. Gumma. 
Microscopic examination of the exudate covering the ulcer is 
somewhat homogeneous and the gumma is typical of such lesions 
occurring elsewhere in the body (Fig. 78 A, B, and C). 
Treatment.—The treatment, of course, is directed towards 
vigorous antiluetic measures. Some patients respond splendidly 119 
CHR0X1C DISEASES OK THE NOSE 
to arsphenamine, while others respond much more rapidly when 
arsphenamine is combined with mercury and the iodides. 
Locally, the usual cleansing measures with alkaline solutions, 
the removal of all bony sequestra without trauma, and cau- 
terization of the granulations comprise the principal procedures. 
The objectionable symptom of the fetor due to necrosis is best 
overcome by frequent douching with potassium permanganate 
solution (1:5000) or by the free use of hydrogen peroxide. Crust 
formation is best prevented by the generous use of 5 per cent am- 
moniated mercury ointment. 
4. Tuberculosis of the Septum 
Primary tuberculosis of the septum is comparatively rare, but 
is associated at times with a tuberculous involvement of the ala 
of the nose or lupus. The lesion usually begins on one side close 
to the tip in the form of a nodule which soon breaks down into 
the typical caseous mass. The granulations about the margin of 
the ulceration are rather profuse. At the bottom of the ulcer 
the denuded septal cartilage may at times be observed and in 
case this has been destroyed in the process the opposite mucous 
membrane becomes subsequently involved. The process is dis- 
tinctly chronic; there is usually an associated secondary infec- 
tion with a resultant swelling and injection of the surrounding 
mucous membrane and enlargement of the regional glands. The 
immediate surrounding area so often described as typically 
pallid has not been observed, as a rule, in our cases. The asso- 
ciated nasal discharge, because of its severity, produces a, der- 
matitis about the nostril and upper lip. Clinically, there is a 
persistent, radiating pain into the face and teeth in contradis- 
tinction to the absence of pain in luetic destruction of the sep- 
tum. The tubercle bacilli can be found if persistent efforts are 
made and histological examination of a small resected portion 
will confirm the diagnosis. 
Treatment.—In addition to general hygienic measures that 
must be adopted, radium and x-ray tlierapeusis have offered the 
best results. Complete removal of the diseased portion with the 
curet and subsequent actual cauterization has produced the best 
results in our experience. 120 
APPLIED PATHOLOGY 
5. Malignant Disease of the Septum 
Sarcoma and epithelioma of the septum have been observed 
by us, but it is doubtful whether they were primary in this 
region. Diagnosis can be made with certainty only upon re- 
moval of a section and subsequent microscopic examination. 
One should be prepared in all instances, if the tissue removed 
shows evidences of malignancy, to continue more radical pro- 
cedures within twenty-four hours. Surgical excision beyond the 
confines of the growth, surgical diathermy, supplemented either 
before or after by radium or x-ray therapy, offer the only means 
for its control. 
6. Papilloma of the Septum 
In addition to the papillomatous growths about the columella 
already described, we have had a case of extensive pajDillo- 
matous formation over the greater portion of the septum on one 
Fig. 79.—Multiple papillomata of the septum. 
side. Tlie irregular excrescences, and in many places multiple 
wart-like formations, characterized it (Fig. 79). At tlie lower 
posterior portion of the septum it was so marked as to block the 
nose. Bleeding was very slight. Microscopic examination 
showed the typical papilloma formation, the finger-like proc- 
esses of epithelium (Fig. 80) being in many places capped by CHRONIC DISEASES OF THE NOSE 
121 
markedly thickened and hornified epithelium (Fig. 81). The 
blood vessels were very sparse. 
Fig. 80.—Benign papilloma of the nose, showing structural formation with finger- 
like projections. 
Fig. 81.—Papilloma of the nose showing hornification. Papilloma had its origin 
from the septum. 
Treatment.—Treatment can be satisfactorily carried out by 
the use of carbon dioxide snow applied in aluminum tube appli- 122 
APPLIED PATHOLOGY 
cators. In the case above mentioned after seven applications 
the growth entirely disappeared, healing with a fairly smooth 
surface, and has remained healed for a period of over six years. 
Radium, fulguration, surgical diathermy and the actual galvano- 
cautery have been used with equal success. 
7. Congenital Absence of the Septal Cartilage 
Congenital absence of the septal cartilage may either be par- 
tial or complete. The usual picture shows a drop tip and no 
resistance to lateral movement. Palpation reveals the absence 
of any or part of the triangular cartilage. The treatment con- 
sists of a plastic operative procedure involving as a rule an 
autotransplant. (Refer to chapter on Plastic Surgery, by Beck, 
in Loeb’s text book.) 
8. Closure of the Posterior Choanae 
Closure of the posterior choanae may be unilateral or bilat- 
eral, partial or complete, membranous or bony. The diagnosis 
is usually overlooked in the routine examination of the nose. 
Digital examination or posterior rhinoscopy will determine the 
condition. The treatment consists in punching out sufficient 
portions of the septal closure and the insertion of a rubber tube 
from behind forward, which is allowed to remain in place for 
several days. 
9. Septum in Atrophic Rhinitis 
The septum in atrophic rhinitis is of interest from the patho- 
logic viewpoint only as it relates to treatment. Various efforts 
have been made to diminish the size of the large air spaces pres- 
ent in the nose by building up the septum. In the various at- 
tempts to implant into a submucously dissected pocket in the 
seijtum, small pieces of cartilage from the septum of another 
individual, only a percentage was successful. One side should 
be operated upon at a time. In one of our successful cases 
where the implant held nicely, a piece of the lip of wound, in- 
cluding cartilage, was removed just preliminary to implanting 
and the following microscopic conditions noted (Fig. 82): the 
perichondrium was very much thickened and a low-grade in- CHRONIC DISEASES OE THE NOSE 
123 
flammalory process involved the cartilage. The mucous mem- 
brane was somewhat hypertrophied and the glands showed a 
definite increase and hypertrophy, instead of the usual atrophic 
condition found in the mucous membrane overlying the inferior 
turbinate in such cases. We have been encouraged in this pro- 
cedure and have subsequently adopted the transplantation of a 
piece of the patient’s costal cartilage below the mucopericlion- 
drium and mucoperiosteum, especially in the region of the in- 
ferior meatus. The successful lessening of the air space gives 
Fig. 82.—Lip of wound in atrophic rhinitis, showing hyperplasia of the mucous 
membrane, especially the glands. The perichondrium is thickened and cartilage 
unchanged. 
relief to the two most annoying symptoms of atrophic rhinitis, 
namely, crust formation and fetor. 
10. Synechia 
Iii intranasal operative procedures and following any me- 
chanical, chemical or thermal manipulation within the nose, 
in which the mucous membrane of contiguous surfaces is 
injured, a synechia is likely to result. This consists of dense 
fibrous tissue with a fine layer of surface epithelium, at times 
appearing almost like a piece of dense mucous membrane. Cut- 
ting the adhesion and keeping the adjoining parts separated by 124 
APPLIED PATHOLOGY 
paraffin or wax splints until healing takes place constitutes the 
treatment. 
INFERIOR TURBINATE 
Pathologic changes in the inferior turbinate may he primary 
or secondary. Thus the following conditions may manifest 
themselves by changes in the inferior turbinated body. 
1. Chronic engorgement, associated with renal and cardiac 
disease. 
2. Hyperplastic rhinitis, presenting either the ischemic or 
boggy appearance. 
3. Vasomotor conditions, manifested by the rapid alternating 
dilatation and contraction. 
4. Accessory sinus disease. 
5. Atrophic rhinitis. 
6. Syphilis, tuberculosis, sarcoma, carcinoma, and myxoma. 
Histological examination, however, reveals the following prin- 
cipal types. It is possible at times, even by clinical examina- 
tion, to anticipate the microscopic findings. 
1. Turgescence 
2. Hypertrophy 
a. Epithelial 
b. Fibrous 
c. Vascular 
d. Osseous 
3. Atrophy 
Turgescence 
A temporary or chronic engorgement, usually vasomotor or 
infectious, will shrink under cocaine. This change is very fre- 
quently found in certain types of individuals with a very sen- 
sitive and highly reactive nervous mechanism. These same 
individuals are for the most part over-sexed. Clinical examina- 
tion during the period of turgescence shows a large, smooth 
turbinate in its entirety. There is but slight deepening of the 
normal color of the mucous membrane. At times one may see, 
during the same examination, the stage of contraction and the CHRONIC DISEASES OE THE NOSE 
125 
turbinate assume almost a picture of atrophy with an ischemic 
appearance. 
Treatment is directed chiefly to general hygienic measures. 
The galvanocautery at times is helpful. These patients are very 
susceptible to suggestion and it is important to note that no 
operative procedure is indicated. 
Hypertrophy 
Macroscopically the types of hypertrophy appear about the 
same but histologically they are quite different. Although the 
various types are usually combined, one type as a rule pre- 
dominates. 
Fig. 83.—Epithelial hypertrophy of the inferior turbinate with folded-in masses. 
(Low power.) 
a. Epithelial hypertrophy occurs usually in association with 
connective tissue hypertrophy. The most marked hypertrophy 
of the epithelium is found in cases of chronic suppurative sinu- 
itis. It is at times infolded and upon microscopic examination 
appears as lakes or channels (Figs. 83, 84 and 85). It is un- 
usual to find any considerable amount of glandular hypertrophy. 
The treatment is principally surgical in the removal of the 
dragging, redundant mass at the floor of the nose. The actual 126 
APPLIED PATHOLOGY 
cautery may he employed, but the following histologic specimen 
shows the apparent futility of such procedures (Fig. 86). 
Fig. 84.—Same as Fig. 83, high power, showing epithelial lakes. 
Fig. 85.—Hypertrophy of the inferior turbinate, showing marked thickening of the 
epithelium with folded-in masses. (High power.) 
b. Fibrous.—Tlie majority of specimens show connective tis- 
sue predominating; the glands and vessels are frequently de- 
stroyed by pressure necrosis. The papillary changes of the CHRONIC DISEASES OF THE NOSE 
127 
posterior ends are principally made up of connective tissue with 
thick layers of epithelium (Figs. 87 and 88). These are spoken 
Fig. 86.—Eschar following cauterization of the inferior turbinate. Specimen 
taken eleven days afterwards, showing involution of the epithelium and its covering 
with a thick, homogeneous exudate. The original pathologic change in this turbinate 
was epithelial hypertrophy. 
Fig. 87.—Papillary hypertrophy of the inferior turbinate, showing the epithelial 
hypertrophy. 
of as posterior hypertrophies or mulberry enlargements (Figs. 
89 and 90). Clinically the picture is one of persistent ob- 128 
APPLIED PATHOLOGY 
struction rather than alternating and periodical obstruction 
such as is found in the turgescent or the intumescent type. Due 
Fig. 88.—Papillary hypertrophy of the inferior turbinate. 
Fig. 89.—Mulberry hypertrophy of the posterior end of the inferior turbinate 
to these dependent enlargements, particularly posteriorly (Fig. 
91), nasal secretions frequently accumulate and patients often 
describe a sudden dropping of mucus into the throat. They CHliOHIC DISEASES OF THE HOSE 
129 
likewise frequently complain of a sensation of a foreign body in 
the back part of the nose, and develop the habit, on this ac- 
count, of rasping back into the throat. Adrenalin or cocaine 
applied will result in a rather slow contraction, and in the area 
of the dependent enlargements there will be noted very little 
Pig. 90.—Posterior end of the inferior turbinate, showing ‘ ‘ mulberry hypertrophy. ’ ’ 
Pig. 91.—Diffuse papillary hypertrophy of the inferior turbinate. 
change. The periosteum overlying the hone is not infrequently 
involved in the inflammatory process. The bone itself shows 
but little change; in one case, however, we found great rarefac- 
tion (Fig. 92). 
Treatment.—Contrary to the other types of hypertrophy, the 130 
APPLIED PATHOLOGY 
treatment in this type is only surgical. The only caution to he 
exercised is not to remove too much of the bony structure. 
Fig. 92.—Inferior turbinate, showing rarefaction. 
Fig. 93.—Chronic intumescence of the inferior turbinate, showing predominance 
of connective tissue with round cell infiltration of the surface epithelium and almost 
complete atrophy of the glands, together with new blood vessel formation. 
c. Vascular.—In chronic intumescence of the inferior turbin- 
ate, although the connective tissue usually predominates, the 
tissue is somewhat edematous and shows many newly formed CHRONIC DISEASES OF THE NOSE 
131 
blood vessels (Figs. 93 and 91). The epithelium is frequently 
infiltrated with round cells. 
This change may he either primary or secondary to some 
sinus infection or systemic disease of the renal, cardiovascular 
system. The clinical appearance of the turbinate shows a dif- 
fuse swelling of the soft tissue with a preponderance at the 
lower and posterior jmrtions. The color is a deep red and often 
when due to cardiovascular conditions it may appear somewhat 
cyanotic. The obstruction seems to be more marked in varia- 
tion of position of the head and this intermittent blockage is a 
Fig. 94.—Same as Fig. 93, high power. 
frequent symptom. Upon applying cocaine or adrenalin solu- 
tion one will find a rapid contraction, of short duration, of the 
soft tissues. 
Treatment is directed towards determining the causative fac- 
tor, whether it he sinus disease or a cardiovascular change. 
Locally, various deturgescent remedies may he applied, as, for 
instance, 10 per cent ichtliyol-glycerine tampons, allowed to 
remain for ten to fifteen minutes, during which time there will 
be a rather profuse outpouring of secretions. Secondly, the use 
of mild astringents, as 5 to 10 per cent zinc sulphate solutions, 
2 per cent silver nitrate solution, or a similar solution of tannic 
acid is advantageous. A 5 or 10 per cent solution of silvol or 132 
APPLIED PATHOLOGY 
neosilvol is our usual remedy for the patients for home use, 
employed in the Beck postural method of treatment (see Fig. 
13). Should this simple treatment in the course of a few weeks 
not suffice, then ignipunctures with the electric cautery needle 
may be made. These punctures are best made from before back- 
wards, usually four or five in number, equally distributed. As 
a rule this condition is bilateral and but one side should be done 
at a time. Plenty of sterile vaseline should be used as after- 
treatment. Operative procedures, such as the removal of any 
part of the turbinate or dee}! linear cauterization, are contraindi- 
cated, yet the latter is the procedure most frequently employed. 
Fig. 95.—Beck’s concliotribe. 
As an extreme measure in a limited number of cases we have 
used the Beck concliotribe (Fig. 95), with which the tissue is 
squeezed to a pulp. This pulp subsequently becomes more or 
less absorbed without granulation tissue formation. Sections 
taken at intervals of these hypertrophies so crushed have shown 
on the third day (the height of the reaction) marked round-cell 
infiltration and areas of necrobiosis (Fig. 96). On the tenth day 
the tissue is practically all shrunken and but little evidence of 
organized tissue remains. Macroscopically after repair has 
taken place the turbinate appears reduced in size and charac- 
teristically rounded and smooth surfaced. When the galvano- 
cautery is used there is usually involution of the epithelium and CHRONIC DISEASES OF THE NOSE 
133 
considerable leucocytic infiltration along the margins of the 
cautery incision (Fig. 97). 
Fig. 96.—Crushing of the inferior turbinate (conchotribe) ; section taken on the 
third day showing marked round cell infiltrated masses of necrobiosis. 
Fig. 97.—Eschar of the inferior turbinate following actual cautery in a case 
of vascular hypertrophy, showing fibrinous organization and papillary formation, 
together with marked leucocytic infiltration. 
d. Osseous.—There are seldom osseous changes, although oc- 
casionally in marked suppurative sinus disease there is an ostei- 
tis present. 134 
APPLIED PATHOLOGY 
Atrophy 
A tendency towards atrophy of the turbinate is occasionally 
seen in cases of chronic sinuitis. In the borderline cases of this 
type it may be difficult to differentiate between this and a true 
atrophic rhinitis. The pathology varies but in degree; however, 
in the former there does not seem to be any primary hyper- 
trophy. 
Atrophic Rhinitis 
Whether or not the term atrophic rhinitis is a misnomer, it is 
generally accepted and applied to a distinct disease entity mani- 
Fig. 98.—Atrophy of the turbinates in atrophic rhinitis. 
fested clinically by a foul odor (ozena) and extensive crust for- 
mation in tlie nose. Whatever possibility we may favor as to 
its etiology, i. e., a specific infection or secondary to a purulent 
rhinitis or accessory sinus disease, or a faulty local development, 
syphilis, or as a local manifestation of some other disturbance— 
the ultimate pathologic examination reveals the one picture. 
Macroscopically the turbinates, particularly the inferior, appear 
small and collapsed (Fig. 98). Early the mucous membranes ap- CHRONIC DISEASES OF THE NOSE 
135 
pear gelatinous-like, later dry and pale. The crust formation 
and odor are prominent features. Microscopically, in the early 
Fig. 99.—Inferior turbinate and early atrophic rhinitis, showing distention of the 
glands. The bone appears normal in structure. 
Fig. 100.—Inferior turbinate and early atrophic rhinitis, showing metaplasia 
of the epithelium of the median side and thickening of the antral side. The mucous 
glands are still present, although distended. 
stages, there is an actual hypertrophy, particularly of the glands. 
These later become markedly distended and by this process lose 136 
APPLIED PATHOLOGY 
their function (Fig. 99). The lining ciliated epithelium becomes 
squamous in type, while the tissue lining the antral side shows 
marked thickening (Fig. 100). The principal change is in the 
bone; i. e., the early disappearance of the marrow spaces (Fig. 
101). In the early period the mucous membrane is covered with 
a mucilaginous secretion, frequently spanning over to the sep- 
tum. After this is wiped off the surface, the glazed appearance 
of the turbinate is in evidence. Very rapidly there seems to be 
a flattening of the bony structure and a corresponding atrophy 
over it. Finally there is almost complete disappearance of the 
Fig. 101.—Middle turbinate in early atrophic rhinitis, showing metaplasia of the 
epithelium and disappearance of marrow spaces. (With apologies for artifacts in 
specimen.) 
inferior turbinate; simply a small ledge remains along its entire 
attachment (Fig. 98). 
The persistent crust formation in the form of definite casts is 
quite pathognomonic and frequently at their forcible removal, 
either by the patient or mechanically, denuded areas will be 
seen. The changes in general appear to be due to nutritional 
disturbance, such as the early increase of connective tissue, dis- 
appearance of the mucous glands, fatty degeneration and des- 
quamation of the epithelium. Secondary infection always takes 
place and nonpathogenic organisms can be isolated. The bac- CHRONIC DISEASES OF THE NOSE 
137 
terial flora is made up of many staphylococci and many varieties 
of bacilli. The bacillus fetidus ozena (putrefactive organism) 
has been considered a specific cause of the disease. The crusts 
when examined show microscopically a great deal of fibrin in 
the meshes of which are many dead epithelial cells and leuco- 
cytes. 
We believe that the type of pathologic change suggests that 
the disorder is a manifestation of some nutritional disturbance. 
Although an associated sinus disease can usually be found, we 
do not believe that there is a direct connection between the two 
conditions. Nevertheless, in the treatment of this condition 
attention must also be directed to the sinus disease if it is pres- 
ent. A number of years ago Beck and Pollock brought out in 
their investigation of this condition the marked deficiency in 
the fibrin content of the blood, and expressed the hypothesis 
that there might be some disturbance in the glands of internal 
secretion, perhaps the thyroid. Since that time the basal 
metabolism test has been made on a number of these patients 
and a minus metabolism rate of from 15 to 40 has been found 
almost routinely. We have therefore added, in the treatment 
of this condition, polyglandular substances—as thyroid, pitu- 
itrin, adrenalin, ovarian or testicular extracts. 
Locally, the cleansing of the ethmoid labyrinth and the irri- 
gation of the antrum adds considerably to the comfort of the 
patient. At this time, as a routine, we add autotransplants of 
costal cartilage, placing them in a submucously dissected pocket 
in order to lessen the air space. 
For the patient’s home use we advise the application of vase- 
line to soften the crusts and should irrigation become neces- 
sary, special instructions must be given to avoid ear complica- 
tions from autoinflation. Alkaline or normal salt solutions are 
to be preferred. For controlling the putrefaction, a 10 per cent 
glucose solution in glycerine is given, which is instilled into the 
nose according to the postural method of treatment, or tampons 
soaked in the solution may be used. We have found vaccines 
of all kinds of practically no value. The complications of this 
disease are secondary atrophic pharyngitis, laryngitis, and 
tracheitis. Autoinflation otitis media from the forcible blowing 
of the nose is not at all uncommon. 138 
APPLIED PATHOLOGY 
The social side of this disease must be considered, for the 
individual is very conscious of his affliction and is shunned by 
others. Employment is difficult to obtain, especially when it 
entails personal contact with others, and marital difficulties are 
often encountered. Instances have been reported where sepa- 
rate maintenance has been granted by the court based on the 
claim of the impossibility of living together because of the fetor. 
Hyperplasia 
Associated with hyperplastic sinuitis, in which the ethmoid 
labyrinth, including the middle turbinate body, is involved, there 
Fig. 102.—Apparently true myxomatous polypi of the inferior turbinate; showing 
also rarefaction of the bone. 
is frequently observed a similar process of the inferior turbinate. 
The gross appearance of such a change is a boggy or edematous 
pale inferior turbinate. The microscopic examination reveals 
the bone rarefied, the mucous glands sparse and the greater por- 
tion of the soft tissue not unlike the structure of a myxomatous 
nasal polyp (Fig. 102). 
New Growths of the Inferior Turbinate 
Sarcoma and carcinoma involving tlie inferior turbinate are 
usually secondary to that of the antrum, nasopharynx or the CHEOHIC DISEASES OF THE HOSE 
139 
superior maxilla. True myxoma or polypi of the inferior tur- 
binate are uncommon. They are to be distinguished from in- 
flammatory edema of the anterior or posterior end. We have 
had one case of a primary solitary carcinoma of the inferior 
turbinate in a Chinaman, in which the microscopic picture was 
melanotic in character. The treatment of malignant growths in 
this region is radical surgery, supplemented by x-ray or radium. 
Lupus or Tuberculosis of the Inferior Turbinate 
We have had one case of lupus of the inferior turbinate which 
was extensively described by Ballenger in his text book. It is 
interesting to note that this particular patient established her 
home on an island off the coast of Florida and continued to 
expose her face, especially the nostrils, to the sun’s rays daily 
for an interval of an hour or two. Within two years, when we 
again observed her, the ulcerations had healed, leaving a smooth 
cicatrix and she has remained cured. 
Syphilis of the Inferior Turbinate 
Syphilitic changes in the later stages are manifest as granula- 
tions, exudates and sequestra. The former show the same pic- 
ture microscopically as elsewhere in the body, but the exudate 
lacks the round cell infiltration as in luetic exudates elsewhere. 
(See Fig. 78.) This condition is, as a rule, always associated 
with a luetic ozena, the characteristics of which are ulceration 
of the mucous membrane and bone destruction. The diagnosis 
can be confirmed by a strongly positive Wassermann reaction 
and the treatment is correspondingly antiluetic. Locally, the 
cleansing methods should be employed. 
CHRONIC RHINOSINUITIS 
As in tlie acute, so may we in the chronic conditions accept 
the statement that chronic rhinitis is also usually sinuitis. It 
is a fact, however, that we may have isolated or predominating 
symptoms and findings of one or the other sinus. It is certainly 
true as far as one or the other side of the nose is concerned. 
Again, the subdivision of the anterior or posterior group of 
sinuses, so splendidly divided by the anatomical structure, the 140 
APPLIED PATHOLOGY 
middle turbinate, can well be thought of as limiting the disease 
to those parts. The infection of one isolated sinus or cell is not 
likely to occur unless it be the antrum of Highmore and that of 
dental origin, and even this will not remain very long without 
involving at least the ethmoid cells by extension. 
As to the frequency of infection of the sinuses, there is a great 
variance of opinion among authors, and our statistics would 
show about as follows: Unilateral sinus infection about four 
times as frequent as bilateral, the anterior group (frontal, 
anterior ethmoid and antrum) about ten times as frequent as 
posterior group (posterior ethmoid and sphenoid). In regard 
to the frequency of infection of the various sinuses of the an- 
terior group, we feel that the antrum of Highmore shows posi- 
tive evidence of infection more frequently than either the 
anterior ethmoid or frontal. This perhaps is caused by dental 
infections extending to this structure. The ethmoid labyrinth 
is next in frequency affected, and then the frontal sinus. On 
account of the lack of symptoms, particularly pain or discom- 
fort, when the antrum and ethmoid are affected, the majority 
of patients do not present themselves until they have the symp- 
tom of pain referring to the frontal sinus. This explains to us 
the discrepancy in the statistics as to which sinus is most fre- 
quently involved. 
From the pathologic point of view rliinosinuitis must be 
divided into various types, principally the suppurative or non- 
suppurative (hypoplastic rliinosinuitis). The suppurative is 
then subdivided into the pyogenic, tuberculous, syphilitic, rhino- 
scleroma, actinomycotic. Aside from the simple pyogenic 
variety, the other forms are quite rare. There are certain 
generalities that apply to all chronic rliinosinuitis, and then 
characteristics that are typical of one type or the other. All 
chronic sinus diseases are associated with discharge, pain or 
headache, disturbance of the sense of smell, respiratory dis- 
turbance, light obstruction and radio-obstruction, disturbances 
of visual apparatus. 
Pathology of Individual Structures 
1. Middle Turbinate.—In chronic suppurative sinuitis (pyo- 
genic) local examination shows the middle turbinate to be dif- CHRONIC DISEASES OF THE NOSE 
141 
fusely enlarged, the mucous membrane injected and thickened, 
usually covered with streaks of pus. When it is severed during 
Fig. 103.-—Chronic hypertrophy of the middle turbinate in chronic suppurative 
sinuitis, showing an increase in the normal tissue elements with preservation of the 
glands. 
rig. 104.—Glandular hypertrophy of the middle turbinate, showing besides 
the increase in glandular elements a rarefying osteitis. Case is one of chronic 
suppurative ethmoiditis. 
therapeutic measures, it cuts through easier than normal, indi- 
cating bone inflammation. The findings in the microscopic exam- 142 
APPLIED PATHOLOGY 
ination will depend on the length of time the disease has existed. 
The epithelium is thickened early, and leucocytic infiltration oc- 
curs in irregular distributions. The glands are fairly well pre- 
served (Fig. 103), the hone shows but slight change; later the 
inflammatory process permeates the soft structures so that the 
glandular apparatus is very much damaged and its place is taken 
by young and old connective tissue. The bone is considerably 
rarefied (Fig. 104) but inflamed, that is to say, the lime salts 
have been removed by the infection. Not alone is the epithe- 
lium thickened, but it is in many places destroyed and replaced 
by connective tissue. In the event of the conditions being 
syphilitic, tuberculous, rhinoscleromatous, or actinomycotic, one 
will hope to find the histological characteristics of these dis- 
eases. Rarely is it that the Spiroclieta pallida, the tubercle 
bacillus, the bacillus of Frisch (or the bacillus of rhinoscleroma) 
or the ray fungus can be demonstrated in the nasal discharges, 
and histology and serology will have to be depended upon for 
diagnosis. 
2. Ethmoid Labyrinth.—-Usually after the middle turbinate 
body has been removed the principal mesial placed cells will be 
found (bulla naso-frontalis, ethmoidalis, and processus unci- 
natus) covered with a similarly infected thickened mucous 
membrane. On cutting into these cells at operation the operator 
will note the degree of inflammation and softening that has 
taken place. In many instances free escape of pus from the 
individual cells will be encountered, and on examination of the 
particles removed true granulation is often found. This form 
of ethmoiditis has been recognized as a necrosing variety. At 
the completion of the ethmoidectomy to the lateral orbital wall, 
the nature of the wall can be determined by palpation with a 
blunt instrument. In markedly progressive cases, it has been 
found to be soft, giving the sensation of wet pasteboard. 
Microscopic examination of particles of ethmoid cells removed 
will show the varieties or degrees of inflammation and the epi- 
thelium thickened, round, with leucocytic cellular infiltration. 
The bone varies from a rarefied state of inflammation (Fig. 105) 
to that of complete necrosis with pus infiltration (Fig. 106), 
and true findings of granulations in many places. The bacteri- CHRONIC DISEASES OF THE NOSE 
143 
ologic examination of the pus will usually reveal a mixed infec- 
tion in which the staphylococcus pyogenes predominate. 
From the above-described pathologic pictures the conclusion 
must be drawn that in the majority of instances conservative 
treatment, such as washing, suction and local application, will 
Fig. 105.—Rarefying osteitis of the ethmoids in suppurative sinuitis. 
Fig. 106.—Ethmoid eurettements in chronic suppurative cthmoiditis, showing areas 
of bone necrosis. 
be of very little benefit; in fact, only the most thorough removal 
of all the cells, because in most instances all the cells are in- 
fected, should be considered. It is true that the anatomical 
configuration of the ethmoid labyrinth is such that not all the 
cells can be reached by the usual route (intranasal) but the 
above treatment refers to all cells that can be reached thus. 144 
APPLIED PATHOLOG Y 
Again, no reference has been made as to a division between the 
anterior and posterior ethmoidal cells because, invariably, they 
are considered as one, namely, the ethmoid labyrinth, and are 
operated upon at the same time. For technic employed, the 
reader is referred to Loeb’s text book on “Surgery of Ear, Nose 
and Throat.” 
3. The Other Sinus Cavities.—The pathologic changes in the 
cavities of the frontal, the antrum, and sphenoid will vary but 
little, since these cavities are all rigid, noncollapsible spaces, 
lined by modified mucous membrane which serves as their 
periosteum. They have only one opening for the inlet and out- 
let for air, for drainage, and ventilation. The only exception is 
the antrum of Highmore where at times accessory openings are 
found. The location of the natural openings of the sinuses be- 
ing in each instance apparently unfavorably placed, usually 
high, would lead one to suspect that this is an important factor 
in the resultant pathologic changes. The pathology of these 
outlets will be considered separately from the cavities them- 
selves. This is especially important in relation to the frontal 
sinus, the opening of which is in reality a channel—the nasal 
frontal duct. 
(a) The anatomical configuration of the nasal frontal duct is 
so important in the pathology and treatment of the frontal sinus, 
that we shall review this phase. 
Anatomical consideration of the various structures of the 
ethmoid and frontal bone would be necessary to elucidate the 
subject if surgical technic were being discussed, but for the pur- 
pose of bringing out the pathological significance as it applies 
to diagnosis and treatment, it will suffice to say that that portion 
of the frontal bone where it joins the nasal bones, namely, the 
internal nasal crest, is the most important. The reactions of the 
bone of this nasal crest to infections are quite different from the 
reactions of the bones of the ethmoid cells. The mucous mem- 
brane, particularly at the recessus frontalis of Killian, which is 
a sharply outlined fossa into which the frontal sinus opens, is 
the most important in relation to blockage to the outlet of the 
frontal sinus. 
The fact that the mucosa is very richly supplied with blood 
in this locality and serves as the periosteum of the duct, will CHRONIC DISEASES OF THE NOSE 
145 
explain the ease with which reaction occurs from inflammations, 
and the persistence in the pathology in the form of swelling 
which leads to permanent changes within the sinus. Necroses of 
the bony walls of this duct are not at all uncommon, and the 
reparative changes following surgical procedures are significant 
in their bony proliferations. 
(b) The ostium maxillaris or opening of the antrum of High- 
more being formed by two elliptical thickenings of bone and 
covered by a mucous membrane, makes it also subject to easy 
closure. Frequently from the continuous outpouring of pus 
Fig. 107.—Lining membrane of the frontal sinus in chronic suppurative pansinuitis, 
showing infiltration and thickening, with areas of myxomatous degeneration. 
from this opening the bone is irritated to growths, and a path- 
ologic entity has been described by Kaufman (Prague) as 
osteopliytic growths of the ostium-maxillarae. 
(c) The sphenoid opening, located in practically the highest 
point of the sinus, is simplest of all considered from the patho- 
logic standpoint, in that it is very large and made up prac- 
tically of two layers of mucous membrane, (1) that lining the 
cavity and (2) mucous membrane of the nose. Therefore, very 
rarely is it subject to closure. The reason given for the fre- 
quency of sphenoid sinus disease is its depth which subjects it 
to retention. 146 
APPLIED PATHOLOGY 
The lining membrane of the cavities themselves is subject to 
the changes indicated in the legends of Figs. 107-112: micro- 
Fig. 108.—Solitary polyp in the frontal sinus in a case of chronic suppurative 
sinuitis, showing areas of myxomatous degeneration. 
Fig. 109.—Same as 10S (high power). 
scopically tlie epithelium thickens, tlie subepithelial tissue be- 
comes infiltrated with pus and round cells and leucocytes, and CHRONIC DISEASES OF THE NOSE 
147 
the deeper part of the structure is transformed into a structure 
not unlike granulations. That, of course, is the more pro- 
Fig. 110.—Pyogenic membrane lining this antrum of Highmore in chronic, sup- 
purative pansinuitis, showing practically a leucocytic wall. 
Fig. 111.—Anterior wall of the sphenoid with chronic suppurative pansinuitis, show- 
ing connective tissue fibrosis. The bone is not involved to any extent. 
nounced picture. In many instances one will discover this 
preservation of some of the mucous glands. Not infrequently 148 
APPLIED PATHOLOGY 
degenerative processes, such as myxoma, are observed. The 
membrane is thickened, very much infected, and covered with 
mucopus. Small areas of epithelial denudation are irregularly 
Fig. 112.—Pyogenic membrane lining the sphenoid in chronic suppurative sinuitis. 
Fig. 113.—Tooth with granuloma attached extending to the antrum, removed in case 
of unilateral chronic suppuration of the antrum and ethmoid sinuses. 
distributed and if tlie bone is examined at these locations, def- 
inite evidences of surface necrosis will be found. In very 
markedly advanced suppuration of the cavity, it will be found 
completely filled out with this thickened material, not unlike CHRONIC DISEASES OF THE NOSE 
149 
a polypus; but, histologically, as will be shown, it is not that. 
In the antrum of Highmore it is necessary to emphasize the 
pathology in the vicinity of the apices of the teeth reaching this 
cavity. The mucous membrane may be entirely wanting, and 
a granulation containing a fistula may lead to the infected apex 
of the tooth (Fig. 113). Special attention must be called to the 
pathologic changes within the sphenoid as well as to the body 
of the sphenoid proper. We have observed a fair number of 
cases, clinically, and one postmortem, in which this bone was so 
softened, due to the process of septic absorption, that a definite 
diagnostic method was developed, namely transmitted pulsation 
from the carotid artery, that could be observed in the region of 
the sphenoid. This was described as an entity by Dr. H. L. 
Pollock as pulsating splienoiditis. It is perhaps only coincident, 
but a fact, that the majority of the cases of pulsating sphenoids 
in which there is pus present are syphilitic and may have posi- 
tive Wassermanns. 
Hyperplastic Rhinosinuitis 
Hyperplastic rhinosinuitis is a very common occurrence and 
lias sucli a clear clinical picture that there can scarcely be an 
excuse for an error in diagnosis. We have already called atten- 
tion to this pathologic entity in the septum and inferior tur- 
binate body. The same process in the bone and mucous mem- 
brane takes place in the middle turbinate and nasal accessory 
sinuses, particularly the ethmoid labyrinth. Clinically the 
patients present themselves with a definite history of nasal ob- 
struction, especially in the upper straits of the nose, attacks of 
sneezing from five to twenty-five times in succession, followed 
by a diffuse watery discharge, at times requiring the use of 
three or four handkerchiefs. These patients invariably com- 
plain about their eyes, and headache is rarely ever wanting, 
not only headache, but actual neuralgic pains about the head 
and face. The sense of smell is affected and in most instances it 
is absent (anosmia) or noticeably deficient (hyposmia). In 
some it is exaggerated (hyperosmia or parosmia) and in others 
it is perverted (kakosmia). 
The examination is definite and striking, in that the nose is 
crowded with pale, waterlogged, thick mucous membrane. In- 150 
APPLIED PATHOLOGY 
Fig. 114.—Multiple polypi under the middle turbinate in early hyperplastic 
ethmoiditis. 
Fig. 115.—Solitary sphenoid polyp. CHRONIC DISEASES OF THE NOSE 
151 
variably there are polypi present of variable size (Fig. 114), in 
some instances so large as to protrude externally through the 
anterior naris, and posteriorly through the nasal pharynx (Figs. 
115 and 116). One of the most frequent associated general con- 
ditions, and not yet well understood, is bronchial asthma. 
Macroscopically, the nasal polypi are invariably multiple, may 
Fig. 116.—Sphenoid polyp. 
Fig. 117.—Solitary pedunculated fibrous polyp removed from the naso-frontal duct, 
in case of chronic nonsuppurative sinuitis. 
be pedunculated (Fig. 117) or sessile. They are grayish white 
in appearance, and when sectioned, permit the escape of a 
watery substance. Only very thin capillaries are found on the 
surface. Histologically, each polypus has its capsule and stroma 
of fibrous tissue within which there are cyst formations (Fig. 
118) of variable sizes. The blood vessels are very scanty and 152 
APPLIED PATHOLOGY 
only demonstrable on the capsule. There is no evidence of any 
nerve supply. The mucous membrane of the middle turbinate 
may itself undergo a similar myxomatous change to that seen 
in the polypi (Fig. 119), although in most instances there still 
remains considerable resemblance to a mucous membrane in 
Fig. 118.—Cystic formation in a nasal polyp in nonsuppurative sinuitis. 
Fig. 119.—Polyp arising from middle turbinate proper. 
that the epithelium is fairly well preserved, the subepitlielial 
tissue up to the hone appears to he in a state of edema (Fig. 
120), and there is leucocytic infiltration (Fig. 121). The hone 
itself is invariably rarefied with large marrow spaces. Some- 
times one of these marrow' spaces is so distended as to form a CHRONIC DISEASES OF THE NOSE 
153 
bony bleb (called turbina bullosa) (Figs. 122, 123, and 124). 
The lining of this bulla (bleb) is endothelial and the fluid con- 
Fig. 120.—Anterior end of the middle turbinate removed in a case of hyperplastic 
ethmoiditis, showing the loss of glandu.ar structure and fibrous changes. 
Fig. 121.—Middle turbinate in nonsuppurative ginuitis, showing degenerated glands 
and infiltrated mucous membrane. 
tained therein is of a gelatinous homogeneous character. The 
ethmoid labyrinth is in a similar rarefied bony condition and 154 
APPLIED PATHOLOGY 
Fig. 122.—Turbina bullosa of the anterior end of the middle turbinate. 
Fig. 123.—Same as Fig. 122 (sagittal section). Turbina bullosa. 
when broken into will be found to be tilled either with crowded 
small polypi or myxomatous degeneration (Fig. 125). In open- 
ing any of the nasal accessory cavities, one will find the same CHRONIC DISEASES OF THE NOSE 
155 
type of degenerated mucous membrane and very frequently 
polypi are present or even crowded within the cavity. 
Fig. 124.—Cyst of the middle turbinate. 
Fig. 125.—Ethmoid mass in case of chronic nonsuppurative ethmoiditis, showing 
no differentiation but practically complete myxomatous degeneration and some 
vacuolization. 
The Middle Turbinate and Sinuses in Atrophic Rhinitis 
The same changes that are observed in the inferior turbinate 
take place in the middle turbinate, except very much later, and 
never to the same extent as in the inferior turbinate. The his- 
tological examination of the mucous membrane appears to show 
a persistence in the mucous glands; however, the epithelium 156 
APPLIED PATHOLOGY 
shows that same metaplastic variety (Fig. 126). The sinuses, 
particularly the ethmoid labyrinth, appear to be infected, but 
Fig. 126.—Middle turbinate in early atrophic rhinitis, showing metaplasia of the 
epithelium and persistence of mucous glands. 
Fig. 127.—Nasal polyp, removed in chronic suppurative pansinuitis, showing 
myxomatous degeneration. 
whether this is a primary or secondary disease has not been 
determined. All the sinuses are smaller in size and in many 157 
CHRONIC DISEASES OF THE NOSE 
instances the radiogram shows the absence of the frontal sinus; 
histologically, the bony structures appear to have little if any 
of the marrow spaces compared to the normal. 
Summary 
In summarizing the various chronic pathologic states, it 
must not be overlooked that very frequently chronic hyper- 
plastic sinuitis can become infected and so transformed into a 
chronic suppurative hyperplastic sinuitis, showing pathologic 
evidences of both conditions (Fig. 127), viz., hyperplastic and 
suppurative. Again, a chronic sinuitis does very frequently 
take on an acute exacerbation in which the pathology will show 
the evidences of chronic, as well as the acute, conditions (refer 
to chapter on acute inflammation). 
SARCOMA OF THE SINUSES 
We have already alluded to this subject in connection with 
sarcoma of the external nose, but as an entity confined to the 
sinuses, it is in the antrum that we have met the disease most 
Figs. 128-152.—Sarcoma of the antrum treated by surgery, x-ray and radium. (For 
description see text.) 
Fig. 128. 
Fig. 129. 
frequently. As to its origin, we feel that it springs most prob- 
ably from the junction of the posterior ethmoid and antral wall. 158 
APPLIED PATHOLOGY 
Fig. 130. 
Fig. 131. 
Fig. 132. 
Fig. 133. 
Fig. 134. 
Fig. 135. CHRONIC DISEASES OF THE NOSE 
159 
Fig. 136. 
Fig. 137. 
Fig. 138. 
.Fig. 139. 
Fig. 140. 
Fig. 141. 160 
APPLIED PATHOLOGY 
One of the most pronounced and interesting cases of sarcoma 
of the sinuses that we have observed, had its origin from the 
alveolar process. The course of this case will be best studied 
from the photographs (which in our practice are always stereo- 
scopic photographs) taken at various times during the three 
Fig. 142. 
Fig. 143. 
Fig. 144. 
Fig. 145. 
years we observed and treated the patient (Figs. 128 to 152). 
(128) When first presented (June 19, 1920). (129) Radium 
needling result (June 24, 1920). (130) Recession of growth 
(July 1,1920). (131) Perforation into antrum (August 6,1920). 
(132) Flattening out of growth and loss of teeth (November 30, 
1920). (133) Growth returning (January 18, 1921). (134) CHRONIC DISEASES OF THE NOSE 
161 
Greater recurrence (July 30, 1921). (135) Progress of growth 
into antrum (November 6,1921). (136) Growth showing ulcera- 
tion (November 6, 1921). (137) Reoperated and specimens 
showing maxilla (November 9, 1921). (138) Radical exentera- 
tion—partial resection of upper jaw (November 15, 1921). 
Fig. 146. 
Fig. 147. 
Fig. 148. 
Fig. 149. 
(139) Artificial prothesis improving feeding and speech (No- 
vember 14, 1921). (140) Recurrence and more tissue removed 
by cautery (December 3, 1921). (141) Recurrence in two weeks 
(December 21, 1921). (142) Greater recurrence showing exter- 
nally (December 21, 1921). (143) Tissue removed (December 162 
APPLIED PATHOLOGY 
24, 1921). (144) Massive dose of radium applied internally and 
externally with (Dose 150 mg. for 24 lirs.) checking of growth. 
Plus x-ray (S. W. L.) (February 11, 1922). (145) Reaction 
following—skin discolored, eye intact (June 30, 1922). (146) 
Beginning fistula externally below orbit (July 7, 1922). (147) 
No growth showing in cavity (July 7, 1922). (148) Deformity 
Fig. 150. 
Fig. 151. 
Fig. 152. 
following destruction (September 7, 1922). (119) Greater de- 
formity—eye motility and vision remaining normal (October 
18, 1922). (150) Greater external destruction; small tendency 
to recurrences, easily controlled by radium (January 4, 1923). 
(151 and 152) Greater destruction to exitus from general weak- 
ness; but no evidence of recurrence (January 4-15, 1923). CHEOHIC DISEASES OF THE HOSE 
163 
In the majority of instances the tumor is confined to one side 
of the nose and sinuses, but in several instances that we have 
Fig. 153.—Spindle cell sarcoma of the anterior wall of the antrum of Highmore, 
associated with chronic suppuration. 
Fig. 154.—Large, small, round, and spindle cell sarcoma of the antrum. 
observed, tlie septum was destroyed in the process and the other 
side was subsequently involved. When the progress of the 
growth of tliis neoplasm is backwards towards the sphenoid and 164 
APPLIED PATHOLOGY 
apex of the orbit, there will be observed additional symptoms 
referable to the nerve supply of the eye muscles (paralysis of 
Fig. 155.—Sarcoma of the nose, showing a highly vascular growth, 
Fig. 156.—Melanosarcoma, high power. The pigment granules are clearly seen in 
the cells. 
the recti). These cases develop very early meningeal involve- 
ment and die from extension of the growth. One of our sphe- 
noid sarcoma cases simulated very much a hypophyseal neo- CHROXIC DISEASES OF THE HOSE 
165 
plasm. This patient was treated with radium needles and very 
rapidly succumbed to meningitis. In another sphenoid sar- 
coma, involvement of the carotid artery was followed by a 
spontaneous rupture of the vessel with uncontrollable hemor- 
rhage and death. Macroscopieally the growth appears so char- 
acteristic that it leaves no doubt in diagnosis. Frequently par- 
ticles of the bony structures, especially when in the region of 
the antrum, are found within the tumor mass. The bone itself 
may well preserve its structural characteristics (Fig. 153). The 
histological changes vary from that of small spindle cell, to 
Fig. 157.—Radium exudate in the same case as in Fig. 156. The exudate consists 
chiefly of fibrin and distintegrated cells. 
that of large spindle cell, round cell and mixed cell (Fig. 154). 
At times the sarcoma contains many blood lakes and vessels 
(Fig. 155). Very rarely are found tumors containing the giant 
melanotic cells which give the poorest prognosis because of 
their rapid destruction (Fig. 156). Following radium treat- 
ment of sarcoma marked exudates form which differ from exu- 
dates due to other causes as well as radium exudates in other 
pathologic structures (Fig. 157). 
Treatment.—In the treatment, aside from surgery, radium 
and x-ray, Coley’s toxin has been employed by us without any 166 
APPLIED PATHOLOGY 
appreciable benefit. Electrothermic coagulation, either by the 
fulguration or the surgical diathermic methods, has been em- 
ployed by us with more or less success. 
The various complications that may result during the course 
of the disease or during treatment such as hemorrhage, pain, 
toxemia (particularly the radiation toxemia), anemia and the 
ultimate deformities, should be met with by the accepted meth- 
ods. Glandular metastases we have not observed, but when 
regional adenopathy occurs, it is taken to be of infectious origin 
in contradistinction to carcinoma, where metastases are very 
frequently met with. CHAPTER IX 
NASOPHARYNX AND OROPHARYNX 
The most frequent chronic pathologic conditions within the 
nasopharynx or oropharynx are the adenoid changes, and since 
the synrptom-conqdex, as well as the treatment, is so closely 
associated with chronic tonsillar disease, it will be more prac- 
tical to describe these conditions as an entity, namely, tonsil 
and adenoid diseases, in a subsequent subhead. 
1. CHRONIC TUBITIS 
As a sequence to acute conditions of inflammation of tlie 
ostium tubae there remains a marked thickening of both the 
lips and the contiguous mucous membrane of the tube at least 
as far as the isthmus. Either direct or indirect inspection 
shows a chronic engorgement, and often a plug of glairy mucus 
within the opening of the tube. Digital palpation will give the 
impression of stiffness, compared to a normal tube. 
Treatment.—The treatment is entirely antiphlogistic, and the 
best means is to apply directly by nasal route, cotton applicators 
saturated with ichtliyol and glycerine in and about the lips and 
mouth of the tube. After a course of a week or two of such 
treatment the direct application of a weak solution of silver 
nitrate (2 to 5 per cent) to the tube, will further relieve the 
inflammatory process. Subsequently finger massage by way of 
the mouth will hasten the absorption of the chronic inflamma- 
tory products. The use of a eustacliian catheter for the treat- 
ment of the tubal inflammation proper is to be preferred. The 
ichtliyol and glycerine can thus be introduced by way of the 
catheter, and the silver nitrate also, although it is preferable to 
employ a flexible silver wire probe, a small pledget of cotton 
which is saturated with the silver nitrate solution being wound 
on the rough end. This being passed through the catheter, 
through the lumen of the tube as far as the isthmus, can be 
allowed to remain in situ for a minute or two. It must be stated 
167 168 
APPLIED PATHOLOGY 
here that this process rarely limits itself to the area described, 
but extends on through the remains of the tube, into the cavum 
tympani, causing the pathologic changes which will be taken up 
later. 
2. PHARYNGITIS—LATERALIS HYPERTROPHICUS 
Pharyngitis is one of the commonest forms of chronic inflam- 
mation found in an adult, and one that is capable of producing 
a great variety of symptoms. Inspection usually reveals a mass 
of thickened mucous membrane behind the posterior pillar of 
Fig. 158.—Lateral pharyngitis (chronic) showing thickened epithelium, bone, lym 
phoid tissue, round-celled infiltration and old connective tissue. 
the fauces, incorporating it. It extends from the lowest portion 
of this pillar upwards, as far as the eustacliian orifice and even 
behind the posterior lip into the Rosenmueller fossa. On very 
close inspection one can frequently see lymphoid masses in this 
structure, especially behind the soft palate. Histologically, it 
is made up principally of markedly thickened mucous mem- 
brane, rich in mucous gland and lymphoid tissues. The sub- 
epithelial tissue is much increased in connective tissue of all 
varieties from round cell to senescence (Fig. 158). The treat- 
ment is most satisfactorily accomplished by the removal either 
by actual cautery or excision. In order to reach every part of it, NASOPHARYNX AND OROPHARYNX 
169 
especially that about the eustacliian tube, it is best to pass a 
urethral rubber catheter through the nose and out through the 
mouth, drawing the catheter forward laterally and upward, thus 
exposing the area to be treated either by direct inspection or 
by the aid of a postnasal mirror (Fig. 159). 
Fig. 159. 
3. ATROPHIC PHARYNGITIS 
Atrophic pharyngitis is most frequently secondary to either 
a chronic suppurative sinus disease or atrophic rhinitis. Clini- 
cal examination shows the surface to he dry and somewhat 
glazed in appearance. It is of a deep red color, and in the 
effort of swallowing the motion of the mucous membrane is 
limited. Although this process is principally confined to the 
na,so- and oro-pliarynx, yet not infrequently will one observe 
the extension into the larynx, especially on the side of the vocal 
cords. In this particular location more often than in the oro- 
pharynx, crust formation develops; however, in the naso- 
pharynx this finding is not at all infrequent. Histologically the 
prominent change is the marked round-cell infiltration with the 
loss of the surface epithelium, and wasting of the mucous glands, 
while the blood vessels are very markedly increased in size and 
number. 
Treatment.—Treatment may be divided into two types, al- 
though both are essential: (a) to the etiologic factor, namely, 170 
APPLIED PATH OLOG V 
the sinus disease or atrophic rhinitis, and (b) directly to the 
atrophic process of the throat. 
The local treatment that has given us the most satisfactory 
result, especially from the annoying symptom of dryness, has 
been digital massage by means of a rough finger cot. It may 
be dipped into an oily solution to prevent trauma. The topical 
application to the entire pharynx, by means of cotton wound 
probes, of Mendel’s solution is still one of the most accepted 
methods of treatment. 
Iodine crystals 1 gr. 
Potassium iodide crystals 10 gr. 
Glycerine to make an ounce. 
The patient will obtain a great deal of relief from the instilla- 
tion through the nose, with the head tilted back, of a solution 
of glucose in glycerine (10 per cent). 
4. THORNWALDT’S DISEASE 
(Chronic Bursitis) 
Thornwaldt ’s disease is comparatively rare and yet very fre- 
quently overlooked because tlie one cardinal symptom and find- 
ing is not recognized; namely, the periodical uncontrollable 
outpouring of a stagnant fluid. If one be fortunate enough to 
have the patient return this fluid, the examination will reveal the 
following characteristics—acid in reaction, rusty in appearance, 
foul odor, and if it is permitted to sediment in a conical glass 
or centrifuge, it will reveal microscopically clumps of mucus, 
many varieties of bacteria, some red blood corpuscles. The 
bursa, which is an embryonic remnant or incomplete closure of 
the recess which is formed at the shutting off of the sella tur- 
cica, becomes infected. The constant accumulation of fluid 
causes further increase in size by distention and acts mechani- 
cally not at all unlike an esophageal diverticulum. 
Inspection, either direct or indirect method, will show in the 
median line of the nasopharynx a swelling, which may vary in 
size according to the amount of granulation tissue and diseased 
mucous membrane within the bursa or whether the contents has 
been expelled or not. The opening of the bursa which is located NASOPHARYNX AVI) OROPHARYNX 
171 
usually at the highest point is not very readily made out and 
really represents a slit rather than a round opening. By press- 
ing on the swelling from below upwards, one may determine 
this opening by seeing the fluid escape. A blunt-pointed 
cannula introduced into the opening will enable the examiner to 
outline the cavity, and the injection of a syringeful of bismuth 
paste through the cannula will further outline the size. An 
x-ray picture, lateral stereoscopic, will give perfect information. 
The pathologic structure of this sac is a fairly normal mucous 
membrane externally, whereas the interior is made up of mark- 
edly thickened pyogenic membrane; but no evidences of any 
mucous glands, and the above-mentioned mucous clumps of the 
fluid which must have found their way in from the nose and 
throat. 
Treatment.—The treatment is to slit this bag from the open- 
ing down to the lowest level and if possible make two lateral 
incisions. By means of a curet, thoroughly scrape away this 
pyogenic membrane. Subsequently cauterize this raw surface 
so that a perfectly smooth scarred area is obtained. It is im- 
portant that no recesses or vestiges of this sac remain, else the 
process will recur. 
5. SYPHILIS OF THE PHARYNX 
Both the secondary and tertiary lesions of syphilis are ob- 
served within the pharynx, although primary chancre has also 
been described in this locality. One of the earliest evidences 
of a secondary stage of the disease is the pharyngitis which in 
reality should be classed as an acute inflammatory process. It 
manifests itself in a very violent inflammation of the mucous 
membrane and it appears very much thickened and devoid of 
secretion. It is, however, of very short duration, irrespective 
of treatment, and usually returns to its normal state. It is quite 
different in tertiary lesions, which are very frequent in this 
locality, all the way from the vault of the pharynx to the pyri- 
form fossae. The gummatous process, which is usually a diffuse 
swelling, has a cyanotic appearance, and within a very brief 
period of time will show in the center a yellowish or breaking 
down appearance. Following this disintegration there appears a 172 
APPLIED PATHOLOGY 
deep sulcus, crater-like lesion, lined with necrotic tissue and the 
line of demarcation of the slough or the gumma can be made 
out by the surrounding violent inflammation. If not treated 
and this sloughing is allowed to go on, there will be seen a sharp 
punched-out lesion with unhealthy granulation in the bottom. 
The secondary infection of such an ulcerated process adds fre- 
quently the element of suppuration to it. A bit of tissue from 
the margin of the ulcer microscopically examined will show the 
typical histological elements of the syphilitic lesion, namely, 
marked round-cell infiltration, with a scarcity of blood vessels, 
Fig. 160.—Healed out luetic cicatrices of the velum palati. 
and those that are present will show the arterial walls thickened 
and the lumina blocked (endarteritis obliterans). 
Treatment.—If treatment is instituted early enough, some of 
the destructive changes often including the uvula will be halted. 
However, at its best, the end results of cicatrization will occur 
(Fig. 160). In those cases where the process has broken down 
and sloughed, the resultant cicatrix is pathognomonic of this dis- 
ease. It is white, radiating stellar in appearance, deforming the 
remaining normal contour of the pharyngeal structure (Fig. 
161). The treatment, of course, a priori is very energetic, 
antiluetic, making use of the three principal substances, mer- NASOPHARYNX AND OROPHARYNX 
173 
cury, arsphenamine, and potassium iodide. Locally the gum- 
matous or swollen process can he very little influenced. In 
conjunction with the general treatment one may hasten absorp- 
tion and improve the circulation by constant warm applications, 
both in the throat as well as externally, by steam inhalations or 
normal salt solution gargles. When the process has once broken 
down, the sooner the slough is thrown off the better. Eight 
here great caution must be exercised against the mechanical 
removal of this slough, because one never can predict how much 
tissue can be saved by the aid of general medication. 
The use of mild irrigation of the crater under direct inspec- 
Fig. 161.—Pharyngeal stenosis—healed lues. 
tion, the application of mild antiseptics are advocated. Nitrate 
of silver (either in stick or strong solution) carefully applied to 
the crater will hasten the cleansing process. At times the crater 
extends into the tonsillar fossa; in such an event, the cavity may 
be filled and caused to retain by position, balsam of Peru or 
solution of methylene blue, acriflavin or Dakin’s solution. The 
same is true of an ulceration in the vault of the pharynx. In 
such an event the head tilted below the level of the neck, will 
help to retain these fluids in that position. Once the ulcer is 
thoroughly clean, it should be cauterized with the actual stick 174 
APPLIED PATHOLOGY 
of nitrate of silver. This will hasten the process of cicatriza- 
tion. Rarely is the symptom of pain present in spite of this 
tremendous destruction, but when present, will require heroic 
doses of morphine because it is the actual neuritis that is caus- 
ing this (nerve exposure). 
The pathology of the cicatricial changes is so individual as to 
require special technic in treatment. Suffice it to say, how- 
ever, that whatever is done by way of relief of the cicatrices, 
must be of extensive resection and long continued after-treat- 
ment, otherwise the difficulties will recur. In assisting the sof- 
tening of the cicatrices, especially in strictures caused by ad- 
hesion of the velum palate to the posterior wall of the pharynx, 
we liavs found electrically heated bougies (Fig. 208) to be of 
especial benefit. The use of thiosinamin, gr. iii, t.i.d., or any 
of its derivatives (fibrolysin, 1 ampule three times weekly hypo- 
dermically) by internal and hypodermic administration, may 
aid in softening the cicatrices. 
6. TUBERCULOSIS OF THE PHARYNX 
Primary tuberculosis of the pharynx is a very rare disease, 
but we have observed it twice in our experience. In both in- 
stances the ulceration was located in the postnasal space, and 
fairly close to the median line. The history of the one case is 
so interesting that we shall describe it in detail, thus covering 
the subject: 
Patient, Mr. X, constantly desired to clear the back of his 
nose, and was very much annoyed by crust formations, of which 
he could rid himself only by removing them with his fingers, 
which procedure was always accompanied by bleeding. His 
complaint had lasted over three years when he first presented 
himself to us. On examination we found an ulcerated swollen 
area on the vault of the pharynx and we considered the pos- 
sibility of infected remains of an adenoid. In removing the 
tissue and examining it microscopically, we found it to be 
typical of tuberculosis, namely, many giant cells, epithelioid 
cells, round-cell infiltration, slight amount of stroma, and no 
lymphoid tissue. The remaining surface after the operation aj3- 
peared to be the anterior common ligament. The healing proc- 
ess was very slow and after three months of attempting to heal NASOPHARYNX AND OROPHARYNX 
175 
the surface, we removed some particles of tissue, which still 
showed microscopic evidence of tuberculosis. 
The patient’s two cardinal symptoms were those of dysphagia 
and radiating pains toward the hack of the head. An x-ray 
picture showed that there was no evidence of any hone lesion 
of the vertebra. By means of rubber catheter retraction of the 
soft palate (Fig. 159) this area was made more accessible for 
the application of the actual cautery. As a result of this latter 
treatment, more rapid healing took place, with a perfectly 
smooth cicatrix. There resulted, however, some permanent dif- 
ficulty in deglutition, but of no particular consequence. I failed 
to state that the regional lymphatic glands of the neck in the 
posterior triangle on both sides were markedly enlarged during 
the entire process of the disease, on the left side breaking down 
and necessitating operation. Examination of part of the gland 
removed, demonstrated tuberculosis. This patient’s chest and 
the rest of the body were entirely free from tuberculosis, and 
seven years later all that remained was a slight enlargement of 
the glands above mentioned. For this condition he has received 
a course of x-ray treatment combined with tuberculin injections. 
Secondary tuberculosis of the pharynx is an entirely different 
disease, for we find usually in the terminal stage pulmonary 
tuberculosis in connection with tuberculous laryngitis. This 
part of the subject will be dealt with in connection with the 
laryngeal diseases. 
7. TUMORS OF THE PHARYNX 
The most frequently met with neoplasm of the malignant type 
is fibrosarcoma. Usually the patients have presented them- 
selves to us after the postnasal space is filled out, the soft and 
posterior part of the hard palate pushed down, and part of the 
growth visible in the oropharynx. It is of a pinkish-gray color, 
somewhat resistant to the touch and smooth. The histological 
examination which is usually deferred until the growth is re- 
moved on account of possible danger of hemorrhage, will show 
the type of sarcoma, whether round, small or large spindle 
celled. It is also important to note whether the blood lakes are 
in excess or not. The most important in the histological picture 
is the amount of fibrous tissue—stroma—present. This usually 
denotes its malignancy, or rather the benignancy. The more 176 
APPLIED PATHOLOGY 
fibrous tissue, the less malignancy and the less probability of 
recurrence when removed. 
The greatest complaint of these young patients is, of course, 
respiratory, especially if the neoplasm reaches well down into 
the pharynx, thus when falling asleep, the tongue comes in con- 
tact with the growth, causing immediate choking. The other 
symptoms are deafness due to the long-continued block of the 
eustachian tube, with secondary involvement of the middle ear. 
Again pressure on the nerves causes considerable pain radiating 
from the head and neck. The speech is definitely nasal. In 
some of the cases where the growth becomes infected, and ulcer- 
ates, there is bleeding and temperature with the secondary 
anemia present. 
Treatment.—The treatment is invariably surgical. However, 
we should give radium, x-ray, and surgical diathermy an oppor- 
tunity to prove their worth. By means of radium needles we 
have been able in several cases even in the recurrent type, to 
riddle the growth from all directions and thus effect its dis- 
appearance. In those cases we were better able to make out 
the possible origin than when we removed the growth surgically. 
Contrary to the accepted belief that these neoplasms arise from 
the sphenoid, ethmoid, posterior lateral wall of the nose, we 
have found their origin to be from Itosenmueller’s fossa. In 
the surgical treatment the soft rubber catheter retraction of the 
soft palate (Fig. 159) should be used. 
We have used radium needles directly into the growth as a 
preliminary measure to surgical removal. The reaction to the 
radium shows a definite increase in the amount of fibrous tissue 
and a definite diminution in the size and number of the blood 
vessels and blood lakes. We have used both the cold wire snare, 
the electrically heated snare, and the method suggested by 
Stuckey of removal with a heavy postnasal forceps. The re- 
sultant hemorrhage is at times very alarming, and it is well to 
have ready, tied to the aforesaid rubber catheters, a postnasal 
tampon, which as soon as the growth is delivered is forced back 
into the postnasal space and retained there by the two tapes 
coming through the nose, which are tied over a gauze sponge 
across the columella. Such tampons should remain in place for 
twenty-four hours and if bleeding still occurs on their removal, NASOPHARYNX AND OROPHARYNX 
177 
they should again be replaced for another twenty-four hours. 
After the surface at the point of severance has healed, and 
should there be observed any remnant of this growth, it is 
proper to cauterize this area by the actual cautery. 
8. SARCOMA OF THE TONSIL 
While sarcoma of the tonsil is not so frequent as the previously 
described disease, it is, nevertheless, of sufficient importance to 
mention the fact that its growth is much more malignant. The 
appearance of the growth is at first like that of a hypertrophic 
tonsil, but soon reaches into the supratonsillar area, causing it 
to bulge not unlike the peritonsillar abscess. It has frequently 
been misaken for this condition, since limitation and fixation of 
the lower jaw is an accompanying symptom. The speech defect 
here is of the “mouth, full of mush” type; the patient, however, 
has rarely any difficulty in breathing until very late, because 
the nose is free. Glands of the neck are rarely present. The 
histological examination of this group is usually of a lympho- 
sarcomatous nature (not Hodgkin’s). Blood lakes are very 
scarce, and there is very little fibrous stroma present. The 
treatment of this condition is most satisfactory by either radium 
or the x-ray, and if surgery is employed then these agents should 
be made use of afterwards, because recurrences are very com- 
mon. An old treatment which we have favored in these condi- 
tions has been the use of Coley’s toxins (Streptococcus erysipe- 
latis and Bacillus prodigiosus). The surgical technic in removal 
is usually wide excision of the growth taking with it normal 
tissue of the palate and muscles surrounding the growth. The 
danger of hemorrhage is so great that a preliminary ligation of 
the external carotid artery is to be advised. 
9. CARCINOMA OF THE PHARYNX 
The most frequent location of cancer of the pharynx is at the 
junction of the base of the tongue, plica triangularis, and the 
base of the tonsil. The usual appearance is that of an irregular, 
pinkish mass, surrounded by infiltrated areas of the structures 
named. The tongue is limited in its protruding action on the 
affected side. Glands in the submaxillary region or near the 178 
APPLIED PATHOLOGY 
angle of the jaw are always enlarged, and frequently matted 
together with the surrounding structures. Kadiating pain into 
the ear is an early symptom and painful swallowing soon fol- 
lows. The removal of a particle of this tissue will disclose the 
typical epithelial cancer in which the pearls are very numerous. 
This is usually so rapid in its progress as to very early encroach 
upon the larynx (Fig. 162) at least to the epiglottis, thus inter- 
fering both with breathing and speaking. Only a step further 
and the mouth of the esophagus will be involved, causing more 
difficulty in swallowing. 
Fig. 162.—Unilateral carcinoma of the tonsil. 
Treatment.—Tlie treatment is rarely feasible of surgical at- 
tainment, because the patients usually present themselves after 
the glands have become involved. In the many attempts that 
we have made in resecting the growth wide of the margin, within 
the pharyngeal cavity including the base of the tongue and the 
removal completely of all the tributary glands of the neck ex- 
ternally, with the preliminary ligation of the external carotid 
and the subsequent use of x-ray and radium, we have not in a 
single instance been able to save the patient nor even slow the 
tide. We have, however, treated a limited number of cases re- 
cently of this type by use of the combined treatment of radium NASOPHARYNX AND OROPHARYNX 
179 
and electrothermal coagulation from within and the short wave- 
length x-ray therapy from without, that promise to give better 
results. 
10. TONSIL AND ADENOID DISEASES 
Probably the most important subject in diseases of the pharynx 
is that of the pathologic changes in the lymphoid tissue. Three 
definite structures, one of which is bilateral, comprise the ana- 
tomical group, namely the lymphoid tissue in the nasopharynx, 
called adenoids, the two definitely incapsulated lymphoid glands 
situated laterally in the oropharynx, called faucial tonsils, and a 
conglomerated mass of lymphoid tissue at the base of the tongue, 
Fig. 163.—Hyperplasia of tonsils with infection, also adenoid mass. 
known as the lingual tonsil. The distribution of the solitary 
lymphoid follicles in the remains of the pharynx must also be 
reckoned with in recognizing diseases of the pharynx. The two 
principal types of pathologic changes that these lymphoid tis- 
sues are subject to are (a) hyperplasia, (b) hypertrophy with 
infection. In the former, which usually occurs in infants and 
young children, there is a marked reproduction of the normal 
lymphoid cells, with very little, if any, of the growth of connec- 
tive tissue (Fig. 163). The appearance of this hyperplastic 
structure is pale, smooth, and soft to the touch. The tissue is 
subject to infection and then the second tyj3e of disease occurs 
in which marked increase in vascularization takes place, with 
the other concomitant elements of inflammation, such as round- 180 
APPLIED PATHOLOGY 
cell infiltration and fibrous formation, taking place. This in- 
fectious material is principally located in tlie crypts of the 
tonsil, although the folds within the lymphoid masses in the 
adenoids frequently harbor the infectious material. The bac- 
teria which usually remain after the acute process subsides, find 
their way from the crypts and folds into the lymphoid tissue 
and thus we have not only cryptic infection, but also lymphoid 
infection. This is particularly noticeable in the solitary follicles 
of the pharynx, as well as the lymphoid tissue at the base of the 
tongue. 
As the process of recurrent acute inflammation in the crypts 
and lymphoid tissues occurs, so does the retention of the infec- 
tious material within these crypts increase. This retention 
causes these crypts to dilate with accumulative masses of de- 
generated epithelium of the crypts, clumps of bacterial flora, 
particles of food and mucus. These masses otherwise known as 
cheesy masses, act as additional factors of irritation. Slowly 
but certainly does this hypertrophic process begin to produce 
atrophy by squeezing out the lymphoid tissue, and there re- 
mains in the majority of the cases a retracted inflammatory 
mass between the two pillars of the fauces, the plica supraton- 
sillaris above, and the plica triangularis below. This is known 
as the submerged, retracted, phimosed tonsil. Owing to retrac- 
tion very frequently the most important crypts are covered over 
by the plicae, producing absolute retention. Thus we have es- 
tablished a natural incubator with numerous distended crypts 
containing bacteria, which are constantly either by themselves 
or their toxins absorbed into the circulation—directly into the 
blood stream or by way of the lymphatics. 
While it is true that in the bacteriologic examination of re- 
tained secretion, there is not very often found any marked viru- 
lence of the organism, it appears that by this being shut off in 
these crypts, virulent hemolytic streptococci find their way into 
the blood stream and thus produce the severe lesions in distant 
parts of the body, as, for instance, vegetation on the valve of the 
heart, inflammatory and destructive lesions in and about the 
joints, inflammations in the sheaths of the nerves, etc. This is 
what we understand as chronic sepsis from foci of infection. 
So far as the adenoid tissue in the postnasal spaces is concerned, [NASOPHARYNX AND OROPHARYNX 
181 
there is less likelihood of producing severe disease, yet the sur- 
faces of retention between the cleaves of the adenoids are so 
large and numerous that the absorption of septic matter from 
them produces definite toxic symptoms. The condition is par- 
ticularly noticeable in children in whom, as a consequence of 
chronic toxemia, we see marked anemias develop. 
The most important symptoms from these infected adenoids in 
the nasal pharynx are obstructive, so that the child, being a 
mouth-breather, does not receive the necessary amount of prop- 
erly warmed air, which in turn gives off less oxygen than were 
the process normal nasal respiration. Obstruction of the 
eustachian tubes frequently leads to recurrent tubal catarrhal 
otitis media. By far the most important difficulty with obstruc- 
tive and infected adenoids is the recurrent infection in the nose 
and down into the trachea and bronchi, otherwise known as 
frequent “colds.” Of course, there are many other symptoms 
of conditions resulting from adenoid disease such as malforma- 
tion of the upper jaw, etc. 
The conglomerated mass of lymphoid tissue at the base of the 
tongue, otherwise known as the lingual tonsil, is but rarely 
complained of. Yet if it is carefully investigated one will find 
at least in the adults that this mass is responsible for many 
symptoms, especially cough. The infection of this lymphoid 
tissue is unquestionably very frequently brought about by the 
infected surface of the tongue. Examination both direct as well 
as with the mirror will reveal irregularly distributed lymphoid 
masses, principally on either side of the epiglottis, reaching 
down into the periform fossa. When the mass enlarges more 
in the center, that is, in the vallecular region and touches the 
epiglottis, there is almost certain to be present an unproductive 
cough, which can always be relieved by locally applying cocaine 
as a test, or by the removal of this tissue. The infection and 
retention in this lymphoid tissue at the base of the tongue play 
a very minor role in the toxic absorption. The lingual tonsil is 
notoriously known to become compensatorily hypertrophied in 
many cases where the tonsils and adenoids have been removed. 
It may be one of our great safety valves against harm being 
done by the promiscuous removal of tonsils in children. This 
subject will be treated later in connection with tonsil stumps. 182 
APPLIED PATHOLOGY 
In regard to the solitary lymphoid follicles of the pharynx, 
it will frequently be found in connection with chronic tonsillar 
and adenoid disease, or as mentioned in the previous chapter in 
chronic lateral pharyngitis, that they become enlarged. There 
are seen one or two distinct blood vessels running to or from 
them, their distribution being along the posterior wall of the 
pharynx. It is quite likely that each follicle thus enlarged is 
actually infected, although no crypts can be demonstrated. 
These follicles also take on activity in some of the cases where 
the tonsils and adenoids have been removed. The histologic 
Fig. 164.-—Tonsil—hyperplasia of lymphoid tissue, showing but slight dilatation 
of the crypts and absence of cheesy masses in them. Normal sinus supratonsillaris 
showing. 
examination of the diseased lymphoid tissue of the pharynx, as 
just described, will vary considerably. If the hyperplastic form 
is examined, principally lymphoid tissue increase, very little 
stroma or inflammatory disease (Figs. 164 and 165) will be 
found. Once the process has become infected, the first changes 
in the epithelium covering the tonsils and adenoids is its des- 
quamation (Fig. 166) (both in the surface of the tonsil as well 
as the crypts). The capsule of the tonsil, which is a part of 
this structure, is frequently found in a state of inflammatory 
reaction, and firmly adherent to the structures surrounding it. NASOPHARYNX AND OROPHARYNX 
183 
In some of the extreme cases, there are only small remnants of 
lymphoid tissue, and the entire tonsil is transformed into a 
Fig. 165.—Adenoids, showing marked increase of lymphoid tissue and very little 
connective tissue. 
Fig. 166.—Adenoids, showing degeneration of the lining epithelium. 
chronic fibrosed mass (Fig. 167), with disease-distended crypts 
running in all directions (Figs. 168, 169, and 170). The ex- 
amination of the solitary follicles as well as the lingual tonsil, 184 
APPLIED PATHOLOGY 
reveals a round-cell infiltration and apparently some new blood 
vessels. 
Fig. 167.—Tonsil, showing remnants of lymphoid tissue and marked increase in 
connective tissue. 
Fig. 168.—Tonsil in chronic lacunar inflammation, showing dilated crypts filled 
with cheesy masses. 
Quite frequently these markedly retracted tonsils are prac- 
tically transformed into a granulation mass, and on attempting NASOPHARYNX AXD OROPHARYNX 
185 
to grasp them and draw them out with volsellum forceps the 
instrument will tear out very easily. Histologic examination 
Fig. 169.—Tonsil, showing dilated crypts filled with detritus containing cholestrin 
crystals in case of chronic tonsillar infection. 
Fig. 170.—Same as Fig. 169, high power, showing cheesy masses filling dilated crypts, 
will demonstrate considerable fibrous tissue, yet it is not of a 
senescent character. There are also present numerous degen- 
erated masses as well as many small blood vessels (Fig. 171). 186 
APPLlED PATHOLOG Y 
From this pathologic picture of chronic tonsil and adenoid 
disease of the pharynx, the treatment must necessarily be di- 
vided into two distinct forms, the surgical and the electrothera- 
peutic. In that form of hyperplasia where there is no infection 
in the crypts, there is no doubt that the reduction of the lymph- 
oid tissues can be accomplished by the employment of x-ray or 
radium, and thus relieve all the symptoms, whereas in that form 
of disease in which infection and degeneration play a part, the 
cure of the condition by any such method cannot be expected, 
and surgical intervention must be employed. The technic of 
applying the x-ray and radium as is employed in our clinic, is as 
Fig. 171.—Tonsil, showing trabeculae of fibrous tissue starting at the inner sur- 
face of the capsule and enclosing masses of degenerated lymphoid tissue; also, 
note the large number of blood vessels of small lumen present. The surface 
epithelium is well preserved. 
described in any modern publication on radio- and electro- 
therapeutics. 
As to the technic of the surgical procedure on the tonsils and 
adenoids the reader is referred to Loeb’s book “ Surgery of Ear, 
Nose and Throat.” We wish to say here, however, that nothing- 
short of complete enucleation of the tonsil and the very careful, 
painstaking, thorough removal of the adenoid tissue in the vault 
of the pharynx will suffice. Notwithstanding this thorough re- 
moval, following the uneventful healing of the parts, masses of XASOPH AllYNX AND OROPHARYNX 
187 
tissue strongly resembling tonsil and adenoid tissue will be 
observed in their previous localities. So far as this tissue in the 
vault of the pharynx is concerned, microscopic examination will 
show it to be made up mostly of granulation tissue, which for 
some reason or other developed at the seat of the denuded area 
(Fig. 172). Perhaps it might be accounted for from overopera- 
tion, leaving exposed the anterior common ligament which 
slowly granulates. The treatment of this granulation in the 
postnasal space can very well be controlled by the application 
of strong astringent solution of silver nitrate. This is best 
Fig. 172.—Persistent granulation after removal of adenoids. 
accomplished with the palate drawn forward by means of a rub- 
ber catheter, the head hanging over the edge of the table, thus 
preventing possibility of the solution dropping into the larynx 
and causing disagreeable symptoms. Although the masses 
found at the lower portion of the tonsillar fossa resemble ton- 
sillar tissue, it will be found that this tissue is not tonsil, but 
rather granulation tissue. However, here we do frecpiently find 
lymphoid tissue which has developed from the neighboring- 
structures and the plica. These masses are very important of 
recognition and to differentiate from what we term tonsil 
stumps. Tonsil stumps are remains of portions of tonsils from 
an imperfect operation, and must in no way be confounded with 188 
APPLIED PATHOLOGY 
tlie tissue masses at the lower pole of the tonsillar fossa, which 
Nature has produced there to fill up the otherwise large reten- 
tion cavity. 
It is true that these masses are subject to inflammation or 
infection because, as was stated before, they contain lymphoid 
tissue. When this difficulty arises, especially with any degree 
of frequency, it is very easily controlled by the use of an electro- 
thermal coagulation. We believe it is poor practice to resect 
these masses on account of the bleeding being difficult to control 
and the occurrence of subsequent contraction between the base 
of the tongue and the pillars of the fossa. It is entirely different 
with the tonsil stumps in which there are repeated recurrent 
attacks of tonsillitis, in which case they produce general symp- 
toms. Such stumps must be thoroughly removed and frequently 
it is a much more difficult operation than an ordinary tonsillec- 
tomy. In regard to the solid lymphoid follicles or enlarged 
lingual tonsil, these are best controlled by the use of the gal- 
vanocautery, although operative procedures are also found in 
the chapter in Loeb’s book. 
11. TUBERCULOSIS OF THE TONSIL 
The primary tuberculosis of the tonsil has been for a good 
many years a very moot question and much discussed subject. 
The great variance in the reports of percentages of primary 
tuberculosis of the tonsil makes it questionable whether such a 
disease really exists. By personal observations in our own cases 
we have, in having sectioned many tonsils, discovered true tu- 
berculosis in an otherwise absolutely healthy individual but 
once. We have, however, found quite a number of tuberculous 
diseased tonsils in patients who had tuberculous glands of the 
neck and were apparently free from lung or other systemic 
tuberculosis. Yet on very careful investigation it was always 
possible to find (especially by the aid of the x-ray of the chest) 
evidences of tuberculosis of the lungs, but more often of the 
peribronchial lymphatic glands. We therefore believe that all 
these apparently primary tuberculous tonsillar infections are 
really secondary and become infected through the blood stream. 
There is another type of tuberculous tonsil which does become NASOPHARYNX AND OROPHARYNX 
189 
infected by either continuity of structure from the laryngo- 
pharyngeal tuberculosis or from the sputum expectorated by 
the patient, lodging in the tonsillar crypts. A tuberculous ton- 
sil unless in a state of ulceration varies but little from the 
ordinary chronic infected tonsil. In one or two instances we 
Fig. 173.—Multiple tonsilloliths. 
Fig. 174.—Tuberculosis of the tonsil, showing cheesy masses in a dilated crypt 
(low power). 
have been fortunate in observing caseation before ulceration 
took place. This caseating process must not be confounded 
with the accumulation and retention of cheesy mucus within a 
crypt whose mouth has become sealed over by adhesions, form- 
ing a so-called cold abscess. 
While on this subject we might mention that at times these 190 
APPLIED PATHOLOGY 
cheesy or cold abscesses are transformed by deposition of lime 
salts into definite concretions, otherwise known as tonsilloliths. 
We have had two such cases; in one the stone weighed 33/2 
grams, and the case resembled clinically a carcinoma, and in the 
other the concretions were multiple (Fig. 173). To continue 
with the tuberculous process, we find the associated glands of the 
neck are very suspicious; such glands when removed frequently 
show tuberculosis. Whether the glands become secondarily 
infected from the tonsil by the lymph stream, or through the 
blood at the same time as the tonsil, has not been definitely 
Fig. 175.—Tuberculosis of the tonsil, showing numerous tubercles and a dilated, 
degenerated crypt, (higher power). 
determined, although Grober’s and Weixelbaum’s experiments 
on animals would tend to show that the former is the ease. The 
microscopic examination of tuberculous tonsils is so definitely 
characteristic of this disease that there can be no mistake made 
in the diagnosis. There are all elements of chronic tonsillar 
infections present with their dilated crypts, etc., plus the giant 
cell, epithelioid cell, round-cell infiltration about these, with 
many areas of caseation or necrosis (Figs. 174, 175, and 176). 
We have never been able either to isolate the tubercle bacillus 
from such tonsillar infections, nor have we been able to iden- NASOPHARYNX AND OROPHARYNX 
191 
tify in sections the tubercle bacillus when especially stained 
for it. 
Treatment.—The treatment of tuberculous tonsil in the types 
described as so-called primary tuberculosis is complete enuclea- 
tion,—the fact of the matter is that the diagnosis is usually 
made after their removal and subsequent histological examina- 
tion. In the tuberculous tonsil wherein ulceration has taken 
place and in which there is associated tuberculosis of the larynx 
and pharynx, and in which there are other general tuberculous 
manifestations, we advise palliative or local treatment rather 
Fig. 176.—Tuberculosis of the tonsil, with caseation, showing typical tubercles 
formed about the central giant cells (high power). 
than surgery. Nothing more radical should he done than actual 
cauterization of the ulcer. In the case of the large or infected 
tonsil of a tuberculous patient whose sputum is laden with 
tubercle bacilli, but whose general condition is good, we have 
removed such tonsils under local anesthesia with definite benefit 
to the patient’s local as well as general condition. The hygienic, 
dietetic and climatic treatment must not be overlooked when 
once the diagnosis has been made and such therapeutic meas- 
ures as tuberculin medication and possibly x-ray or surgery to 
the glands of the neck should be urged. 192 
APPLIED PATHOLOGY 
12. LUETIC TONSIL 
Every one knows that patients who have systemic lues may 
have simple chronic infections of their tonsils and are operated 
on for such difficulties. A subsequent examination of such ton- 
sillar tissue both grossly and microscopically does not show any 
evidence of luetic changes. There are, however, syphilitic 
lesions in the tonsil, as already described in the same disease of 
the pharynx, which are not operable. At the same time we must 
recognize a syphilitic entity of the tonsil, syphiloma, which dif- 
fers clinically, as well as pathologically. We have had one such 
Fig. 177.—Luetic tonsils, showing round cell infiltration and caseous gummata. 
case in whom a unilateral swelling of the tonsil existed and in 
whom there were no other evidences of syphilis, not even a 
positive Wassermann reaction. This tonsil was removed and on 
subsequent histologic examination showed definite signs of 
syphilis, namely, thickened blood vessels, marked round cell 
infiltration, and caseous gumma formation (Fig. 177). The 
healing of the wound was uneventful, contrary to the usual slow 
healing process in luetic individuals. 
13. ACTINOMYCOSIS OF TONSIL 
Actinomycosis of tlie tonsil is usually associated with the dis- 
ease about the mouth called ‘‘lumpy-jaw.’’ The author has ob- NASOPHARYNX AND OROPHARYNX 
193 
served one such case from the Pathologic Institute of Prague, in 
which the actinomycotic process appeared first within the tonsil 
and extended from the eustachian tube to the middle ear. The 
pathologic appearance of the tonsil showed a great deal of in- 
duration and very firm adherence to the peritonsillar structures. 
Numerous fistulas not recognized as crypts virtually riddled the 
tonsil and from them could be expressed greenish yellow bodies 
which proved under the microscope to contain the typical ray 
fungus. The treatment is general—potassium iodide and x-ray 
and radium. 
14. HYPERKERATOSIS OF THE TONSIL 
Hyperkeratosis of the tonsil must be regarded as a part of the 
same disease of the entire lymphoid ring of the pharynx, otlier- 
Fig. 178.—Leptothrix. The characteristic whitish spots are observed on the base 
of the tongue as well as on the tonsil and pillars. 
wise known as Waldeyer’s ring. It is characterized by the 
formation of yellowish white masses within the crypts as well 
as on the surface of the tonsil, fairly well scattered (Fig. 178). 
It resembles much the appearance of an acute follicular tonsil- 
litis, except there is no redness or swelling of the remainder of 
the pharynx. In attempting to remove these masses by swab or 194 
APPLIED PATHOLOGY 
by forceps one will find that they are tenaciously adherent, but 
upon successful removal of the particle little or no bleeding oc- 
curs and no pain is experienced. 
Microscopical examination of such keratinous material 
(horny), when properly stained with Lugol’s solution (Grams- 
iodine), will demonstrate the characteristic leptothrix buccalis 
having dead epithelial cells and many non-pathogenic micro- 
organisms in its masses with scarcely any pus cells present. 
As stated above, the associated pathology of the base of the 
tongue, that is, of the lingual tonsil, the postnasal space, the 
adenoid region, the lateral masses behind the posterior pillars 
and occasionally on the anterior pillars, is quite characteristic. 
The patients thus affected complain but very little of dryness 
in the throat, irritating and tickling (scratchy feeling), but are 
very much perturbed by the appearance of the whitish masses 
in their throats. Since the general practitioner is usually 
first consulted, and in many instances is not acquainted with 
this pathologic entity, one obtains a history of the previous 
administration of antitoxin because of its being mistaken for 
diphtheria. The etiology is not known but one does find the 
presence in many cases of poor mouth hygiene and dental caries. 
The leptothrix is perhaps a purely accidental component due to 
putrefaction. It is seldom found in any one who uses tobacco. 
The microscopic picture is one of chronic infection of the ton- 
sil leading to fibrosis. On the surface and within the top of the 
crypts are found in great abundance the keratinous changes. 
Treatment.—The treatment is best directed toward the cauter- 
ization of these masses by the use of the galvanocautery point, 
but it is accepted by the majority, and we believe it, that the 
chronic infection within the tonsil is probably the most potent 
factor and therefore tonsillectomy is advised. 
The dental hygiene is of the utmost importance. Mouth 
washes of the super-oxidized solutions, such as hydrogen per- 
oxide, perchloride of iron, chlorate of potash, and potassium 
permanganate are the favorite forms. 
15. BENIGN TUMORS 
Almost every type of benign tumor lias been described in lit- 
erature as having occurred in this region, but we have had ex- NASOPHARYNX AND OROPHARYNX 
195 
perience only with lipoma, adenoma with colloid degeneration, 
ecchondroma, mixed tumor (mixo-fibro-angioma), bismuthoma, 
and cysts. It no doubt would be of interest, at least casuis- 
tically, to describe each individual condition, but it will suffice 
from the pathologic point of view to group them as a whole and 
say that with the exception of the lipoma they are all unilateral. 
The actual pathologic diagnosis was always made after the 
tumor was removed. The universal symptoms were those of 
phonetic disturbances, some embarrassment in breathing espe- 
cially during sleep, but rarely any pain. The bilateral lipoma 
was associated with a case of Dercum’s disease. In regard to 
Fig. 179.—Tonsillar crypt filled with bismuth paste, showing the communication 
of the crypts. 
the bismuthoma, it is necessary to mention that the bismuth 
paste was injected for therapeutic purposes. Several months 
after this treatment the patient presented himself with this def- 
inite unilateral enlargement. The tonsil was removed and on 
section showed the crypt blocked and distended with bismuth 
(Fig. 179). 
The bismuth paste had acted as a foreign body irritant and 
produced a connective tissue reaction around the bismuth vase- 
line particles. These spaces, surrounding the paste are lined 
with a rather narrow rim of multinucleated cytoplasmic bands 196 
APPLIED PATHOLOGY 
resembling syncytium. Between the spaces, in the more cellular 
parts of the tissue, are larger and smaller multinucleated giant 
cells of the foreign body type, in some of which, as well as in 
the adjacent smaller cells, may be fine bismuth granules (Fig. 
Fig. 180.-—Photomicrograph showing the foreign body giant cells most numer- 
ous in the region of the bismuth masses. Some are small, containing 3 to 5 oval 
nuclei irregularly arranged, others are larger and contain 10 or more nuclei. Some 
of the giant cells as well as the endothelial-like cells are seen to have a phagocytic 
tendency. (High Power x7000.) 
180). A few scattered areas of round-cell infiltration occur 
among the hyperplastic connective tissue. The cells are chiefly 
small lymphocytes together with a moderate number of plasma 
cells. CHAPTER X 
CHRONIC DISEASES OF THE LARYNX 
The most frequent chronic disease of the larynx met with in 
our experience is cancer. Most laryngologists, however, will 
probably come in contact with more cases of the chronic, simple 
laryngitis. In the diagnosis of the various pathological proc- 
esses affecting the larynx there is one absolutely necessary 
factor; that is, experience. It is necessary to have seen a great 
number of cases and to have a very competent and reliable 
teacher to interpret correctly the clinical findings. While it is 
true that the microscopic examination of sections of tissue re- 
moved will reveal the actual pathology, it is not so desirable 
from the practical viewpoint in diagnosis as the clinical ex- 
amination. 
There are two methods of examining the larynx, the direct 
and the indirect; and the former again may be subdivided into 
the spatula and suspension methods, each having its definite 
value. The indirect method is the simplest and most agreeable 
to the patient and is to be preferred. However, in some in- 
stances a combination of all the methods will be necessary in 
order to make a diagnosis. The various aids, such as bacterio- 
logical, serological and x-ray examination will prove of addi- 
tional diagnostic value. A clear history is essential, especially 
as to such symptoms as interference with the voice, its duration, 
the association of pain, cough, etc. 
CARCINOMA OF THE LARYNX 
As we have mentioned before, carcinoma is the most frequent 
pathologic condition affecting the larynx that we have met with 
in our experience. It is to be noted that in different localities 
the laryngologist sees different prevalent types of laryngeal 
pathology. For example, in the west, as in California, Colorado 
and New Mexico, tuberculosis of the larynx will probably be 
seen most frequently; while in the resorts—as Hot Springs, 
197 198 
APPLIED PATHOLOGY 
Arkansas, syphilitic laryngitis will probably be met with most 
frequently. We have for years followed an axiom in diagnosis, 
Fig. 181.—Carcinoma of the arytenoids and cords. The polypoid nature is to be 
noted. 
Fig. 182.—Carcinoma of larynx, extending from the pyriform fossa. 
from which we have had no reason to deviate—that any man 
over forty who has had hoarseness that has existed for six weeks CHRONIC DISEASES OF THE LARYNX 
199 
or longer, and which has not disappeared during that period, is 
to be suspected of having cancer. Unfortunately, in by far the 
majority of cases that we have seen, because of the advanced 
nature of the process, there was not much difficulty in making 
the diagnosis. There was usually marked swelling within the 
larynx with caulifiower-like excrescences (Figs. 181, 182, and 
183). One or both arytenoid cartilages would be limited in their 
motion, or perhaps fixed. Corresponding to the side involved, 
definitely palpable lymph glands in the anterior or superior tri- 
Fig. 183.—Carcinoma of the hypopharynx extending into the larynx. 
angles of the neck along the course of the great vessels were 
observed. 
Some impairment of the voice is practically always present, 
from a varying degree of hoarseness to complete aphonia. 
There is a constant desire to clear this part of the throat and 
an annoying laryngeal cough is usually in evidence. Very fre- 
quently there is painful and difficult swallowing, owing to the 
encroachment on the pharyngo-esophageal region. Invariably 
when a process has extended to this degree the contiguous part 
of the epiglottis and base of the tongue is likewise involved 
(Fig. 184). In such an extensive process as this encroachment 
upon the sensory nerves of the neck results in marked neuralgic 200 
APPLIED PATHOLOGY 
pains, referred to different parts of the head and neck, especially 
the ear. 
The absolute diagnosis, after having excluded such conditions 
as syphilis and tuberculosis, can be established by biopsy and 
microscopic examination of a section of the tumor. Very early 
in the disease the diagnosis is much more difficult, especially 
Fig. 184.—Carcinoma of the larynx, involving the tongue, showing hard, ragged, 
infiltrated and ulcerated mucous membrane. 
Fig. 185.—Carcinoma of the larynx. Gross specimen, 
when there is a coexisting syphilis or tuberculosis of the larynx. 
Again it is to be emphasized that one should always be prepared 
to carry out radical procedures immediately, or within twenty- 
four hours, after the section has been removed for examination. 
There is no doubt but that a biopsy hastens the development of 
metastases in carcinomatous involvement. CHRONIC DISEASES OF THE LARYNX 
201 
Pathology.—Grossly, the lesions, as shown in the clinical pic- 
ture in Figs. 181, 182, and 183, namely, located in the posterior 
half and necessarily involving the neighboring structures as the 
pharynx and tongue have the appearance of irregular cauli- 
flower-like masses and are quite soft to the touch. In the cases 
where the masses are located intralaryngeally and anteriorly 
they very frequently find their way subglottic and extend within 
the ventricle of the larynx as far as the cricoid cartilage (Fig. 
185). Not infrequently are these neoplasms ulcerated and be- 
come secondarily infected. If the growth has been present 
Fig. 186.—Carcinoma of the larynx, showing typical epithelial pearls (low power) 
for a sufficient length of time the cartilage in the vicinity of 
the growth undergoes absorption and this change may easily he 
verified by the x-ray showing irregularities in the outline. 
Just as soon as the perichondrium becomes involved in the 
carcinomatous process, the case must be considered extrinsic 
because the lymphatics draining this structure become readily 
infected and involve the regional glands. It is quite different 
with carcinoma in the posterior half because the contiguity, as 
mentioned before, of these structures with the esophagus and 
pharynx, makes them positive of malignant invasion. There- 
fore the statement that is so prevalently made that a cancer 202 
APPLIED PATHOLOGY 
within the larynx, the so-called laryngeal “safety-box,” is not 
well taken. There is no safety location in cancer of the larynx. 
Fig. 187.—Carcinoma of the larynx showing some typical epithelial pearls (high 
power.) 
Fig. 188.—Carcinoma of the larynx, showing typical epithelial pearls under high 
power. The early central degeneration is shown in one of the pearls (high power). 
The fixation of the arytenoids is not solely caused by the neo- 
plasm, but the associated inflammatory infiltration. Compara- CHRONIC DISEASES OF THE LARYNX 
203 
tively rarely is the epiglottis involved in this process but it is 
important to note that it is free because it may be permitted to 
Fig. 189.—Carcinoma of the larynx, showing marked activity of the malignant 
epithelial cells. 
Fig. 190.—Carcinoma of the larynx, showing epithelial pearls and a considerable 
number of blood vessels and connective tissue. 
remain in a total extirpation of the larynx. Should the epiglot- 
tis be involved and be left, it would defeat the purpose of the 
procedure. 204 
APPLIED PATHOLOGY 
Microscopic Examination.—The most frequent type that we 
have encountered has been the straight epithelial variety which 
Fig. 191.—Carcinoma of the larynx, showing combined activity of the cartilage 
cells1. 
Fig. 192.—Carcinoma of the larynx, showing “ nests” of epithelial cells and older 
connective tissue and uninvaded blood vessels. 
has been characterized by the presence of “pearls” (Figs. 186, 
187, and 188). In other types where the epithelial pearls are CHRONIC DISEASES OF THE LARYNX 
205 
more sparse, carcinoma cells are found in great masses of multi- 
nuclear epithelial cells, so-called medullary carcinoma (Fig. 
189). Again, in other instances, wherein epithelial pearls are 
present, a considerable number of blood vessels and connective 
tissue are demonstrable (Fig. 190). Sections in which the car- 
tilage was infiltrated with carcinoma cells seem to indicate the 
inflammatory reaction with activity of the cartilage cells (Fig. 
191). In one instance of a slow growing carcinoma, the section 
revealed considerable older fibrous tissue (Fig. 192). In such 
cases, where x-ray and radium are employed extensively, there 
Fig. 193.—Carcinoma of the larynx, after radiation, showing some round cell 
infiltration and evidence of chronic inflammatory changes but no active malignant 
cells. 
are changes demonstrable, that are botli interesting and im- 
portant. The round-cell infiltration with fibrous tissue forma- 
tion, degenerative epithelial cells and no active malignant cells 
are the usual findings (Fig 193). 
Treatment.—The prognosis of cancer of the larynx is always 
very grave and the only type of case that offers any encourage- 
ment for cure is one that is seen in an early stage, where the 
neoplasm is small and confined to the anterior and interior por- 
tion of the larynx, and only then when it can be widely re- 
moved. Our most successful results have been obtained when 206 
APPLIED PATHOLOGY 
we removed the entire larynx. X-ray, radium, fulguration, sur- 
gical diathermy, and the various “medicinal” cures for car- 
cinoma, have not proved to be beyond the experimental stage, 
so that we believe surgery is the method of choice and thus far 
offers our only hope. However, such measures as we have men- 
tioned may supplement surgical procedure. At the same time, 
we wish to state that the use of short wave-length x-ray therapy 
is of great aid to surgery. It should be employed before and 
after operation so as to insure against a most serious possibility, 
namely, cancer cell implantation through the manipulation. 
TUBERCULOSIS OF THE LARYNX 
The question is still unsettled as to whether we may or may 
not have a primary tuberculosis of the larynx. Insofar as our 
Fig. 194.—Interarytenoid tuberculoma simulating papilloma. 
own experience goes, we have never encountered a case where 
there was not definite evidence of a tuberculous process in the 
lungs. We have, however, many times seen quite a progressive 
lesion of the larynx in an apparently healthy, robust individual, 
but on closer examination, especially by means of the radio- 
gram, and particularly stereoscopically viewed, either a latent CHRONIC DISEASES OF THE LARYNX 
207 
or active process in the lungs could always he demonstrated. 
The laryngeal picture varies considerably from a simple inter- 
Fig. 195.—Tuberculous infiltration of the cord and epiglottis. More of the type 
of subepithelial infiltration. 
Fig. 196.-—Tuberculosis of the larynx, involving the arytenoids and the epiglottis 
which is markedly edematous. 
arytenoid excrescence to tlie most markedly edematous, infil- 
trated, ulcerated condition (Figs. 194, 195, 196, and 197). One 208 
APPLIED PATHOLOGY 
can clearly observe from the study of these illustrations the 
marked edema and infiltration of the epiglottis as well as the 
Fig. 197.—Tuberculosis of the larynx. The tuberculoma formation about the 
arytenoids, together with ulcerations on the epiglottis are to be noted. Also note 
the rat-bitten appearance of the cords. 
Fig. 198.—Tuberculosis of larynx showing typical tubercle formation, 
arytenoids. The “rat-bitten” appearance of the vocal cords, 
usually confined to one side, is characteristic. These tremen- CHRONIC DISEASES OF THE LARYNX 
209 
dous infiltrations, and especially when ulcerated, are responsible 
for the dysphagia that accompanies this disease. There is one 
form of tuberculosis of the larynx that does not show very much 
on laryngeal examination, in which the pathologic process is a 
subepithelial infiltration and which is oftentimes baffling in a 
differential diagnosis between lues and tuberculosis (Fig. 195). 
Histologically, there is found the characteristic tubercle 
formation which is diagnostic (Fig. 198). At times tissue re- 
moved from a tuberculous larynx will not show the character- 
Fig. 199.—Chronic inflammation of the larynx in case of advanced pulmonary 
tuberculosis, showing marked round cell infiltration but no tubercle formation or 
giant cells. 
istic tubercle or giant cell (Fig. 199), but rather a chronic 
inflammatory process. 
Treatment.—The treatment of tuberculous laryngitis is di- 
rected primarily toward the focus in the lung and that is more 
in the realm of other fields of medicine. The local treatment to 
the larynx is practically of no curative value and only palliative 
measures have a place in the management of this disease. We 
have reference particularly to the dysphagia and hoarseness. 
Topical application of local anesthetics such as cocaine, anes- 
thesine, orthoform, and the various emollients, as liquid petro- 
latum, and chloretone have all been tried with more or less, 210 
APPLIED PATHOLOGY 
principally less, benefit in the management of this affection. 
Intralaryngeal injection of a weak formalin solution or the iodo- 
form-ether mixture spray are of decided benefit for the relief 
of pain on swallowing. Painful ulcerative surfaces are best 
controlled by topical application of lactic acid (50 per cent) to 
the ulcer. Surgical and semisurgical measures, as, for instance, 
curettement of the ulceration, actual cautery, amputation of the 
epiglottis, injection of the superior laryngeal nerve with alco- 
hol, tracheotomy to place the larynx at rest, all have their 
definite indications, and, at times, startling results are obtained 
from their employment. That special pathologic form of sub- 
epithelial infiltration, of which variety we have only observed 
a very few cases, but which have been observed by Mullen, 
Lockhardt and Carmody of Colorado, has best been influenced 
by climatic change under the guidance of specialists in tuber- 
culosis, particularly laryngologists. Recently we have observed 
a case of this form of luetic laryngitis which was treated in 
combination by a laryngologist and radium therapist with re- 
actions (burns) most distressing. 
SYPHILITIC LARYNGITIS 
Iii large laryngeal clinics, especially abroad, one will observe 
very many cases of this disease but in this country and in pri- 
vate practice it is not so frequently met. It goes very com- 
monly, masquerading under the guise of a chronic laryngitis in 
which no other symptom except hoarseness is present. The 
appearance is that of a deep injection of the entire larynx and 
the infiltration is mostly confined to the cords and subglottic 
region. Occasionally there are local gummatous formations, 
either in the arytenoids or epiglottis and in very pronounced 
cases the entire thyroid cartilage becomes markedly infiltrated, 
particularly the perichondrium. Breaking down of the gumma, 
which becomes secondarily infected, forms one of the most de- 
structive lesions of the larynx and in such instances the symp- 
tom of respiratory embarrassment is very marked, and often 
necessitates tracheotomy. When the cricoid cartilage takes part 
in this pathologic change, then the associated difficulty in de- 
glutition is also pronounced. As the result of these destructive CHRONIC DISEASES OF THE LARYNX 
211 
changes, which are associated with marked sloughing, there will 
be, when the end result is obtained, marked deformity and cica- 
tricial formation (Fig. 200). The history and other concomi- 
tant findings of lues together with a serological test (positive 
Wassermann), will suffice to make a diagnosis. A particle of 
tissue if removed by biopsy will reveal a true picture of chronic 
inflammation with the syphilitic vascular changes, endarteritis 
obliterans. 
Treatment.—The treatment is very energetic antiluetic with 
arsphenamine, mercury and potassium iodide, by their accepted 
Fig. 200.—Laryngeal stenosis; luetic origin. The marked cicatrization and the 
almost complete destruction of the epiglottis are to be noted. 
methods of introduction. It must be remembered that in a 
larynx that is already stenotic when iodides or arsphenamine 
are administered, especially in large doses, a sudden increased 
difficulty in breathing may result from what is known as the 
Herxheimer reaction, which is an acute edema. It is noteworthy 
that antiluetic treatment for the disease in this locality is not so 
prompt in its action and the explanation may be sought in that 
the perichondrium is principally involved and responds but 
very slowly. Surgical measures are at times necessary, such as 
emergency tracheotomy, as was stated before, as well as reliev- 212 
APPLIED PATHOLOGY 
ing tension perichondritis, thus preventing complete cartilagi- 
nous absorption. The procedure corresponds to an atypical or 
incomplete laryngotomy. We have just completed a case of this 
kind wherein such measures proved their efficacy. The manage- 
ment of the deformities due to cicatrization is mainly mechano- 
surgical and may be found described in Loeb’s textbook. 
CHRONIC SIMPLE LARYNGITIS 
The principal changes in this disease are hypertrophy of the 
mucous membrane or the submucous tissue or both; involving 
anatomically all of the divisions of the larynx but principally 
the ventricular bands and the true vocal cords. Not only is the 
Fig. 201.—Singers ’ nodules. 
larynx involved but invariably is the nose, pharynx and trachea 
associated in the process. The fact of the matter is, the laryn- 
gitis is usually secondary to some chronic nasal or sinus dis- 
ease and consequently the treatment should be directed towards 
the nose. 
The appearance of the larynx is of a mottled-red, the cords, 
having lost their luster, show very frequently markedly injected 
blood vessels over their surface and occasionally, with the cords 
in complete abduction, subglottic hypertrophies can be made CHROXIC DISEASES OF THE LARYXX 
213 
out. On plionation, especially in the highest register, the vocal 
cords, in their attempt at approximation will fail on account of 
their thickened margins and the hoarse voice is the result. 
From the faulty use of the voice during the attack of chronic 
laryngitis, on some part of the edge of the cord, an excrescence 
forms, which at first may be only the size of a pinhead, gradu- 
ally grows, with a slightly broader base and to a point which 
assumes a whitish color. This is the so-called singer’s node and 
in our clinic we have coined the phrase “corns” on the vocal 
cords because it is almost analogous in its etiology and path- 
ology to the corns on the toes. Occasionally, these nodes are 
bilateral and when they occur they are usually at the vocal 
process (Fig. 201). When the vocal nodule takes on more active 
growth with additional degeneration we have another patho- 
logic entity of the larynx, namely, a fibrous polyp. 
FIBROUS POLYP 
The symptoms of hoarseness in fibrous polyp (Fig. 202) are 
the same as in the previous condition except much more pro- 
Fig. 202.—Solitary fibrous polyp of the cord (pedunculated) 
nounced and there is a constant effort made of clearing the 
larynx of this movable growth which is usually pedunculated 214 
APPLIED PATHOLOGY 
in character. On inspection during phonation, the greater part 
of the growth may be found caught between the cords and may 
deceive the observer as to the actual size of the neoplasm, there- 
fore it is well in doing such an examination to have the patient 
make a forcible expiratory effort. 
The microscopic examination of the vocal nodule, as well as 
the fibroma, shows simple fibrous tissue in varying stages of 
development. In the vocal nodule, however, is considerable de- 
generation of the epithelium, particularly hornification; whereas, 
in the polyp, we find myxomatous degenerative changes. 
Throughout the polyps are found numerous capillaries (Fig. 
203). 
Fig. 203.—Laryngeal polyp showing fibrous tissue in various stages and numerous 
capillaries. (Low power.) 
Treatment.—The treatment of chronic simple laryngitis has 
already been alluded to in advising attention to the nose and 
nasal accessory sinuses. As to the larynx, direct vocal hygiene 
which implies proper use of the voice, avoidance of irritants as 
tobacco and dust and such other irritants as very hot and cold 
food or drinks. Topical applications should be used with the 
greatest of discretion because we have seen numerous cases 
which have been over-treated by strong astringents, such as 
nitrate of silver. The mildest astringent treatment in the form 
of zinc sulphate (1 to 2 per cent solution) and used either in CHRONIC DISEASES OE THE LARYNX 
215 
spray or laryngotracheal injection, as well as liquid petrolatum 
or chloretone inhalant used similarly, are very gratifying to the 
patient. It is very rarely that one sees a chronic laryngitis of 
the type mentioned clear up entirely with recovery of clear 
voice. One of the most striking recoveries that we have had in 
this condition has followed the removal of markedly infected 
tonsils and the clearing up of a grave pyorrhea alveolaris. 
In the treatment of the singer’s nodes, the best results have 
been obtained by advising the proper use of the voice, particu- 
larly under supervision of an experienced vocal teacher. Occa- 
sionally, the nodules are so large as not to respond to the latter 
treatment and surgical intervention will be required. While 
we do not describe any surgical measures in this text, we would 
like to mention here that we had the best results in removing 
the tiniest vocal nodules by suspension laryngoscopy. Radium 
has not proved of any value in the treatment of this condition 
in our hands. The true fibroma polyp is only dealt with sur- 
gically. 
PAPILLOMA OF THE LARYNX 
Papilloma of the larynx is distinctly a disease of childhood 
and is characterized by hoarseness and very frequently difficulty 
in breathing. If the physician is fortunate enough to see the 
case in the very beginning, he will find that the growth usually 
starts from the free edge of the vocal cord near the posterior 
commissure (Fig. 204). The entire surface of the larynx be- 
comes involved very rapidly (Fig. 205), and the growth migrates 
both downwards and upwards, giving rise to considerable em- 
barrassment in respiration. 
Early in the disease the growth is soft to the touch and par- 
ticles can easily be removed during even such a simple examina- 
tion. If, however, the growth has been removed and recurs, 
which it frequently does, the sensation on palpation is much 
firmer. The secondary pus infection of this neoplasm is an 
important consideration in the pathologic change. The respira- 
tory embarrassment, as well as the therapeutic measure em- 
ployed to give laryngeal rest, frequently requires tracheotomy 
and we have observed in two of our cases a true papilloma 
growing externally around the tracheal fistula (Fig. 206). It is 216 
APPLIED PATHOLOGY 
frequently quite difficult to make an examination in these chil- 
dren but there is one method which to us has proved best and 
that is by a direct Jackson illuminated laryngoscope. 
Fig. 204.—Benign papilloma of the ventricular band. 
Fig. 205.—Multiple papillomata of the larynx. The sessile base is to be noted. 
Tlie histologic pathology consists of the characteristic papil- 
lary, finger-like projections, which are principally made up of CHRONIC DISEASES OF THE LARYNX 
217 
Fig. 206.—Papillomatous formation about the tracheal fistula. 
Fig. 207.—Papilloma of the larynx, showing typical papillae formation. 218 
APPLIED PATHOLOGY 
connective tissue containing many small blood vessels and cov- 
ered with a thin layer of pavement epithelium (Fig. 207). 
In the examination of the tissue from the recurrent papilloma, 
more evidence of connective tissue formation is found, probably 
due to the secondary infection. 
The treatment has received a great impetus in recent years in 
the employment of radium. No other neoplasm is so favorably 
influenced by radium as is this, especially if attacked early or 
in the nonrecurrent type, but even in the event of the recurrence 
this mode of treatment has proved efficacious. As to the technic 
of radium application, as we do in other electro- and radio- 
therapeutic measures, we refer the reader to standard texts on 
the subject. We would like to say, however, that we practice 
teamwork in having the radiologist treat these cases with us. 
The principal treatment still in vogue in this condition is the 
surgical removal and in reference to this phase the reader is 
referred to Loeb’s text book. 
ECCHONDROMA OF LARYNX 
We have observed two cases of this unusual condition of the 
larynx, one occurring in a vocal teacher. These neoplasms were 
in both cases small, sessile, one being located near the posterior 
commissure and the other being most anterior. The cardinal 
symptom in both was hoarseness, the diagnosis clinically was 
fibroma, and surgical intervention was carried out. One growth 
was removed by suspension laryngoscopy and the other by the 
external subhyoid route and both patients obtained very satis- 
factory voices. 
The histologic examination revealed the growth to be prin- 
cipally made up of hyaline cartilage. 
LARYNGEAL PARALYSES 
Laryngeal paralysis does not at all times come within the 
domain of the laryngologist. It may he considered as distinctly 
borderline. The most frequent form of paralysis of the laryn- 
geal muscles is that due to involvement of the left recurrent 
laryngeal nerve. This is the result of pressure either by an CHRONIC DISEASES OF THE LARYNX 
219 
aneurysm or mediastinal growth. Other such cases have re- 
sulted either from pressure on the nerve by an enlarged thyroid 
gland or postoperatively in removal of this gland. We have 
seen one case in which the clinical diagnosis was tuberculosis of 
lymphatic glands of the neck and in which the sputum showed 
large numbers of the tubercle bacilli, even though the chest 
examination was absolutely negative for tuberculosis. X-ray 
examination in this case likewise showed no evidence of a tuber- 
culous focus in the lungs. The larynx, in addition to the paral- 
ysis, showed a very mild inflammatory process that could not 
from clinical examination be considered a tuberculous laryn- 
gitis. 
Treatment is directed towards the etiologic factor. Little can 
be done for the associated hoarseness and cough. 
Abductor paralysis of the larynx is invariably associated with 
other bulbar symptoms. Immediate tracheotomy becomes neces- 
sary when the alarming symptom of suffocation, with inspira- 
tory stridor is present. The pathologic change is a nerve de- 
generation from the bulb. The prognosis is very grave and a 
permanent tracheotomy is usually necessary. In recent years' 
laryngologists have practiced removal of the vocal cords on one 
side and we have had two such cases with permanent relief from 
this procedure. In one case the larynx was slit, while in the 
other the resection was done under suspension laryngoscopy. 
In this type of paralysis sensation of the larynx is abolished, 
which gives the additional difficulties of food and fluids entering 
the respiratory tract. This, as a rule, results in a severe spas- 
modic cough and not infrequently in a bronchial or pulmonary 
infection. It is to be noted here that in recurrent laryngeal 
nerve paralysis the pathological process is in reality a pressure 
atrophy. The nerve is at first stretched and subsequently under- 
goes degenerative processes. 
A functional or hysterical laryngeal paralysis is quite com- 
mon. The only change that has been noticed in these cases in 
which there has been persistence of the aphonia is the apparent 
atrophy of the musculature of the vocal cords. The clinical 
picture of such a case is the bilateral bowing of the vocal cords, 
leaving a large space in the middle in the efforts at approxima- 
tion. The arytenoids come together fairly well. 220 
APPLIED PATHOLOGY 
Suggestive therapeutics or psychoanalysis have been used. 
Our most successful results have been obtained when these 
measures have been combined with treatment directed to the 
larynx; i. e., the application of the galvanic, faradic or high 
frequency current. The most frequent error in differential 
diagnosis between the various types of paralyses is that of mis- 
taking a unilateral paralysis for a neoplasm with fixation of the 
arytenoids. CHAPTER XI 
CHRONIC DISEASES OF THE TRACHEA, BRONCHI, AND 
ESOPHAGUS 
It has been only in recent years, since the advent of direct 
bronchoscopy, that diseases of the trachea entered the realm 
of the laryngologist. 
CHRONIC MUCOPURULENT TRACHEITIS 
Ill clironic mucopurulent tracheitis there is marked thickening 
of the mucosa and increase in both vascular and glandular ele- 
ments. Examination shows a deep red injection with irreg- 
ularly distributed areas of thick, tenacious secretions. Micro- 
scopically, the picture is typical of a chronic inflammation and 
the mucous glands are distended. 
Treatment.—In the treatment, one must direct his efforts to 
determine the primary etiological factor; i. e., whether the con- 
dition is secondary to sinus disease or is a primary infection of 
the trachea itself. It is very often secondary as a complication 
of an acute rhinopharyngitis. Local treatment consists essen- 
tially of removal of the secretions by suction, either by direct 
bronchoscopy or under suspension. The local application of mild 
astringents, such as silver nitrate, is of benefit. Intratracheal 
injections of oily mixtures are soothing to the irritable cough 
which is invariably present. Autoinjections can be accom- 
plished by the technic suggested by Dundas-Grant. This can 
be simplified by teaching the patient to pass a soft rubber 
catheter until it extends just below the soft palate and with the 
head well back, slowly injecting the solutions into the larynx 
and trachea, making an effort not to swallow during the period 
of injection. If methylene blue is added to the solution, it can 
be definitely proved that medication applied in this manner 
reaches the larynx and trachea. 
At times the mucus is so tenacious as to necessitate irrigation 
with normal salt or sodium bicarbonate solutions. The internal 
administration of expectorant mixtures, such a,s ammonium 
221 222 
APPLIED PATHOLOGY 
chloride and ipecac is of benefit. Change of climate, particu- 
larly to the mountains of North Carolina, in reality gives the 
very best results. 
SYPHILITIC TRACHEITIS 
Syphilitic tracheitis is usually associated with an extensive 
syphilitic laryngitis. The pathologic process is essentially the 
same as in the latter case, but the ulcerations are usually mul- 
tiple and at times involve the complete circumference of the 
trachea. During the process of healing marked cicatricial con- 
tractures occur. 
Treatment.—In addition to antisyphilitic measures, the local 
application of silver nitrate solutions to the lesions is of ad- 
vantage. This can be done either by direct bronchoscopy or 
suspension. In the resultant scars and strictures it may be 
necessary to pass bougies, particularly electrically heated 
bougie tube (Fig. 208), and at times intubation or tracheotomy 
is indicated. 
NEOPLASMS OF THE TRACHEA 
Although any of the forms of malignant or benign growths 
may involve this region, we have seen only carcinoma, papilloma 
and adenomatous thyroid gland perforated by pressure. 
Carcinoma of the Trachea 
Carcinoma of the trachea is usually so far advanced when the 
patient presents himself for examination as to leave very little 
doubt as to the diagnosis. Upon examination an irregular mass 
is seen, usually, with streaks of blood over its surface. Hemop- 
tysis is frequent, particularly after the violent spasms of 
coughing. Removal with a punch forceps or curet of a piece of 
tissue for examination will reveal the type of malignancy. In 
our case it was an adenocarcinoma. 
Treatment.—Surgical resection supplemented by radium or 
x-ray offers the only hope. 
We have had three cases of papilloma of the trachea, all co- 
existent with papillomata of the larynx. In one of our cases an 
Papilloma of the Trachea CHRONIC DISEASES OF THE TRACHEA 
223 
extensive papillomatous mass extended externally through the 
tracheotomy wound. (See Fig. 206.) The treatment consists 
of radium and surgical removal. 
ADENOMA OF THE TRACHEA 
Primary adenoma is exceedingly rare in this location. We 
have had one case which was a direct extension of adenoma of 
the thyroid and pressure of the growth caused atrophy of the 
cartilaginous rings. The associated growth of the thyroid gland 
suggested the diagnosis and the removal of the main gland veri- 
fied it. A secondary plastic reconstruction of the trachea with 
a rib transplant gave a very good result. 
BRONCHORRHEA 
Bronchorrliea is essentially a disease for tlie internist to man- 
age but in recent years, since the advent of the bronchoscope 
and suction, considerable benefit has been obtained in this stub- 
born condition. It is essentially a chronic purulent bronchitis. 
Treatment.—The patient is placed in a semi-Trendelenburg 
position and irrigation instituted through the bronchoscope of 
one side of the lung at a time with a sodium bicarbonate solu- 
tion (10 grains to the ounce), alternating with immediate suc- 
tion and subsequent insufflation of bismuth powder is carried 
out. 
CARCINOMA OF THE ESOPHAGUS 
Tlie most frequent chronic disease of the esophagus that the 
laryngologist meets with is carcinoma. The location of the neo- 
plasm varies and in our experience we have found it most fre- 
quently in the upper half, and the majority of these (perhaps 
50 per cent) in the vicinity of the cricoid cartilage. Unfor- 
tunately in most of these instances the growth was so far ad- 
vanced that only palliative measures could be instituted. The 
examination by the esophagoscope is positive but precaution is 
to be exercised in passing the instrument so as to prevent hemor- 
rhage and perforation with its complications. Biopsy and 
microscopic sections may be made. Early gastrostomy is to be 224 
APPLIED PATHOLOGY 
advocated so as to enable the radium treatment to be success- 
fully carried out. This latter treatment may be either implanta- 
tion of radium emanations, radium needles or a tube containing 
radium capsules (refer to texts on this subject). We have also 
employed short wave-length x-ray. 
ESOPHAGEAL DIVERTICULUM 
Esophageal diverticulum is a borderline condition and the 
description of the same is withheld to the publication of the 
borderline of nose, throat, and ear diseases. Suffice it to say, 
however, that in the differential diagnosis, many times this 
condition has been confused with a carcinoma of the esophagus. 
The radiogram together with the barium meal is so positive a 
diagnostic test of this condition that it leaves very little doubt. 
The esophagoscope in finding the opening to the diverticulum 
is of additional value. 
STRICTURES OF THE ESOPHAGUS 
The most common form of strictures is secondary to burns by 
caustic lye which is being employed as a household cleanser. 
Efforts are being made to prohibit the sale of this substance for 
such purposes because of these accidents and to educate the 
laity; however, such mishaps still occur and with considerable 
frequency. Other caustics such as carbolic acid and strong 
alkalies and acids taken accidentally form another larger group 
of possible etiologic factors. Post-syphilitic and diphtheritic 
ulcerations are potent factors, as in their healing-out process 
there is a great tendency toward cicatrization and subsequent 
stricture formation. The removal of foreign bodies, especially 
if they have remained in the esophagus for a longer period, dur- 
ing which time decubitus by pressure has occurred, is frequently 
followed by stricture. The unskilled use of the esophagoscope 
and other instruments used in this locality often lead to trau- 
matic esophagitis which may result in stricture. Infection of 
the esophagus which is comparatively easy, may be followed by 
abscess and ultimate stricture formation. 
Tumors within the mediastinum, such as aneurisms and CHROXIC DISEASES OE THE TRACHEA 
225 
Hodgkin’s disease may compress the esophagus from without 
and produce constriction by pressure. The enlarged liver, par- 
ticularly the lobus spigelii, may constrict the esophagus in its 
course through the diaphragm. The reader is referred to the 
pioneer work of Mosher on this subject. Trophic idcers follow- 
ing extreme burns often occur and give rise to constriction after 
healing. A large group of strictures of the esophagus are func- 
tional or spasmodic, usually occurring in neurotic women. We 
have already mentioned the stricture caused by malignant dis- 
ease. The recent war has also brought out the effect of poison- 
ous gases on the esophagus and the subsequent stricture for- 
mation. 
The diagnosis of all strictures is usually made positive by aid 
of the fluoroscope and radiogram by use of the barium meal. As 
Fig. 208.—Electrically heated bougie for esophagus with thermostat (two other 
sizes made, one for the nose, another for the eustachian tube.) 
to the determination of actual pathology the esophagoscope will 
be of most value. A thorough history is of inestimable value. 
Pathology.—The gross pathology of strictures of inflammatory 
character will vary as to the causative factor and the duration 
of the stricture. Post-diphtheritic and syphilitic cicatrices are 
most dense and form webs partly or completely annular in type. 
Excision of a particle of a cicatrix will demonstrate the histo- 
logical character, whether dense or less so. The best prognostic 
findings are blood vessels within the scar because one can an- 
ticipate more successful bouginage and subsequent absorption 
of the inflammatory products. The cicatrices following the use 
of caustics are much more amenable to bouginage. 
Treatment.—The treatment, aside from that in malignant 
strictures and those caused by extrinsic tumors, is best carried 
on by bouginage. The exact technic of this procedure really 
must be referred to in special texts on the surgery of these parts. 226 
APPLIED PATHOLOGY 
It suffices here, however, to state that medicinal aid such as 
thiosinamin (gr. iii t.i.d.) or its derivative, fibrolysin, are of 
value, the latter being given hypodermatically, one ampule every 
other day. 
The electrically heated bougie of Freund (Fig. 208) has given 
excellent results in the few cases in which we have employed it. 
The technic we have employed is after passing the bougie 
through the stricture the current is allowed slowly to reach 55° 
C. It is permitted to remain in situ at lirst five minutes and, 
within a week, up to thirty minutes, depending upon the results 
of softening of the stricture. CHAPTER XII 
CHRONIC DISEASES OF THE EAR 
CHRONIC OTITIS EXTERNA 
Chronic Otitis Externa may be classified anatomically as fol- 
lows : 
1. Pinna. 
2. External Auditory Canal. 
1. Pinna 
Malformations.—These may be congenital or acquired. The 
following table with accompanying illustrations made up of 
cases that have come under our observation will suffice to outline 
the subject: 
Congenital 
I. Complete absence of one or botli auricles. 
II. Absence of part of ear. 
III. Asymmetry of tlie two ears. 
IV. Accessory or multiple ears (poliotia). 
V. Abnormally large ears (Macrotia or Otomegaly). 
1. Of the cartilaginous portion. 
2. Of the lobule (length or width). 
VI. Abnormally small ears (Microtia). 
VII. Abnormal form but normal size. 
1. Flattening of the periphery. 
2. Cleft lobule. 
VIII. Abnormal protrusion of auricle (Otopostasis). 
IX. Drooping ears (Roll or dog ears). 
X. False position of the auricle (Heterotopy). 
XI. Adhesions of the ear (Synechia). 
Acquired 
I. Complete or partial absence due to: 
1. Traumatic or mechanical destruction. 
2. Thermal. 
3. Chemical. 
227 228 
APPLIED PATHOLOGY 
4. Disease— 
(a) Infectious. 
(b) Malignancy. 
(c) Symptomatic. 
II. Enlargements of ear: 
1. Hematomata. 
2. Neoplasms. 
3. Inflammations. 
Fig. 209.—A group of congenital malformations of the ear in the process of recon- 
struction. Four degrees, complete absence to presence of half of the auricle. 
III. Abnormal protrusions. 
IV. Abnormal form but normal size due to: 
Shriveling following perichondritis, infected 
hematoma or abscess. 
V. Adhesions of the ear after abscess, etc. Cicatriza- 
tion from burns. Postoperative adhesions. CHRONIC DISEASES OF THE EAR 
229 
VI. Postauricular deficiencies—Retroanricnlar fistulae 
following radical mastoid operations. 
A detailed description of this subject would take up more 
space than can be given in this book. Furthermore, it should be 
Fig. 210. 
Fig. 211. 
Fig. 212. 
Fig. 213. 
Figs. 210-225.—Congenital partial absence of auricle, complete absence of middle 
and internal ear, right. Polyotia, left. Plastic reconstruction, Gillis method of tube 
formation from neck. Septal cartilage implants. Twelve separate steps in the 
operation. 230 
APPLIED PATHOLOGY 
considered as a borderline subject and as such it will be treated 
in the prospective volume. We wish to call attention, however, 
to the fact that these ear affections have not received the atten- 
Fig. 214. 
Fig. 215. 
Fig. 216. 
Fig. 217. 
tion they should have by the otologist. It is true that this is 
the most discouraging work we have to do and results from 
treatment are most unsatisfactory. Yet there are points of CHRONIC DISEASES OF THE EAR 
231 
social importance that compensate for the effort. One is the 
depression that the parents feel in having a deformed child, 
especially if the condition is congenital, and they wish to have 
Fig. 218. 
Fig. 219. 
Fig. 220. 
Fig. 221. 
something done to correct this deformity (Fig. 209); and the 
other is the individual, himself, who frequently shuns society on 
account of the deformity (Figs. 210-225). In most of the con- 232 
applied pathology 
Fig. 222. 
Fig. 223. 
Fig. 224. 
Fig. 225. CHRONIC DISEASES OF THE EAR 
233 
Fig. 226.—Congenital macrotia and macrocephalia. Front and back views. 
Fig. 227.—Congenital deafness, ex- 
ternal ear deformity and right facial 
paresis in brothers. 
Fig. 228.—Congenital verruca (wart) 
deeply brown pigmentation. Behind 
ear. 234 
APPLIED PATHOLOGY 
Fig. 229.—External ear completely torn off in elevator accident. Side and back views. 
230 
231A 
2317? 
Fig. 230.—Part of external ear bitten off by dog. 
Fig. 231 A.—Artificial ear used in correction of case shown in Fig. 230, as well as 
in case shown in Fig. 229. 
Fig. 2311?.—Artificial ear held in place by spectacles. CHRONIC DISEASES OF THE EAR 
235 
Fig. 232.—Partial destruction of ex- 
ternal ear and scars about the face and 
scalp. The usual deformity following in- 
jury by shrapnel in the late war. 
Fig. 233.—Practically complete loss 
of external ear associated with scarring 
of the left side of the face and neck 
following burn of third degree. 
Fig. 234.—Partial loss and contrac- 
ture of the external ear and side of the 
face following accidental application of 
95 per cent carbolic acid. 
Fig. 235.—Retroauricular fistula follow- 
ing radical mastoid operation. 236 
APPLIED PATHOLOGY 
genital cases the canal, middle and internal ear are also in- 
volved. The thorough knowledge of the embryology is impera- 
tive in the proper conception of the subject of congenital cases. 
A large group of the cases are those following disease and in- 
jury especially since the war. 
In the acquired form each case is an entity of its own and 
necessitates individual treatment, invariably surgical. The 
reader is referred to Beck’s chapter in Loeb’s “Surgery of the 
Nose, Throat and Ear” (Figs. 229 to 235). 
Chronic Eczema of Pinna.—Most of the times chronic eczema 
of the pinna is associated with the same pathologic process of 
the external auditory canal; however, there are many cases con- 
fined to the pinna and to only part of it. This is particularly 
the case in association with what is termed status eczematosus 
in children wherein there is present a phlyctenular conjuncti- 
vitis, adenoid and tonsil disease, and enlarged lymphatic glands 
of the neck. The most frequent location of this eczematous 
process of the pinna is in the crease behind it and over the 
lobule. We had one case of the most joersistent chronic eczema- 
tous condition of the pinna and canal on both sides in which 
there was present a chronic middle ear suppuration. The bac- 
terial flora was the most complex and the bacillus pyocyaneus 
could not be recovered from cultures, and there was no green 
colored appearance of the colonies. If any organism was at all 
predominating it was the Bacillus pseudodiphtheria} and pro- 
digiosus. Only after a radical mastoid on both sides did the 
eczematous process abate, but the condition never did clear up 
entirely. 
The treatment is that of chronic eczematous condition any- 
where of the body and since the bacillus pyocyaneus is very fre- 
quently present in abundance, one will find that boracic acid 
powder and the application of silver nitrate, 5 to 10 per cent 
solution, will be the most effective in relieving the symptoms of 
moisture and itching. Water localty is to be avoided. 
Chronic Perichondritis.—Following the acute process of peri- 
chondritis, especially of the traumatic infectious form, chronic 
perichondritis is the most frequently met with. Owing to the 
absorption of the cartilage and the subsequent contraction of 
the inflammatory connective tissue, there results a deformity, at CHRONIC DISEASES OF THE EAR 
237 
least a marked thickening of the skin and underlying structures 
(Figs. 236, 237 and 238). 
The treatment consists in cleaning up any infectious tract or 
place that may still he present. The chronic inflammatory prod- 
ucts are little if at all influenced by the application of most 
remedies: Ichthyol or Crede’s ointments and tincture of iodine 
occasionally applied may influence the process of absorption. 
The deformity is only amenable to surgical plastic measures as 
implants of cartilage or fascia lata. 
Tumors of External Ear.—1. Benign Tumors.—We have seen 
only two cases of nonmalignant tumor, namely, chondroma and 
paraffinoma, of the auricle. 
236 
237 
238 
Fig. 236.—Chronic perichondritis. Prize fighter’s tin ear. 
Fig. 237.—Chronic perichondritis. Roll or cauliflower ear following spontaneous 
hematoma opened and infected. 
Fig. 238.—Chronic perichondritis with fistula following incision of a subperiosteal 
abscess. 
Chondroma.—There was no history of trauma or inflamma- 
tion. More than three-fourths of the pinna and part of the ex- 
ternal auditory canal began to enlarge and thicken when the 
patient was a small boy and by the time we saw him at the age 
of twenty-three he had a smooth growth especially at the helix 
and antihelix (Figs. 239), which was hard to the touch yet it 
could be bent slightly. It had not grown any for the past five 
years and he came only on account of cosmetic reasons. Part 
of the growth Avas resected and it cut with considerable diffi- 238 
APPLIED PATHOLOGY 
culty although nowhere was any sensation of bone encountered. 
The histologic examination revealed normal cartilage cells and 
no inflammatory products were present. 
Paraffinoma.—The patient had a soft roll ear (congenital de- 
fect) and an attempt was made to stiffen and reshape it by 
paraffin injections. The melting point of the paraffin that was 
injected could not be determined but judging by the feeling of 
the growth it probably was what is known as Eckstein’s hard 
paraffin which is usually injected hot. The main mass was lo- 
cated at the antilielix (Fig. 240) and on the jmsterior surface of 
the auricle. The color of the whole ear was dark red and in 
Fig. 239.—Chondroma of pinna and external auditory canal 
cold weather would become cyanotic. Pain was constantly pres- 
ent. The patient said that the mass especially posteriorly was 
growing. We resected a small and safe portion of the mass 
from the posterior region and found it to be histologically char- 
acteristic of a paraffinoma (Figs. 60-68). 
2. Malignant Tumors.—The most frequently met with malig- 
nant neoplasm is epithelioma, or carcinoma, and it is the only 
kind we have had in our practice. The usual location of its 
development is at the external auditory meatus. From there it 
invades the tissues externally towards the parotid gland and 
neck and inwardly into the canal. The regional lymphatic CHRONIC DISEASES OF THE EAR 
239 
glands of the neck are involved very early. The pain, espe- 
cially of a radiating neuralgic character, is usually present. The 
Fig. 240.—Paraffinoma of pinna injected to correct a soft roll ear. 
Fig. 241 A.—Epithelioma of pinna 
and external auditory canal having a 
parotid salivary fistula, facial paralysis, 
glands of the neck, and partial ankylosis 
of the mandibular joint. 
Fig. 241 B.—Total loss of pinna fol- 
lowing use of radium for epithelioma. 
The squama, root of zygoma, and mas- 
toid process exposed and dry (no 
evidence of bone necrosis or odor). 
growth soon ulcerates, becomes secondarily infected, and breaks 
down, so that a defect soon develops. The neighboring struc- 240 
APPLIED PATHOLOGY 
tures, especially tlie parotid gland with the facial nerve, be- 
come involved very early so that the patient has both a salivary 
fistula and a facial paralysis. It is also very common to have 
a marked limitation of motion to the lower jaw from involve- 
ment of the mandibular joint. 
The patient shown in Fig. 241 A had all the symptoms and 
findings described above. The microscopic examination of such 
an epithelioma is quite characteristic of poorly differentiated 
epithelial cells and the pearls are present in large numbers. The 
blood supply wTas unusually great in this case and there were 
frequent hemorrhages from the wound. 
If one sees and diagnoses a case very early, then a thorough, 
wide excision is the only possible chance for a cure. It is very 
good practice to employ radium and x-ray (short wave-length) 
before and after operation, but they are not to be substituted 
for the operation. Only when the case has so far advanced that 
it is inoperable should x-ray and radium be employed alone. 
It is further necessary to remove all enlarged and small or 
visible lymphatic glands which are tributory to the location of 
the growth. Large doses of morphine are frequently necessary 
to subdue the severe pain. The odor which is always present is 
best controlled by formalin soaked dressings. Recently we em- 
ployed the electrocoagulation method of destruction of an ej:>i- 
thelioma of the pinna and found that the odor was much less 
than following the use of the cold method of operating. Should 
a patient have no recurrence following any methods of treat- 
ment, then the defect is to be corrected by plastic. It must be 
remembered, however, not to cover too early any area that is 
the least suspicious; therefore, waiting for six months to a year 
is good practice. 
External Auditory Canal 
Cerumen.—Inspissated wax in the external auditory canal is 
a very common trouble and only when it either completely 
blocks the canal or comes in contact with the tympanic mem- 
brane does it produce symptoms. Certain individuals are more 
predisposed to suffer from the accumulation of ear wax, par- 
ticularly those persons following certain occupations. We have 
observed it mostly in bakers, street cleaners and people working 
in cloth and clothing factories. CHRONIC DISEASES OF THE EAR 
241 
Very frequently during the extremely hot weather, the patient 
will notice the sudden shutting off of his ear and difficulty in 
hearing. Contact with the drum may produce more stormy 
symptoms, such as tinnitus, dizziness, vertigo and pain. The 
pain frequently radiates toward the head and neck. Slight devi- 
ation from the normal configuration of the canal or hony ex- 
crescences may play a part in the retention of the wax, especially 
if for some reason the ceruminal glands may become irritated 
and hypersecretive. The treatment is to remove the wax and 
this is best accomplished by syringing it out. The stream is to 
be directed up and backwards in the auditory canal. The in- 
spissation of the wax plug is often so marked as to require a 
preliminary softening for removal. A solution of sodium bicar- 
bonate, gr. xv, glycerine dr. iii, and water oz. i, dropped into 
the ear several times during the day will suffice. Peroxide of 
hydrogen may be used instead. Should the ceruminal plug not 
come away after this application, followed by syringing with 
warm water, then one must remove it mechanically. This is to 
be performed with the greatest of care since traumatism is very 
easily produced. At times a cliolesteatomatous mass mixed with 
it or with dirt may be mistaken for a wax plug and this is usu- 
ally much more difficult to remove than simple cerumen. 
Chronic Eczema of the External Auditory Canal.—This is very 
frequently associated with either an eczematous process of the 
pinna or it may be secondary to, or associated with, an acute or 
chronic suppurative middle ear disease. The pathologic change 
is the same as eczema in any part of the body. The most dis- 
tressing symptoms are itching and scabbing. This leads to the 
patient’s using all sorts of things to scratch the ear, such ar- 
ticles as ear spoons, hairpins, matches, toothpicks, pencils and 
the finger nails. This usually causes an infection and often- 
times an acute diffuse otitis externa. 
Treatment consists in prohibiting the use of these implements 
and avoidance of the use of water. The canal should be packed 
with gauze impregnated with ointments and we have found the 
ammoniated mercury, 5 per cent, or iclithyol ointment, 10 per 
cent, most satisfactory in our practice. Most frequently after 
the process has almost recovered, there is a recurrence, and 
therefore we consider this affection practically incurable. The 242 
APPLIED PATHOLOGY 
stenosis of the canal that so frequently accompanies this con- 
dition, especially in the cases of chronic suppurative otitis 
media, may become very significant in the possible cause of 
retention. The treatment of this latter difficulty is the gradual 
dilatation by firm gauze packing. The underlying pathologic 
condition of the stricture is a chronic subcutaneous infiltration, 
even a perichondritis and periostitis; especially is this found in 
the cases that followed the repeated acute diffuse otitis externa 
and particularly where the bacillus pyocyaneus was predomi- 
nating or where the moulds existed for a longer period. 
Chronic Otitis Externa Sicca or Exfoliata.—Some of the most 
persistent external ear cases are those where the patient com- 
plains of constant itching and where we find nothing but a 
dry canal and instead of cerumen a detritus which when closer 
examined is found to be mostly exfoliated epithelial cells and 
small particles of hard wax. This formation is probably the 
result of the constant scratching of the canal in response to the 
itching. The dry canal without the itching is frequently found 
associated with progressive deafness of the chronic inflamma- 
tory form. We are of the opinion that both the dryness and 
itching of the external auditory canal is the result of a disturb- 
ance of the fifth nerve either ganglionic or peripheral, the itch- 
ing being irritative and the dryness trophic. There is possibly 
an analogy between this ear affection and that described as 
herpes zoster oticus, which has been definitely established by 
J. Ramsey Hunt as a disease of the geniculated ganglion. We 
have in one case of herpes zoster oticus complicated with facial 
paralysis, elicited a history of marked itching of the canal for 
a longer period preceding the acute attack of blisters. We also 
associated a chronic peritonsillitis with recurrent quinsy as a 
possible etiologic factor. The marked itching that this patient 
had had was cured following a tonsillectomy, as was the more 
rapid recovery of the herpes zoster and facial paralysis. We 
also have a fair number of these dry and itching ear canals that 
were relieved by tonsillectomy and attention to the teeth. Other 
treatment than the above is only symptomatic. We have found 
the home use of an ointment made up of phenol, menthol and 
anesthesin each gr. x in lanolin * i, to give most relief. This 
is applied into the canal by means of a properly cotton wound CHRONIC DISEASES OF THE EAR 
243 
tooth pick. Internally sedatives as bromides are at times of 
benefit. 
Chronic Otitis Externa in Which Moulds Are Present.— 
Chronic otitis externa in which moulds are present is a very 
persistent form of ear disease, unless a jDositive diagnosis by the 
aid of the microscope is made, when treatment is usually very 
efficacious. The mould present may be the Aspergillus which 
may be black (niger) or yellow (flavus) and at times greenish 
(fumigatus). The Penicillium variety may also be present, as 
well as other varieties, as Verticillium. 
The extreme itching present with the patients frequently re- 
moving masses of detritus from the ears is very significant. 
Pain is not an infrequent sign due to the inflammation of the 
canal. As stated before the microscopic examination showing 
the mycelium is absolutely necessary. The treatment consists 
in withholding watery solutions in irrigation of the ear. Instil- 
lation of salicylic acid in alcohol, 5 per cent solution, every two 
or three hours (this is at times very painful for a few moments) 
for one day, is, as a rule, all that is necessary. The raw canal 
can be painted with 5 to 10 per cent solution of silver nitrate 
and that followed by zinc salve. 
Animal parasites that appear in chronic external ear diseases 
or connected with chronic suppuration of the middle ear are 
rare, yet we have observed some cases in public institutional 
practice. These are cases of very negligent indolent persons 
whose bodily hygiene is bad. It is the maggot that is found 
incorporated in pus and epithelial masses. The external audi- 
tory canal is very much inflamed and in one particular case the 
regional glands in the neck were much enlarged and tender. 
The mechanical removal of these larvae (maggots) and thor- 
ough cleansing of the canal is usually all that is necessary. Of 
course, the general hygienic improvement is most important. 
CHRONIC OTITIS MEDIA 
The various pathologic types may be mentioned as: 
1. Chronic otitis media purulenta. 
(a) Pyogenic 
(b) Pyogenic and cholesteatomatous 244 
APPLIED PATHOLOGY 
(c) Tuberculous 
(d) Syphilitic 
(e) Foreign bodies 
(f) Neoplastic 
2. Chronic nonsecretive otitis media. 
(a) Hyperplastic or hypertrophic 
(b) Adhesive 
(c) Atrophic. 
3. Otitis media residualis of Wittmaack. 
4. Otitis media serosa or mucosa. 
While it is true that the middle ear may be solely involved, 
yet in the majority of the above-mentioned conditions the mas- 
toid cells likewise participate in the same process. It would be 
well, therefore, to consider these conditions as tympanomastoid 
disease. 
CHRONIC SUPPURATIVE TYMPANOMASTOIDITIS 
Chronic suppurative tympanomastoiditis, which usually fol- 
lows an acute process which has failed to heal, will show the fol- 
lowing pathologic changes: 
Granular 
perforation 
Multiple 
perforation 
Fig. 242.—Schematic outlines of perforations as to prognosis, 
Perforations.—Perforations may be single or multiple, central 
or peripheral. Considerable information is suggested by the lo- CHRONTC DISEASES OF THE EAR 
245 
Marginal tegmen 
perforation 
Central attic perforation 
Posterior superior 
marginal perforation 
L,arge central perforation 
Central tubal perforation 
Posterior inferior 
or mastoid marginal 
perforation 
Anterior inferior marginal 
perforation 
Inferior or fundus 
marginal perforation 
Fig. 243.—Schematic illustration of multiple perforations 
Fig. 244.—Polyp in ear completely filling the external canal in case of chronic 
suppurative otitis media. 
Tig. 245.—Incus removed in case of chronic suppurative otitis media, (showing 
an osteitis in its long process.) 246 
APPLIED PATHOLOGY 
cation of the perforation. Thus, following the illustrations (Figs. 
242 and 243), the central perforations are, as a rule, of very little 
consequence from the standpoint of complications, whereas 
peripheral perforations are always dangerous, as to the pos- 
sibility of the development of intracranial complications. An 
attic’ perforation is very apt to be followed by brain abscess or 
meningitis. Posterior-superior perforations, or necrosis at the 
incudostapedial joint, are also likely to be followed by intracra- 
nial complications. In posteroinferior perforations the facial 
Fig. 246.—Ankylosis of the malleus and incus removed in case of chronic suppura- 
tive otitis media, showing necrotic areas in both bones. 
Fig. 247.—Center perforation healed over 
by thin scar. 
Fig. 248.—Thickened margin of cen- 
tral perforation, showing marked injec- 
tion of the lining of the middle ear. 
nerve and horizontal semicircular canal may be involved. In 
inferior or fundus perforations the jugular bulb may be in- 
volved, with a subsequent thrombosis. In anteroinferior per- 
foration the internal carotid artery must be considered. Mul- 
tiple perforations whether central or peripheral are suggestive 
of syphilis or tuberculosis. When granulations surround the 
perforation it is more likely to be tuberculous. Granulations 
protruding from a single perforation, especially marginal, are 
usually of pyogenic origin complicated by cholesteatoma and CHROXIC DISEASES OF THE EAR 
247 
necrotic bone. At times this type of granulation may grow into 
the external canal, forming an aural polyp (Fig. 244). 
The ossicles are usually well preserved in chronic tympano- 
mastoid disease (Fig. 245). However, very frequently, espe- 
cially in the large central perforations, part of a hammer handle 
will be found either absorbed or necrotic. Likewise, the malleus 
and incus may be completely ankylosed (Fig. 246). Healing- 
takes place only in moderately large perforations and a mem- 
brane forms which is usually of a grayish, shiny appearance, and 
can be made out clearly with the aid of a Siegle’s otoscope (Fig. 
247). The lining membrane of the middle ear proper can fre- 
quently be seen through a central perforation, apparently thick- 
ened (Fig. 248). 
In the mastoid cells from the aditus ad antrum and extending 
through the entire cellular system one may find various patho- 
logic changes. Either the lining membrane of the cells is thick- 
ened as well as the bone, or the cells may be filled with granula- 
tion tissue and the bone is soft. At times cholesteatomatous 
masses may occupy the mastoid cavity to a greater or less ex- 
tent. The cholesteatomatous matrix can be peeled out in layer 
formation. Fistulous tracts may be present throughout the 
mastoid, either single or multiple. 
Treatment.—In central perforations, whether large or small, 
the case is not, as a rule, an operative one. In marginal per- 
forations there is always associated bone necrosis and surgical 
interference is usually necessary. We believe that the watchful 
waiting in this type of case is a dangerous procedure. Again, 
in central perforations attention must be directed to the naso- 
pharynx. Direct medication can be applied through the eusta- 
chian tube and middle ear proper. Recurrence will usually fol- 
low an attack of acute rhinitis. Such other procedures may be 
adopted as Bier’s hyperemia, suction, vaccines, etc. We have 
in recent years been using in addition to strong solutions of 
silver nitrate applied directly to the granulation tissue in the 
middle ear, such solutions as suggested by Callison, instilled 
directly into the ear. (Tincture of iodine, 15 drops; phenol, 15 
drops; alcohol, 4 drams; water q. s. 1 ounce.) It should be men- 
tioned here that every chronic discharging ear may give rise 248 
APPLIED PATHOLOGY 
at any time to intracranial complications and necessitate opera- 
tive procedure. 
We emphasize the importance of keeping it dry by instructing 
the patient not to allow water to get into the external ear. Boric 
acid powder, when the perforation is large, is lightly packed 
into the canal as far as the tympanic membrane, or strips of 
gauze are lightly placed in the canal in contact with the per- 
foration. Here we would like to make the point again as we did 
in acute otitis media, that the external auditory canal is the 
only place in the body where gauze alone may rationally be used 
as capillary drainage. Another great aid in our treatment, and 
Fig. 249.—Beck’s wall plate. Filtered compressed air and gauge; vacuum bottle 
and gauge; rheostat for light and cautery; illuminating gas outlet; three separate 
sockets. 
which we employ constantly in every case, is capillary suction. 
The suction is obtained from an automatic pump placed far 
away from the offices and the vacuum bottle with a gauge is at- 
tached to our wall plate (Fig. 249). The cannulae which are the 
same as shown in Fig. 12, are used and are worked by the same 
cutoff. 
We have also in a limited number of patients given this suc- 
tion treatment as home treatment by employing the water suc- 
tion apparatus as shown in Fig. 11, and using the oil silk or 
rubber flexible tijo which prevents injury. CHRONIC DISEASES OF THE EAR 
249 
Other means are tried by us such as are employed by most 
otologists with varying success. In using such antiseptic solu- 
tions as acriflavin (1:1000), mercurochrome (5 per cent solution) 
and gentian violet (1 per cent solution), all of which have a dis- 
agreeable tendency to stain the skin about the ear, it will be 
found that covering the external parts of the ear with lanolin 
will avoid this staining somewhat. Dakin’s solution has been 
found too irritating and of no particular value. 
CHRONIC NONSECRETIVE OTITIS MEDIA 
There is a form of middle ear disease that does not show any 
demonstrable pathology in the accessory spaces of the mastoid. 
A hyperplastic process involving the drum itself is part of this 
pathologic condition. The luster of the drum disappears and a 
distinct thickening of the drum membrane is to be noted. We 
have had one such case which terminated fatally during an 
intercurrent cardiovascular disease* in which we were able to 
demonstrate postmortem diffuse hyperplasia of the mucous 
membranes in the middle ear. This condition, however, is to be 
differentiated from a distinctly hypertrophic form, which is a 
definitely inflammatory disease extending from the nasopharynx 
through the eustachian tube. Roentgen-ray examination in this 
type of case will show much greater density in the middle ear 
region and some clouding of the mastoid cells. We have also had 
a postmortem examination of a case of this type (hypertrophic) 
in which death was due to an intercurrent affection.* The mas- 
toid was well pneumaticized and the cells were lined with a 
thickened membrane. The bone itself was unchanged, in marked 
contradistinction to the definitely hyperplastic changes involv- 
ing the bone in the first-named type. In the cavum, the attic, 
and aditus ad antrum the membrane showed a distinct hyper- 
trophy. The epithelium was considerably thickened and the 
subepithelial structures much infiltrated, while a large amount 
of connective tissue was present. The mucous glands appeared 
larger and more numerous than normal, in the region of the 
tympanic membrane near the eustachian tympanic opening. 
sections of specimens removed at the postmortem were exhibited at 
the meeting of the American Academy of Ophthalmology and Oto-Laryngology in 
Denver in 1908. These were lost by the committee on Pathologic Exhibit and conse- 
quently it is impossible to have the microphotographs for this publication. 250 
APPLIED PATHOLOGY 
Within the cells proper there was found a serous, though sterile, 
fluid. 
ADHESIVE OTITIS MEDIA 
Adhesive otitis media is usually the legacy of a previous 
hypertrophic otitis media with resulting adhesions throughout 
the entire tympanic cavity, including the attic. These adhesions 
may result in change of position of the ossicles and of the drum 
(Fig. 250). The mobility of the tympanic membrane is there- 
fore restricted to a greater or less extent. At times one will find 
calcareous deposits in these markedly retracted drums, espe- 
cially if there is a history of previous existing suppuration (Fig. 
Fig. 250.—Marked retraction of the 
drum with displacement of the ossicles. 
Fig. 251.—Calcareous deposit in a drum 
membrane. 
251). In one available specimen from a postmortem examina- 
tion of a case diagnosed clinically as of this type* there were 
found to he dense fibrous adhesions in the attic, between Shrap- 
nell’s membrane and the ossicles. The ossicles themselves 
appeared somewhat ankylosed to each other. The eustachian 
tube showed marked thickening and hypertrophy of the mucous 
membrane, particularly in the region of the isthmus. Micro- 
scopic examination showed hypertrophy of the lining membranes 
and considerable increase in the connective tissue elements. 
The blood vessels were small in size and few in number. 
ATROPHIC OTITIS MEDIA 
Atrophic otitis media is apparently hut a further stage of the 
hypertrophic form in which there is secondary atrophy. The 
tympanic membrane in these cases is markedly retracted and 
*See footnote on page 249. CHRONIC DISEASES OF THE EAR 
251 
very greatly relaxed, being easily drawn out but immediately 
recoiling into its original position. A physical force has been 
described as the causation of this retraction, a vacuum being- 
produced as the result of occlusion of the eustachian tube. His- 
tologic examination of specimens in this condition* reveals an 
atrophied tympanic membrane made up chiefly of scar tissue 
covered with a thin layer of epithelium. 
OTITIS MEDIA RESIDUALIS OF WITTMAACK 
(Writer’s Terminology with apologies to author) 
One of the most interesting and fascinating contributions to 
{■(/ 
Fig. 252.—Section through the mastoid of a six year old child after latent hyper- 
plastic otitis, showing complete arrest of pneumatization. The bone is sclerotic and 
the subepithelial tissue tilling the antrum is hyperplastic. (After Wittmaack.) 
otology is that of Wittmaack. Iiis work is based on years of 
observation and investigation of the temporal bone at various 
ages, from fetal life to old age (Figs. 252, 253, and 254). It has 
particular reference to the pneumatization of the mastoid proc- 
ess. He believes that the ultimate structure of the mastoid is 
dependent on developmental conditions at birth, which he desig- 
*See footnote on page 249. 252 
APPLIED PATHOLOGY 
nates as otitis media neonatorum. This is the result of amniotic 
fluid finding its way into the middle ear during parturition, thus 
giving rise to a cessation of the normal process of absorption 
and subsequent pneumatization. He is of the opinion that a 
type of myxomatous material remaining within the middle ear 
is responsible for the development in later life of various affec- 
tions of the ear. He feels that this material is subject to infec- 
tion, giving rise to the recurrent otitis media of childhood and 
Fig 253.—Section through the mastoid tip in a two year old baby, showing a 
partly pneumaticized mastoid, with the nonpneumaticized portion filled with marrow 
cells and a partly developed cellular network. The mucous membrane shows fibrinous 
changes and there is much fat present. (After Wittmaack.) 
to the chronic adhesive processes of later life. Arrested pneu- 
matization may therefore result, which predisposes towards 
suppurative conditions of the mastoid cavity. He believes, 
furthermore, that the so-called sclerosed mastoid associated with 
chronic suppuration is not the result of the suppuration per se, 
but that the sclerosis is primarily an arrest or failure of pneu- 
matization. CHEOXIC DISEASES OF THE EAR 
253 
We are at variance with several factors suggested by Witt- 
maack. For the past ten years we have as a routine x-rayed the 
tympanomastoid region of every case of progressive deafness, 
and have found clear pneumatization of the mastoid cells in a 
great majority of cases of chronic, nonpurulent otitis media. 
We furthermore believe that the sclerotic process is a reaction 
Fig. 254.—Section through the mastoid in an adult 60 years of age, showing nor- 
mal pneumatization. At the periphery one sees active pneumatization going on. 
(After Wittmaack). 
to inflammation and not a developmental abnormality as a result 
of the presence of amniotic fluid within the middle ear cavity. 
A case will emphasize our belief. 
Miss H., aged twenty-five years, a medical student, developed 
a violent right acute otitis media with bulging red drum and 
pain over the mastoid and temporal region, necessitating para- 
centesis. Stereoroentgenograms of both mastoids showed a 254 
APPLIED PATHOLOGY 
clear and extensive pneumatization of both mastoid processes. 
The acute processes progressed to a chronic suppurative otitis 
media and after nine weeks’ observation and treatment, the pa- 
tient went to China. Eight years later she returned to us and 
examination of the right ear showed a purulent discharge from 
the postero-inferior marginal perforation, with a very foul odor. 
The hearing in that ear was markedly reduced. The patient 
complained of vertigo and unilateral headache. Roentgen ex- 
amination at this time, eight years after the acute process, 
showed a completely blocked mastoid with no vestige of any 
mastoid cells in evidence. A radical mastoid operation was per- 
formed and not a single cell was found throughout the entire 
process, with the exception of the antrum which was likewise 
Fig. 255.—Osteofibrosis and chronic suppurative otitis media showing complete 
fibrosis of the mastoid cells. The bone is changed into fibrous tissue. There is no 
evidence of any recognizable bony structure or necrosis. 
practically obliterated. Microscopic examination of chips of 
bone removed showed a distinct fibrosis and no evidence of 
pneumatic cells (Fig. 255). 
CHRONIC OTITIS MEDIA SEROSA OR SEROMUCOSA 
Chronic otitis media serosa is comparatively rare and seldom 
the forerunner of an infectious process. Jt usually occurs in the 
aged, particularly in those who appear to have excessive secre- 
tions in the nasopharynx. The tympanic membrane appears 
thickened and gray and often shows a dark line traversing it 
horizontally. This line appears to change its position when the CHRONIC DISEASES OF THE EAR 
255 
head is tilted forward or backward. Upon inflation one can 
hear the gurgling sound of free fluid in the cavity. Inspection 
of the drum immediately after such inflation will show scattered 
spots. Upon incision of the drum membrane a serous or sero- 
mucous fluid will be emitted, especially when aided by the Val- 
salva method. At times it has been necessary to establish a 
permanent perforation with the actual cautery in order to pro- 
vide exit for this increased seromucous secretion because these 
incisions have a tendency to close too soon. We have operated 
upon one such case in which the patient complained of consider- 
able mastoid pain, and heaviness of the head, the x-ray showing 
marked mastoid involvement. We operated upon the mastoid 
and found a marked accumulation of serous fluid within the mas- 
toid cells. The membrane lining of the cells was considerably 
thickened and the fluid was .sterile inasmuch as upon bacteri- 
ologic examination, both smear and culture were practically neg- 
ative. Microscopic examination showed hypertrophy of the 
epithelium and subepithelium but no glandular hypertrophy. 
The bone was unchanged. This condition occurring as a uni- 
lateral affect ion would suggest that it probably is not of systemic 
origin. 
Treatment of Chronic Nonsecretive Otitis Media.—The treat- 
ment should be directed towards an effort to determine the 
underlying etiologic factor and correlating the type of pathology 
present. In all cases the nasopharyngeal pathology should be 
corrected. However, when there are adhesions, for instance, 
little therapeutic result can be expected by the straightening of 
a deflected septum or the removal of hypertrophied tonsils. 
These measures are much more valuable in the very earliest 
manifestations of these various aural conditions. In the hyper- 
plastic and hypertrophic forms the introduction of electrically 
heated bougies through the eustacliian tube, by way of a. eusta- 
chian catheter, is of value (similar to technic in esophageal 
bouginage) (Fig. 208). The injection of a few drops of a 2 per 
cent dionin solution into the middle ear once or twice a week 
will hasten the absorption of inflammatory products. This can 
best be introduced through the eustacliian tube by means of the 
Weber-Liehl catheter, through a eustacliian catheter. 
After the dionin produces the desired reaction (hyperemia of 
the drum membrane), a Bier’s suction pump is adjusted to the 256 
APPLIED PATHOLOGY 
external meatus, hermetically closed; and gentle pull on the 
pump will further tend to break up adhesions. Caution must be 
exercised so as not to forcibly produce hemorrhage of the mem- 
brane. 
Nascent iodine introduced per eustachian catheter by means 
of the apparatus herein illustrated has been used (Fig. 256). 
The Pfannenstiel treatment has been a favorite of ours for 
years. This consists of the internal administration of a satu- 
rated sodium iodide solution in large doses, 60 to 100 drops 
within 24 hours. Hydrogen peroxide is then immediately intro- 
duced into the external auditory meatus with the head inclined 
to the opposite side, the peroxide being retained in the canal for 
Fig. 256. 
ten minutes with five changes of the solution during this time. 
A chemical reaction takes place in which there is free nascent 
iodine liberated within the tissues by a process of osmosis (Fig. 
257). This is followed by the use of Bier’s pump as described 
before. 
The local use of nascent heat will hasten the absorptive proc- 
ess. To accomplish this we have employed heated metallic CHRONIC DISEASES OF THE EAR 
257 
mercury, introduced into the external auditory canal against the 
drum membrane by means of a tube (Fig. 258). The tube 
contains about 50 grams of metallic mercury, which is 
heated readily over an alcohol flame for a few seconds. The 
neck of the tube near the mouth has a rubber collar which allows 
it to fit tightly into the external auditory canal. To-and-fro 
motion of the head from shoulder to shoulder while firmly hold- 
ing the tube in the ear, gives the desired massage and heat 
to the membrane and the impulse is transmitted to the ossicles. 
The mercury massage has the combined value of the heat and 
the action of the impulse against the drum. Inflation is of as- 
sistance and the introduction of medicaments, as ethyl iodides, 
through the Politzer bag is also of value. Mild massage by the 
Fig. 257.-—Schematic drawing’ for the Pfannenstiel treatment. 
rhythmic pressure of the tragus, producing a condensation of 
air in the external canal, can be used bv the patient. This 
should be done four to ten times a day, about twenty compres- 
sions being made each time. The use of any or all of these 
remedies, while strictly indicated, is very frequently abused and 
the condition is aggravated rather than relieved. It is partic- 
ularly true in the use of the many mechanical appliances, such 
as the vacuum pumps and concussion apparatuses. In the 
hyperplastic form it is well to remember the importance of cor- 
recting any possible dietary deficiency that may be present, par- 
ticularly the fat soluble A vitamin and inorganic salts. In the 
adhesive types not too much relief should be expected from any 258 
APPLIED PATHOLOGY 
method of treatment. Various surgical procedures have been 
suggested for removing the adhesions blit even these have been 
unsuccessful for the most part. Persistence in treatment and at- 
tempts at treatment may accomplish a great deal, and often 
accomplishes a brilliant result as illustrated by the following 
case, and could be foisted and made unfair use of in advertising. 
The West Case.—While attending a convention in a small 
city, in a neighboring state, I was asked to see a lady, twenty- 
nine years of age, a music teacher, who had for years been very 
hard of hearing and was now anticipating the unpleasantness of 
Fig. 258.—Mercury tube. 
having to give up her vocation on this account. The examina- 
tion showed that she could hear the loud voice only on contact 
and the tympanic membrane was dull and markedly retracted. 
The Rhine was negative and with markedly prolonged bone 
conduction; high tones were very well heard. Inflation gave 
practically no improvement and Siegle’s otoscope showed limita- 
tion in mobility of the drum. There was a distinct history of 
many attacks of rhinosinuitis and the family history and the CHRONIC DISEASES OE THE EAR 
259 
question of lues were absolutely negative. The Pfaimenstiel 
treatment was advised in combination with the Bier’s liyper- 
emia by suction pump which was carried out by her own physi- 
cian. As a result of this treatment the patient had such star- 
tling benefit, as to improvement of hearing, that all who knew 
the patient were tremendously impressed. The most important 
point was the lasting effect, which extended over a period of 
three years during which time the hearing was practically nor- 
mal for both conversation and whispered voice. At this time 
the patient died following an infection from an intercurrent 
disease. In attempting to obtain similar results by this means 
of treatment in many cases of the same type, we have never suc- 
ceeded as in this case, but have been able to improve a fair 
number. 
Other methods of treatment by others, as, for instance, the 
passing of a flexible wire applicator wrapped with a small piece 
of cotton and dipped into a weak solution of silver nitrate, into 
the pharyngeal end of the eustachian tube, have been heralded 
as cures just because of perhaps one case’s claiming to be mark- 
edly benefited. Such happenings as the West case and the latter 
may lead to the exploitation of hopeless cases. 
In the adhesive type, furthermore, we have used the following 
procedures: Thiosinamin, 3 grains three times a day is given by 
mouth. Fibrolysin, one ampule three times a week, has been 
given hypodermatically. (lentle massage of the tympanic mem- 
brane and ossicles by means of the Delstanclie pump, in connec- 
tion with periodical inflation, galvanism, medical diathermy and 
the high frequency current should be given a trial. We have 
also used x-ray and radium, with no particular benefit. 
In the atrophic variety very little can be accomplished. This 
condition is usually the end result of a much neglected or much 
over-treated case. Especially is this true when the practice of 
autoinflation (Valsalva method) has been followed over a long- 
period of time. This in itself can produce much stretching of 
the tympanic membrane with secondary atrophy. Heath, of 
London, lias recommended a procedure which has not been ac- 
cepted generally, but with which we have had, in well selected 
cases, favorable results. The principle of the procedure is to 
produce a chemical inflammatory reaction in the drum mem- 
brane by the introduction of solutions of cantharidin and sodium 
hydroxide in varying strengths. This is applied particularly 260 
APPLIED PATHOLOGY 
in tlie upper posterior portions of the drum. The applications 
are continued daily until a marked reaction occurs. By gentle 
massage the resulting scales on the drum can he removed. Inso- 
much as the musculus stapedius and the tensor tympani may 
likewise be relaxed, the deep sinusoidal current should he em- 
ployed. 
In the otitis media seromucosa type, the injection either 
through the eustachian tube or perforation made in the drum, of 
mild astringent solutions, especially of zinc, is of some benefit. 
SUMMARY OF PATHOLOGIC PROCESSES IN CHRONIC 
MASTOID DISEASE 
The various changes occurring in the chronic form of mas- 
toiditis can he classified as the following (the various processes, 
however, may coexist): 
1. Osteofibrosis or sclerosis. 
2. Osteofibrosis with fistular tracts. 
3. Osteofibrosis, fistular tracts and cholesteatomatous 
infiltration. 
4. Osteofibrosis, fistular tracts, cholesteatomatous infil- 
tration with cavity formation containing cholestea- 
tomatous matrix. 
5. Tuberculous osteitis. 
6. Syphilitic osteitis. 
7. Actinomycotic osteitis. 
8. Reparative osteitis. 
9. Foreign body in mastoid. 
(a) Sequestrum. 
(b) Any other substance. 
10. Neoplasms. 
(a) Sarcoma. 
(b) Carcinoma. 
(c) Endothelioma. 
1. Osteofibrosis.—As the name implies, the mastoid bone is 
converted into a more or less solid bone (see Fig. 255). The 
cortex is hard and bleeds very little. The cells are conspicuous 
Chronic Mastoid Disease CHRONIC DISEASES OF THE EAR 
261 
Fig. 259.—Chronic suppurative otitis media, showing osteo-fibrosis with fistulae 
formation. There are evidences of necrosis, with tracts lined with granulation tissue 
and filled with pyogenic material. (Low power.) 
Fig. 260.—Otitis media suppurativa chronica (high power), showing necrosis 
with accompanying fibrous reparative process—a chronic osteofibrosis with fistulous 
tract, filled with pus and granulation tissue. 
by their absence, and oftentimes not a single cell is found until 
the antrum is reached. If any cells are present, they are very 
small and usually located in or near the tip. The degree of 262 
APPLIED PATHOLOGY 
Fig. 261.—Chronic suppurative otitis media, showing osteofibrosis, fistulous tracts 
and cliolesteatomatous infiltration. The epithelial masses have a center of pus and 
show the spreading into the bone. 
Fig. 262.—Otitis media suppurativa chronica. Showing cliolesteatomatous matrix 
from the mastoid cavity, with erosion of surrounding tissues. The material is poorly 
stained and shows no differentiation. 
sclerosis depends a great deal upon the preexisting type of mas- 
toid structure, i. e., pneumatic or diploic. In the former the 
fibrosis is more complete than in a large celled mastoid. The CHRONIC DISEASES OF THE EAR 
263 
Fig. 263.—Otitis media suppurativa chronica. Tuberculous osteitis with fine, 
fistulous tract leadiug towards the surface. The center of the tubercle shows evi- 
dence of caseation and round-celled infiltration. 
Fig. 264.—Otitis media suppurativa chronica. Showing tuberculous focus with fistula. 
histologic findings show the dense bony structure or necrotic 
areas. 
2. Osteofibrosis with Fistular Tracts.—Practically the same 
findings are encountered as in the preceding form except that a 
few cells are met with, and a number of tracts lined with granu- 264 
APPLIED PATHOLOGY 
Fig. 265.—Sequestral osteitis showing particularly the worm-eaten appearance of the 
edges of the sequestrae. 
Fig. 266.—Sequestral luetic osteitis. 
lation tissue and pus (Figs. 259 and 260). The bleeding is also 
more pronounced. In these eases there is frequently found an 
exposure over the promontory of the horizontal canal as well 
as the tegmen, a condition well to remember in the acute exacer- 
bations, as causes of brain abscess, meningitis and labyrinthitis, CHRONIC DISEASES OF THE EAR 
265 
The facial canal, bony lateral sinus wall and other portions 
of the labyrinth are less frequently the seat of these necrotic 
areas. These localized necrotic areas are usually covered with 
granulations and it is. considered had practice to remove them 
as they serve as protection to further septic invasion. 
3. Osteofibrosis, Fistular Tracts and Cholesteatoma.—Again 
the same pathologic changes are found as in the two varieties 
previously mentioned and in many cases the cholesteatomatous 
changes are not possible of detection grossly in the mastoid, but 
are microscopically (Fig. 261). However, when the antrum, 
aditus and attic are exposed by operation one will be able to 
remove a considerable mass of cholesteatomatous material (Fig. 
262). All are familiar with the characteristics of these masses, 
but they can he further identified grossly by the Bruehl test, by 
adding a few drops of chloroform to a mass which will turn 
a yellowish green (eholesterin). The microscope will always 
demonstrate the characteristic crippled epithelial cells. 
4. Osteofibrosis, Fistular Tracts, Cholesteatoma with Cavity 
Formation.-—-The cavity that is found in these cases varies in 
size from that of a small marble to the size of the mastoid proc- 
ess and extends in some cases beyond its confines. The location 
of this cavity may he at the tip, over the antrum or continuous 
with the attic to the antrum, the so-called spontaneous radical 
mastoid operation. Pressure atrophy of the bone due to the 
continuous formation of epithelium in layers like an onion, plus 
the necrosis due to the infection, is the explanation of this 
cavity formation. These masses often contain particles of 
necrotic bone (bone dust) which may he demonstrated by mi- 
croscopic examination of previously centrifuged washings from 
the ear. The cavity itself is lined by a glistening membrane 
known as the matrix from which the new epithelial cells form 
(see Fig. 262). This matrix is not a mucous membrane or skin, 
not even an epithelial cicatrix. 
5. Tuberculous Osteitis of the Mastoid.—Grossly, this con- 
dition cannot he identified, except that it may be suspected when 
the fistular tract formation is very marked, even finding one 
or more on the cortex, which is uncommon in other forms of 
chronic otorrhea. Again there are often softened areas of con- 
siderable size surrounded by very dense bone (Figs. 263 and 266 
APPLI ED PAT 11OLOG Y 
264). Granulations are also more numerous throughout the mas- 
toid process. Actual collections of pus are present in which, 
however, we have never found the tubercle bacillus. 
6. Syphilitic Osteitis of the Mastoid is as a rule a sclerosed 
process but not eburnated. At times it is entirely softened con- 
taining sequestra of considerable size (Figs. 265 and 266). The 
granulations surrounding such a sequestrum are large and flabby 
and do not bleed very much. The three cases of this type which 
we have identified with subsequent microscopic examination all 
had the characteristic of having very little calcareous material 
remaining in the bone (Fig. 267). 
Fig. 267.—Mastoid chip in chronic suppurative otitis media of luetic origin, show- 
ing an osteofibrosis. The bone is soft in areas and fibrous in other places. Bismuth 
infiltration also is seen. 
7. Actinomycosis of the Mastoid.—Two cases of actinomy- 
cosis are on record, one by Majochi and the other which the 
author had the pleasure of studying under his service with Pro- 
fessor Zanfal and the pathologist Professor Cliiari at the Uni- 
versity of Prague. It was found that the mastoid bone includ- 
ing the cortex was practically riddled with fistulae containing 
thick pus in which there were the characteristic yellowish bodies 
(actinomyces). The bone was quite soft otherwise. 
The patient was a farmer of middle age. He was operated 
upon for mastoid which had a very stormy and protracted CHRONIC DISEASES OF THE EAR 
267 
course. Intracranial invasion complicated the case and the pa- 
tient died following a rupture of the internal carotid artery 
which became involved in the process as it passed through the 
temporal bone. Particles of tissue removed from different parts 
of this bone, as well as the soft parts, showed the characteristic 
histologic picture of actinomycosis. 
The treatment, aside from surgery of the necrotic areas, is the 
administration of potassium iodide in fairly large doses and the 
x-ray. 
8. Reparative Osteitis of the Mastoid.—The pathologic proc- 
ess refers to the reoperated cases. The previously exenterated 
Fig. 268.—Epidermal scar of healed radical mastoid cavity, showing the ab- 
sence of any blood vessels or any resemblance to true skin. It is scar tissue covered 
by a thickened epithelial layer. 
cavity is either tilled with granulations, cliolesteatomata or 
both, or it is lined by the characteristic epithelial scar (Fig. 
268). The bone of these cavities is as a rule very hard and tlie 
edges or margins of the cavity are thickened and irregular. It 
always appears (especially if one does the reoperating on his 
own case) as though the bony cavity were much smaller than 
when it was made at the previous operation. Bleeding is very 
free from these granulations as well as from the bone. (See 
Figs. 39 and 40.) There can scarcely be a description of the 
various parts of the mastoid since each case is an entity in itself. 268 
APPIUi:l) PATHOLOGY 
9. Foreign Body in the Mastoid.—(a) The sequestrated type 
is, except in the syphilitic osteitis already described, most fre- 
quently met with in children, usually the result of an incom- 
plete simple mastoid operation, especially in the cell route or 
confluent variety of mastoiditis. These sequestra are always 
surrounded by somewhat healthy granulations, bleeding very 
freely. The sequestrum is usually very easily dislodged, is ir- 
regular in shape and has the appearance of being the axial part 
of several mastoid cells. At times these sequestra are very 
small, flat, with very pointed edges (Fig. 265). (b) As to 
other foreign bodies, they may be shots, bullets, shell fragments, 
parts of instruments, such as gouges, knife and scissor blades. 
Surrounding such a foreign body is usually an infected area 
with or without granulations, depending upon the length of 
time that the foreign body has been in the mastoid. The only 
treatment of both types is early operative interference. 
10. Neoplasms of the Mastoid.—We have had all the three 
varieties of malignant growth, sarcoma, carcinoma and endothe- 
lioma, but they always resulted from extension of similar 
growths in the vicinity of the mastoid. In the case of sarcoma, 
it was a retromaxillary tumor that finally involved the mastoid 
process. In the carcinoma, it was the result of a progressive 
epithelioma of the external ear, and in the case of endothelioma 
it followed a primary growth of that nature from the middle 
ear. The gross pathology was that of a malignant disease of 
bone anywhere in the body, except that it was complicated by 
secondary infection. The microscopic changes are also those 
characteristic of sarcoma, carcinoma and endothelioma. The 
type of endothelioma in this particular case was endovascular. 
CHRONIC DISEASES OF THE INTERNAL EAR 
A thorough knowledge of the pathologic processes concerned 
in the various diseases of the internal ear is imperative in order 
to arrive at a proper diagnosis and to institute the proper 
treatment. Unfortunately, in this country postmortem material 
is scarce and but little actual pathologic examination of the 
temporal bone in chronic diseases of the internal ear has been 
made. Our source of information has, therefore, been from the CHRONIC DISEASES OF THE EAR 
269 
clinics abroad. The chief conditions involving the internal ear 
in a chronic process are as follows: 
1. Neuritis of the eighth nerve. 
2. Neuritis secondary to middle ear inflammation. 
3. Chronic suppurative labyrinthitis. 
4. Syphilitic labyrinthitis. 
5. Otosclerosis. 
(>. Traumatic labyrinthitis. 
7. Hemorrhage into the labyrinth. 
8. Occupational labyrinthine disease. 
9. Congenital labyrinthine affections. 
10. Neoplasms. 
1. Neuritides of the Eighth Nerve.—The etiology in these 
cases is, as a rule, either toxic or infectious. The process, having 
been instituted as an acute one, may continue and become 
chronic. Inflammatory processes may be primary in the nerve 
itself, or secondary in the nerve as the result of inflammation 
elsewhere; i. e., otitis media, acute infectious diseases, etc. Al- 
cohol, lead and quiniii are particularly apt to cause a neuritis 
of the eighth nerve. Almost any toxemia, whether it be gastro- 
intestinal or otherwise, may be the determining factor in a 
chronic neuritis of the auditory nerve. Either portion of the 
nerve may be involved with ecpial frequency. Syphilis is a most 
frequent cause, and there is no doubt that focal infections, par- 
ticularly in the teeth, tonsils and sinuses, give rise to a chronic 
neuritis of the auditory nerve, either of the cochlear or vestibu- 
lar branch, or both. The pathologic process may involve any 
portion of the nerve. 
The symptoms are those of irritation and subsequent destruc- 
tion of the nerve. In the former instance there is hyperacusis, 
tinnitus, or dizziness with nystagmus followed by deafness. The 
functional reactions of the vestibular apparatus are altered. 
Treatment.—Treatment primarily is to be directed toward the 
etiologic factors. If it is toxic in origin, for instance, because 
of the use of alcohol or tobacco or various drugs, the cause 
should be removed and vigorous elimination established. "When 
the process is syphilitic, vigorous antisyphilitic treatment should 
be instituted. During the initial administration of arsphenamine 270 
APPLIED PATHOLOGY 
11 le clinical symptoms become much worse and this has led many 
otologists to avoid the use of this arsenic preparation in the 
treatment of this condition. We, however, are firmly of the 
belief that it is not a question of omitting arsphenamine but of 
increasing the size and frequency of the dose. The reaction is 
rather typical and is known as the Herxheimer reaction. If the 
cause is suspected to be secondary to some chronic focus of in- 
fection, then that should be removed if possible. 
2. Neuritis Secondary to Middle Ear Inflammation.—Either 
during an acute or chronic inflammatory process of the middle 
ear one may find a true affection of the auditory nerve without 
the bony structures of the labyrinth being destroyed. In the 
acute conditions it is very easy to understand how by contiguity 
of tissues the nerve may become inflamed. In the chronic proc- 
esses it is more of an anesthesia, if such term is permissible, or 
from the fact that deafened people forget to listen and thus the 
nerve stops functioning from nonuse. The treatment is directed 
to reeducation of the nerve and lip reading. Hearing devices 
are also advised. 
3. Chronic Suppurative Labyrinthitis is usually associated 
with chronic suppurative tympanomastoid disease or is a se- 
quence to acute labyrinthitis. The infectious process is located 
usually either over the promontory of the horizontal semicircu- 
lar canal, at the floor of the antrum, or in and about the oval 
window, or it may be located anywhere in the vicinity of the 
labyrinth. There is present a bone necrosis which may be par- 
tial or complete, and the typical fistula symptoms may be elic- 
ited. It is important that this fact be kept in mind when doing 
a radical mastoid operation. Should a defect in the horizontal 
canal or any part of the labyrinth be encountered covered with 
granulations, then the granulations should be let alone, or else 
a localized process might be converted into a diffuse labyrinth- 
itis. Syphilis or tuberculosis may be the primary factor in this 
process. We have observed a rather complete mass necrosis of 
this region in several cases during the course of a chronic sup- 
purative process, and during the operative procedure sequestra 
and portions of the cochlea were removed with the granulation 
tissue. In three such cases that we have observed, no meningeal 
reaction followed, due probably to well formed barriers at the CHRONIC DISEASES OK THE EAR 
271 
internal auditory meatus. All three eases had a permanent 
facial paralysis before operation and there was complete deaf- 
ness and absence of any vestibular response. When the fistula 
test proves positive after a radical mastoid operation has pre- 
viously been performed and suppuration still persists from the 
region of the labyrinth, it may be necessary to destroy the laby- 
rinth and thus do away with a potent factor in the development 
of a meningitis, etc. 
4. Syphilitic Labyrinthitis.—In connection with chronic sup- 
purative ear disease, the labyrinth may be involved. There may 
be present a syphilitic osteitis without suppuration, same as a 
gummatous process anywhere else in the body. The x-ray pic- 
ture in such cases is very much like the one we find in very 
active osteospongioma (otosclerosis). The serological examina- 
tion is of the greatest value and in the cases we have observed, 
the Wassermann test was usually strongly positive. The treat- 
ment is, of course, antiluetic. 
5. Otosclerosis.—The term otosclerosis has been accepted by 
otologists since the work of Politzer, Siebenmann and Katz as 
indicating a definite entity. Most authors are agreed as to the 
pathologic change itself. This knowledge has been gained by 
the microscopic examination of such specimens as have been 
available. There is osteoporosis of the bone of the labyrinth 
in consequence of which the dense petrous bone is replaced in 
certain areas by vascular, spongy bone, especially in the region 
of the anterior bony margin of the oval window. In its early 
stages the process is a true new formation of osteoid tissue and 
not a transformation of old bone. It is characterized by the 
large size of the osseous spaces and the haversian canals; the 
spaces are filled with connective tissue rich in cells, which sur- 
round large and small blood vessels. Osteoclasts are not seen at 
any time. Later on the diseased area becomes sclerosed by 
the deposition of the new bone in the walls of the spaces. There 
is usually a sharp line of demarcation from the uninvolved por- 
tions. In the early stages the nerve structures are as a rule 
normal. 
It must be recognized that several varieties of the disease 
may exist, varying in mechanical results according to the region 
involved, i.e., the oval window, with resulting fixation of the 272 
APPLIED PATHOLOGY 
foot-plate of the stapes; foci of pathological changes in widely 
separated portions of the petrous hone, and in parts of the laby- 
rinthine capsule not closely related to structures essential to 
cochlear function; and in parts involving directly the cochlear 
structures. 
The etiology of this condition is obscure. Kauffman has pro- 
duced experimentally in young rats, which have been maintained 
on a diet low in fat soluble A vitamine and in calcium, abnor- 
malities of the osseous capsule of the internal ear which are 
identical with the lesions above described. The analogies be- 
tween the changes in the temporal bone in experimental rickets 
and the lesions which have been described in otosclerosis sug- 
gest that the latter condition may be a late result of rickets or 
a manifestation of a dietary deficiency still existent during adult 
life. 
The pathologic process has suggested the use of the x-ray as 
an aid in making the diagnosis and this often reveals the rare- 
factive process in the region of the foot-plate of the stapes. 
Treatment.—Recognizing the change, it is evident that but 
little can be expected from treatment unless it is instituted very 
early in life. In addition to hygienic measures, the various ex- 
tracts of the glands of internal secretion have been used. As 
soon as the diagnosis is made it is best to start lip reading and 
not wait until the patient has become very deaf. The various 
devices on the market to aid hearing are at times of benefit. 
6. Traumatic Labyrinthitis most frequently occurs in conjunc- 
tion with a basal skull fracture. It may be unilateral or bi- 
lateral. Although most frequently such conditions are acute 
and prove fatal, occasionally a chronic process does result. AYe 
have had one such case of bilateral posttraumatic chronic laby- 
rinthitis that recovered and although a facial paralysis per- 
sisted on one side there was still some functional response in the 
labyrinth of both sides. Another etiologic factor is trauma dur- 
ing a mastoid operation, particularly the radical procedure. 
The injury, in all probability, is directed at the locus minoris 
resistentice, the horizontal semicircular canal. Again, in the 
removal of the ossicles the foot-plate of the stapes is luxated, 
and infection enters through the oval window. It is, as a rule, 
a localized process although intracranial infection may follow. 
Gunshot wounds and injuries from high explosives were re- CHRONIC DISEASES OE THE EAR 
273 
sponsible during the World War for many such cases. We have 
observed two cases of the latter type which subsequently recov- 
ered and the labyrinth continued to function, although the for- 
eign bodies remained in situ. In brain concussion, with prob- 
ably hemorrhage into the canal, a similar condition may ensue. 
Treatment.—The treatment depends entirely upon the individ- 
ual case. In that type associated with basal skull fracture it is 
important that no irrigation or manipulation be done. The pa- 
tient should be warned against blowing his nose after conscious- 
ness is regained. Absolute rest is essential; ice-cap to the head, 
and the internal administration of urotropin are indicated, dur- 
ing the acute stage. Little can be done after the process becomes 
chronic, except surgical procedures. As a preventive measure 
during the radical mastoid operation great caution should be 
maintained not to injure the region of the horizontal canal. 
Likewise, in removal of the ossicles little force should be used 
in order not to dislocate or actually remove the stapes should 
there be an ankylosis of the ossicles. 
7. Hemorrhage into the Labyrinth.—Although hemorrhage 
into the labyrinth is in reality an acute process, its tendency to 
recur as Menier’s symptom complex makes it of sufficient im- 
portance to be mentioned. Apart from concussion, renal and 
cardiovascular disease and the blood dyscrasias are the most 
frequent etiologic factors. Recovery, as a rule is rare and some 
disturbance of the labyrinth persists. The blood becomes organ- 
ized within the labyrinthine capsule and postmortem specimens 
have been seen in which there was complete obliteration of parts 
of the labyrinth undoubtedly due to such organization. The 
treatment is directed towards the systemic pathological condi- 
tion. 
8. Occupational Labyrinthine Disease.—Foundry workers are 
particularly liable, because of the constant hammering, to suffer 
from labyrinthine disease. The continued exposure to excessive 
heat connected with such labor may also be an etiologic factor. 
There is said to be a severance of the nerve fibers in the organ 
of Corti. It is to be emphasized that as soon as one engaged in 
such an occupation presents the first symptom of labyrinthine 
irritation, as hvperacusis, diplocusis, tinnitus, dizziness or deaf- 
ness, he should be strongly advised to give up his work. Cassion 274 
APPLIED PATHOLOGY 
workers sooner or later, because of the great change from posi- 
tive to negative pressure, develop some pathologic change within 
the labyrinth. Some observers believe that the nerve degenera- 
tion present is rather the result of the toxic action of the gases. 
Here, too, the giving up of the occupation at the tirst evidence 
of disturbance of function of the labyrinth should be advised. 
9. Neoplasms.—The most frequent neoplasm is rather retro- 
labyrinthine and involves the auditory nerve. The location of 
auditory nerve tumors is usually in the internal auditory 
meatus. The tumor progresses in its growth towards the brain 
and the exit of the auditory nerve at the cerebello-pontile angle, 
at which point it frequently develops into considerable size. As 
the facial nerve is also located in the internal auditory meatus, 
it may likewise become involved either by pressure or by direct 
extension of the growth. The type of tumor is either neuroma, 
glioma or sarcoma. The treatment is, of course, surgical. 
10. Congenital Affections of the Labyrinth.—These occur most 
commonly in the congenitally deaf and secondary to a syphilitic 
meningitis or rickets intra utero. Both the cochlea and semi- 
circular canals are markedly distorted in their bony formation 
and at times found obliterated. There is usually present com- 
plete atrophy or lack of development of the nerve and of the 
membranous structures. Any number of anomalies may be pres- 
ent in the anatomical structures of the middle ear. Only educa- 
tion, as lip reading, can be of assistance in these cases. INDEX 
A 
Abductor paralysis of the larynx, 219 
Abscess, acute peritonsillar, 42 
and perichondritis, 60 
brain, acute, 90 
extradural, 89 
intradural, 90 
of septum, 18 
perisinus, 86 
retropharyngeal, 37 
tonsillar, acute, 44 
Absence of auricle, 229 
Actinomycosis of the mastoid, 266 
of the tonsil, 192 
Acute diseases of the ear, 60 
of larynx, 51 
of nose, 17 
of pharynx, 36 
of trachea, 55 
esophagitis, 59 
fulminating sinuitis, 33 
labyrinthitis, 85 
mastoiditis, 72 
ostium tubitis, 38, 66 
otitis media, 66 
perichondritis and abscess, 60 
paranasal sinus disease, 30 
peritonsillar abscess, 42 
rhinitides, 24 
sinus disease in children, 31 
tonsillar abscess, 44 
Adenoid and tonsil diseases, 179 
Adenoma of the trachea, 223 
Adhesive otitis media, 250 
Angina, Vincent’s, 46 
Animal foreign bodies in the ear, 66 
Ankylosis of malleus and incus, 246 
Anosmia, 149 
Antrum in sinuitis, 34 
sarcoma of, 157 
of Highmore, in rhinosinuitis, 145 
Artificial eai, 234 
Atrophic otitis media, 250 
pharyngitis, 169 
rhinitis, 134 
middle turbinate and sinuses in, 155 
septum in, 122 
Auditory canal, chronic eczema of, 241 
diseases of, 63 
external, diseases of, 240 
Auricle, absence of, 229 
B 
Bacteriology of rhinosinuitis, 20 
Beck ’s conchotribe, 132 
irrigation unit, 26 
wall plate, 248 
Bell’s palsy, 94 
Benign tumors of the tonsils, 194 
Bezold’s mastoid, 82 
Bleeding, pharyngeal, 50 
Burns, injuries to trachea by, 56 
of ear, 62 
of larynx, 54 
Bursitis, acute, 37 
chronic, 170 
Brain abscess, acute, 90 
Bridge of nose, 24 
Brigg’s method of transillumination of 
antrum, 32 
Bronchi, acute diseases of, 59 
chronic diseases of the, 221 
Bronchorrhea, 223 
0 
Carcinoma of the esophagus, 223 
of the liypopharynx, 199 
of the larynx, 197 
of the pharynx, 177 
of the trachea, 222 
Cell route infection in mastoiditis, 73 
Cerebral hernia, 91 
Cerumen, 240 
Chemical wounds of larynx, 53 
Cholesteatoma of mastoid, 265 
Chondroma, 237 
Chronic bursitis, 170 
diseases, 96 
of the larynx, 197 
of the nasopharynx, 167 
of the nose, 96 
of the trachea, 221 
mastoid disease, 260 
mucopurulent tracheitis, 221 
nonsecretive otitis media, 249 
otitis media, 243 
serosa, 254 
perichondritis, 236 
rhinosinuitis, 139 
tubitis, 167 
Complications of mastoiditis, 84 
Compound fracture of nose, 17 
Conchotribe, Beck’s, 132 
Congenital absence of septal cartilage, 122 
275 276 
INDEX 
Congenital—Cont’d 
affections of the labyrinth, 274 
deafness, 233 
lesions, facial paralysis and, 95 
macrotia, 233 
malformations of ear, 227 
Crust formation in atrophic rhinitis, 136 
Cut throat, 53 
trachea in, 56 
Cyst of middle turbinate, 155 
Cystic formation in nasal polyp, 152 
D 
Dermatitis of ear, 62 
Deviations of the septum of the nose, 109 
Diphtheria, 45 
Diphtheritic laryngitis, 52 
tonsillopharyngitis, 46 
Disease of the larynx, 51 
Diverticulum, esophageal, 224 
E 
Ear, acute diseases of, 60 
adhesive otitis media, 250 
animal foreign bodies in the, 66 
artificial, 234 
atrophic otitis media, 250 
burns of, 62 
chronic diseases of the, 227 
congenital macrotia, 233 
congenital malformations of, 227 
dermatitis of, 62 
eczema of, 236 
foreign bodies in the, 65 
frost-bites of, 60 
internal, chronic diseases of the, 268 
malformations of, 227 
malignant tumors of, 238 
otitis externa, 60 
diffusa, 64 
furunculosa, 63 
traumatica, 65 
paraffinoma of, 238 
trauma of, 234 
tumors of, 237 
verruca behind, 233 
Ecchondroma of the larynx, 218 
Eczema, chronic, of auditory canal, 241 
of pinna, chronic, 236 
Edema of the pyriform fossa, 49 
Eighth nerve, neuritides of the, 269 
Electrically heated bougie, 225 
Electrothermal coagulation, 188 
Endarteritis obliterans, 172 
Epiglottis, 49 
tuberculous infiltration of, 207 
Epipharyngitis, 36 
Epithelial hypertrophy of inferior tur- 
binate, 125 
Epithelioma of ear, 239 
Epithelioma of the nose, 103 
Epistaxis, 24 
Esophageal diverticulum, 224 
Esophagitis, acute, 59 
Esophagus, carcinoma of the, 223 
chronic diseases of the, 221 
mouth of, 49 
strictures of the, 224 
Ethmoid labyrinth in chronic rhinosin- 
uitis, 142 
Etlimoids in sinuitis, 35 
Ethmoiditis, hyperplastic, 150 
External nose, chronic diseases of the, 
96 
Extradural abscess, 89 
F 
Facial paralysis, acute, 93 
infectious diseases associated with, 
96 
Fibrous hypertrophy of inferior turbin- 
ate, 126 
polyp of larynx, 213 
removed from naso-frontal duct, 151 
Fissure formation in nose, 21 
Follicular tonsillopharyngitis, 39 
Foreign bodies in the ear, 65 
in the larynx, 53 
in mastoid, 268 
in nose, 22 
in the trachea, 55 
Fracture of the nose, 17 
Frost-bite of nose, 20 
of the ear, 60 
Frontal sinus, in rhinosinuitis, 144 
polyp of, 146 
Frontals in sinuitis, 35 
Furunculosis of the nose, 20 
G 
Gas burn ulceration, 57 
injury of respiratory tract by, 56 
Glandular hypertrophy of middle turbin- 
ate, 141 
Granulation, persistent, after removal of 
adenoids, 187 
Granuloma in antrum of Highmore, 148 
Gumma of external nose, 99 
Gunshot wounds, 53 
H 
Head traction to aid swallowing, 41 
Hematoma of nose, 23 
Hemorrhage into labyrinth, 273 
Hernia cerebri, 91 
Herniation of the tympanic membranes, 
69 INDEX 
277 
Hyperkeratosis of the tonsil, 193 
Hyperosmia, 149 
Hyperplasia of the inferior turbinate, 
138 
Hyperplastic rhinosinuitis, 149 
Hypertrophy, fibrous, 126 
of inferior turbinate, 125 
osseous, 133 
vascular, of inferior turbinate, 130 
Hypopharyngitis, 48 
Hypopharynx, carcinoma of, 199 
Hyposmia, 149 
Hysterical laryngeal paralysis, 219 
I 
Inferior turbinate, 124 
atrophy of, 134 
hyperplasia of, 138 
hypertrophy of, 125 
new growths of, 138 
syphilis of, 139 
tuberculosis of, 139 
turgescence of, 124 
Inflammation of the larynx, 209 
Injuries of the trachea, 56 
Interarytenoid tuberculoma simulating 
papilloma, 206 
Internal ear, chronic diseases of the, 268 
Intradural abscess, 90 
Irrigation unit, Beck’s, 26 
K 
Kakosmia, 149 
Koerner cell infection, 82 
L 
Labyrinth, congenital affections of, 274 
hemorrhage into, 273 
neoplasms of, 274 
Labyrinthine disease, occupational, 273 
Labyrinthitis, acute, 85 
chronic suppurative, 270 
complicating mastoiditis, 85 
syphilitic, 271 
traumatic, 272 
Laryngeal diphtheria, 52 
paralysis, 218 
polyp, 213 
stenosis, 211 
Laryngitis, acute simple, 51 
chronic simple, 212 
syphilitic, 210 
Larynx, acute diseases, of, 51 
carcinoma of, 197 
Larynx, chronic diseases of, 197 
inflammation of, 209 
eechondroma of the, 218 
foreign bodies in the, 53 
Larynx—Cont’d 
papilloma of the, 215 
singer’s nodules, 212 
trauma of, 53 
tuberculosis of, 206 
Lateralis hypertrophicus, 168 
Leptothrix, 193 
Lingual tonsil, diseases of, 181 
inflammation of, 49 
Lues of the septum, 117 
of the mesopharynx, 47 
Luetic cicatrices of velum palati, 172 
tonsil, 192 
Lumpy jaw, 192 
Lupus of the nose, 96 
Lupus or tuberculosis of the inferior 
turbinate, 139 
M 
Macrocephalia, congenital, 233 
Macrotia, congenital, 233 
Malformations, of ear, acquired, 227 
Malignant diseases of the septum, 120 
tumors of ear, 238 
Mastoid, actinomycosis of, 266 
cholesteatoma of, 265 
disease, chronic, pathologic, 260 
fistular tracts of, 263 
foreign bodies in, 268 
neoplasms of, 268 
' osteofibrosis of, 260 
reparative osteitis of the, 267 
syphilitic osteitis of, 266 
tuberculous osteitis, 265 
Mastoiditis, acute, 72 
complications of, 84 
facial paralysis as complication of, 
93 
atypical types of, 81 
cell route, 72 
infection, 73 
extradural abscess as complication of, 
89 
hernia cerebri as complication of, 91 
histopathology in, 75 
intradural abscess as complication of, 
90 
labyrinthitis complicating, 85 
meningitis as complication of, 91 
osteophlebitic, 72 
perisinus abscess complicating, 86 
sinus thrombosis as complication of, 
87 
squamozygomatic, 82 
vascular route, 72 
vascular route infection, 79 
Melanosarcoma, 164 
Membrana tympani, anatomical con- 
figuration of, 68 
perforations of, 244 278 
INDEX 
Membranous pharyngitis, 45, 47 
Meningitis, 91 
Mercury tube for pressure treatment and 
massage in ear diseases, 258 
Mesopharyngitis, 39 
Mesopharynx, 39 
Middle ear inflammation, neuritis second- 
ary to, 270 
Middle turbinate and sinuses in atrophic 
rhinitis, 155 
cyst of, 155 
glandular hypertrophy of, 141 
in atrophic rhinitis, 136 
pathology of, in rhinosinuitis, 140 
polyp from, 152 
turbina bullosa of, 154 
Missiles, injuries to trachea by, 56 
Mucopurulent tracheitis, chronic, 221 
Mulberry hypertrophy of inferior tur- 
' binate, 129 
Myxomatous degeneration, 145, 156 
N 
Nasal frontal duct, in rhinosinuitis, 144 
infection in adenoid disease, 181 
septum, congenital absence of, 122 
deviations of the, 109 
diseases of, 109 
lues of, 117 
malignant diseases of, 120 
papilloma of the, 120 
traumatic, 115 
tuberculosis of, 119 
Nasopharynx, chronic diseases of, 167 
Necrosis in mastoiditis, 73 
Neoplasms of the labyrinth, 274 
of the mastoid, 268 
of the trachea, 222 
Neuritides of the eighth nerve, 269 
Neuritis secondary to middle ear inflam- 
mation, 270 
Nevus of the nose, 100 
New growths of the inferior turbinate, 
138 
Nipple perforation of the membrana 
tympani, 70 
Nose, abscess of septum, 18 
acute diseases of, 17 
bridge of, 24 
chronic diseases of the, 96 
chronic vestibulitis, 109 
cpistaxis, 24 
epithelioma of the, 103 
fissure formation in, 21 
foreign bodies in, 22 
fracture of, 17 
frostbite of, 20 
furunculosis of the, 20 
gumma of, 99 
hematoma of, 23 
Nose—Cont ’cl 
inferior turbinate, 124 
internal, diseases of, 109 
lues, 98 
lupus of, 96 
nevus of the, 100 
notches, following septal abscess, 24 
papilloma of, 105 
pus infections of, 100 
rhinophyma, 9(5 
rhinoscleroma, 100 
rhinosinuitis, 25 
sarcoma, 102, 164 
septal abscess of, 23 
tuberculosis of the, 96 
tumors of the, 100 
vestibulitis acute, 21 
vestibulum of the, 109 
Notched nose following septal abscess, 
24 
O 
Occupational labyrinthine disease, 273 
Oropharynx, chronic diseases of, 167 
Osseous hypertrophy, 133 
Osteitis of the etlimoids, 143 
reparative, in mastoiditis, 78 
Osteofibrosis and chronic suppurative 
otitis media, 254 
of mastoid, 260 
Osteophlebitic mastoiditis, 72 
Osteofibrosis with fistular tracts of 
mastoid, 263 
Ostium maxillaris, in rhinosinuitis, 145 
Ostium tubitis, acute, 38, 66 
Othematoma, 60 
Otitis externa, 60 
dilfusa, 64 
furunculosa, 63 
sicca, chronic, 242 
in which moulds are present, 243 
traumatica, 65 
media, acute, 66 
adhesive, 250 
atrophic, 250 
chronic, 243 
nonsecretive, 249 
residualis of Wittmaack, 251 
serosa or seromucosa, chronic, 254 
Otosclerosis, 271 
P 
Pansinuitis, suppurative, 145 
Papilloma of the larynx, 215 
of the nose, 105 
of the septum, 120 
of the trachea, 222 
Paraffinoma of ear, 238 
of the nose, 105 INDEX 
279 
Paralysis, acute facial, 93 
laryngeal, 128 
Paranasal sinus disease, acute, 30 
Parosmia, 149 
Perforation, nipple, of the membrana 
tympani, 70 
Perforations of tympanic membrane, 244 
Perichondritis and abscess, 60 
Periostitis in mastoiditis, 81 
Perisinus abscess, 86 
Peritonsillar abscess, acute, 42 
rupture of, 43 
Perichondritis, chronic, 236 
Pfannenstiel treatment, 257 
Pharyngeal bleeding, 50 
stenosis, 173 
Pharyngitis, 168 
atrophic, 169 
membranous, 45, 48 
Pharyngitis, pseudomembranous, 48 
Pharynx, acute bursitis, 37 
diseases of, 36 
carcinoma of th°. 177 
epipharyngitis, 36 
hypopharyngitis, 49 
retropharyngeal abscess, 37 
salpingitis, 38 
syphilis of the, 171 
Thornwaldt’s disease, 170 
tuberculosis of, 174 
tumors of the, 175 
Pinna, acute diseases of, 60 
chronic eczema of, 236 
malformations of, 227 
Pneumatization of mastoid, 253 
Polyp, fibrous, of larynx, 213 
in ear, 245 
in frontal sinus, 146 
Polypi in ethmoiditis, 150 
Posterior choanae, closure of the, 122 
ethmoid and sphenoid in sinuitis, 35 
Postural method, Beck’s, for introduc- 
tion of fluid into nose, 27, 28 
Pseudomembranous pharyngitis, 48 
Pus infections of the nose* 100 
Pyriform fossa, edema of, 49 
Q 
Quinsy, 42 
R 
Radium exudate, 165 
Reparative osteitis of the mastoid, 267 
Respiratory tract, gas burns of, 56 
Retroauricular fistula following radical 
mastoid operation, 235 
Retropharyngeal abscess, 37 
Rhinitides, acute, 24 
Rhinitis atrophic, 134 
middle turbinate and sinuses in, 155 
septum in, 122 
Rhinophyma, 96 
Rhinoscleroma, 100 
Rhinosinuitis, 24 
chronic, 139 
complications, 27 
ethmoid labyrinth in, 142 
hyperplastic, 149 
pathology of middle turbinate, 140 
S 
Salpingitis, 38 
Sarcoma of the nose, 102, 164 
of the sinuses, 157 
of the tonsil, 177 
Septal abscess of nose, 23 
Septum, nasal (see Nasal septum) 
Sequestral luetic osteitis, 264 
Seromucosa, otitis media, 254 
Serous labyrinthitis, 85 
Singer’s nodules, 212 
Sinuitis, acute fulminating, 33 
antrum in, 34 
ethmoids in, 35 
frontal s in, 35 
Sinus cavities in rhinosinuitis, 144 
disease in children, 31 
paranasal, 30 
thrombosis in mastoiditis, 87 
Sinuses, sarcoma of the, 157 
Sphenoid opening, in rhinosinuitis, 145 
polyp, 150 
Squamozygomatic mastoiditis, 82 
Stenosis of the larynx, 211 
pharyngeal, 173 
Strangulation, 53 
Streptococcic sore throat, 48 
Strictures of the esophagus, 224 
Subperiosteal abscess in mastoiditis, 81 
Suction apparatus, 25 
Suppurative pansinuitis, 145 
sinuitis, 140 
tympanomastoiditis, chronic, 244 
Swallowing, head traction to aid, 41 
Synechia, 123 
Syphilitic labyrinthitis, 271 
laryngitis, 210 
osteitis of the mastoid, 266 
tracheitis, 222 
Syphilis of the inferior turbinate, 139 
of the pharynx, 171 
T 
Tliornwaldt’s disease, 37, 170 
Tongue, base of, in hypopharyngitis, 48 
Tonsil, actinomycosis of, 192 
and adenoid diseases, 179 280 
INDEX 
Tonsil—Cont’d 
hyperkeratosis of the, 193 
luetic, 192 
sarcoma of the, 177 
tuberculosis of, 188 
Tonsillar abscess, acute, 44 
Tonsilloliths, multiple, 189 
Tonsillopharyngitis, 39 
Tonsils, benign tumors of, 194 
hyperplasia of, with infection, 179 
Trachea, acute diseases of, 55 
adenoma of the, 223 
carcinoma of the, 222 
foreign bodies in the, 55 
injuries of the, 56 
injuries to, by gas, 56 
neoplasms of the, 222 
papilloma of the, 222 
Tracheal fistula, papillomatous formation 
about, 217 
Tracheitis, acute, 55 
chronic mucopurulent, 221 
syphilitic, 222 
Transillumination of antrum, Brigg’s, 32 
Trauma of ear, 234 
of larynx, 53 
Traumatic facial paralysis, 94 
labyrinthitis, 272 
septum, 115 
Tuberculosis of the inferior turbinate, 
139 
of the larynx, 206 
of the nasal septum, 119 
of the nose, 96 
of the pharynx, 174 
Tuberculosis—Coot ’<1 
of the tonsil, 188 
Tuberculous osteitis of the mastoid, 265 
Tubitis, chronic, 167 
Tumors of the external ear, 237 
of the nose, 100 
of the pharynx, 175 
Turbina bullosa of the middle turbinate, 
154 
Turgescence of inferior turbinate, 124 
Tympanic membranes, herniation of the, 
69 
nipple perforation of the, 70 
Tympanomastoiditis, chronic suppura- 
tive, 244 
U 
Unilateral carcinoma of the tonsil, 178 
V 
Vascular hypertrophy, 130 
route infection in mastoiditis, 79 
Velum palati, luetic cicatrices of, 172 
Verruca, congenital, behind ear, 233 
Vestibulitis acuta, 21 
chronic, 109 
Vincent’s angina, 46 
W 
Wax, inspissated in auditory canal, 240 
West case, 258 
Wittmaack, otitis media residualis of, 
251