Therapeusis And Prognosis | Operating Microscopes

By GEO. A. LELAND, A. M., M. D.
OF BOSTON, MASS.

General Therapeusis. Treatment in the diseases of the upper airpassages may be divided into general and local, the former of which may first be considered. And it may be premised that these regions are not to be considered as separate from the rest of the body, but as a part of it, and not only influencing it but being influenced by it the corollary of which is that they are not always to be subjected to local treatment alone, but that the general diseases and conditions of the body are to be taken into account. For it will frequently be found that general treatment is far more efficacious in the removal of some of the manifestations of disease in the upper air passages than local treatment, which is so often, in these days of enthusiastic specialism, given the most prominent, if not the only, place in the thoughts of some so called laryngologists. An early recognition of these conditions may often save the patient from much discomfort and expense, and the physician from no little anxiety and apprehension. For many local manifestations of general disease are only aggravated by local treatment e. 9., an acute gouty pharyngitis, late syphilitic tumefactions of the tonsils, the first swelling of late syphilis in the nose, the laryngeal papillomata which precedemalignant disease, and so on.

Aside from the exanthemata, (including typhoid fever) with their characteristic throat manifestations, which will doubtless be discussed in theirproper articles, there are. some common, every day conditions which cause much discomfort and no little alarm. One of the most common of these is rheumatism, where there is very little to be seen. The faucial and pharyngeal mucosa shows but slight redness, often in small areas, variable in their locations, more or less early in the day. The history, not only of the individual, but of the family near and remote, assists in the diagnosis. The lithemic diathesis perhaps shows frequent manifestations not only in him, but in various members of his family, even in several generations. In such a throat it is not rational to suppose that the local exhibition of the usual sprays or pigments will produce more than a very transient amelioration, and may, especially the latter, produce only discomfort; this, however, may yet serve a purpose by making the throat seem so much worse that, when the irritation subsides the patient considers himself better. It is here that general remedies, directed to the diathesis are to be employed The correction of ailments of the prima via, such as gastrointestinal c atarrh, and regulation of the bowels;. the exhibition of the lithic solvents, such as the various salts of potash and lithia, the salieylates and salicylic acid (always, however, using these last either not at all or with great caution where there is a tendency to deafness, from middle ear or labyrinthine lesions), piperazin, etc. ; the regulation of diet, especially as to the ingestion of foods containing uric acid, and the xanthin group, notably red meats and tea and coffee according to Haig,,' urging the importance of drinking large quantities of pure water (the English rule being 3 to 5 pints daily) these among other measures may be mentioned. The solvent action of some of the alkaline tablets, dissolved slowly in the mouth and followed by a copious drought of water, is often of local service, notably those prepared from the Ems Springs by evaporation, and known as the Ems pastilles.

It is notable that in his discussion of general therapy for disease of the upper air passages, Dr. Phillip Schech devotes a page and a half to the mention and recommendation of mineral waters.

A peculiar manifestation of the lithemic diathesis, and a very distressing one, is the dry mouth and throat rarely complained of by the aged. The salivary and mucous secretions are nearly if not quite absent; the tongue is dry and parched and at times painfully cracked; destitution is almost impossible. The urine will show almost no color, very light specific gravity, and very small amounts of uric acid and especially of urea. Here some of the measures above noted, assisted at the onset and perhaps longer by minute doses of pilocarpin muriate or nitrate, will produce wonderfully satisfactory results, while the whole gamut of local applications may be tried in vain.

Another form, perhaps, of lithemic diathesis, or at any rate of malassimilation, is the thick throat associated with obesity. The faucial appearances here are those of a very narrow space behind the velum, the surface of which is thrown into ruge by gagging and phonation, thus almost entirely closing the passage. This thickening can most probably not be gotten rid of by local applications without danger of producing too great reaction and later even cicatrices, which may leave the throat in a worse condition than before. Treatment should be directed to the general condition; to the digestion, both gastric and intestinal; to the action of the liver and the kidneys. And it is possible that we may hope from the study of glandular therapy to find that some of these cases are due to a greater or less degree of Basedow's disease, as was well shown in the report of a case of 11 myxedema of the throat " by Dr. Farrow, in the last " Transactions of the American Laryngological Association."

In the writer's experience some cases of submucous thickening of the throat have apparently been much benefited by the exhibition of thyroid extract. Of course, in cases of thickened hypertrophic pharyngitis a local cause may be found in improper nasal respiration, which, as will be referred to in its proper place, can be corrected.

Closely allied with these rheumatic diatheses is the gouty; and it will be found of great value to recognize its acute or chronic manifestations. In its acute form we find a crimson red, thick, shiny mucous membrane of the pharynx and fauces, where the characteristic feature is the extremely acute pain, much aggravated by swallowing, which seems much more than the manifestations call for. It would be hopeless to use sprays except for slight and transient benefit, and the usual pigments would only produce extreme discomfort for a longer or shorter time. It will be found in the history of such a patient that he has perhaps bad some gout before in other and more usual locations, and that he has remedies which be is accustomed to use; and these will doubtless produce a much more satisfactory cure of his throat than other means. And so also in the chronic gouty throat or in the throat convalescing from the acute stage, which has lost its shiny reddened appearance and has become flabby and pale with a muco purulent, viscid, sticky secretion, remedies directed to the diathesis are much more efficacious than those for local application, except so far as they are beneficial as cleansing agents. In all these conditions allied to the lithemic diathesis it is necessary to pay a great deal of attention to the diet; and here a general physician who has a thorough mastery of the physiology and pathology of digestion, or the throat specialist who adds this also to his specialty, will have greater success than lie who treats locally.

There is another condition described as neuralgia of the throat where there is a great complaint of painful sensations both at rest and upon movement, especially probably in the latter part of the day, and the pain is of a sharp and lancinating quality; here local applications are absolutely contra indicated, since they generally produce an aggravation of the discomfort. It will be found that the patient is anemic or neurasthenic and that general treatment is much more serviceable than local. Here, however, it may be said as applying to this condition, as well as to those which have been before mentioned, that where the symptoms are especially referred to any one part, the patient feels much better to be doing something; and while not much is to be expected from local treatment per se, some simple gargle may be prescribed as a placebo.

Another painful condition of the throat is to be found in hardworked individuals, especially professional men. It is not infrequent that over¬ worked physicians, clergymen, teachers, and even lawyers have a painful condition of the throat come on at the end of the day: this is simply a con¬dition of muscular and nervous fatigue, in which local applications are of little benefit, but where rest, and tonics like nux vomica, is very efficacious. It is not infrequent to have an overworked physician drop into the office late in the day complaining of just this fatigue of the throat, and it is with great satisfaction that we can assure him that there is no alarming malady threat¬ening. Public speakers doubtless have this trouble much aggravated by an improper use of the voice, and the so called “ministers’ sore throat " is often but the result of the American method of talking back in the throat with indistinct arti culation swall owing of the words, as the Germans call it. Correction of bad habits with attention to the general condition of the patient; will here give the best results. Some of the lozenges may be of assistance to reduce hyperemia or to induce moisture when there is a sense of dryness, but they are merely palliative; the underlying cause must be sought out and abolished.

In this place may be mentioned a peculiar condition of the pharyngeal mucosa characterized by thickening, pale pinkish color, sluggish scanty secretion, and obstinacy under treatment, which, on the exhibition of iodids and perhaps mercurials, will seem to be due to a latent taint of specific disease, although the history is doubtful or absolutely negative and there are no other lesions to be discovered in ordinary examination. This is not very common, but should always be borne in mind; and it will be found that this treatment does Dot always have to be used as a last resort. The pathology of this condition has probably not been toughly worked tip but it may be said in general, judging from clinical observation, to be a submucous infiltration with more or less involvement of the superficial lymphatic structures which have a rather pale and asthenic appearance. These may easily break down in a superficial loss of substance with a grayish base; not the usual appearance of a mucous patch, but more nearly that of a superficial abrasion from rough treatment, a scraping off of the surface, as it were. It may not be true that these appearances are always due to specific disease; but it has happened to the writer to have them clear up so kindly under the iodid of potash or syrup of hydriodic acid, perhaps assisted by biniodid of mercury and afterward to find ail obscure history of infection, that it does not seem to be a condition of great rarity. Of course, where there are the characteristic lesions of secondary or later stages, the ordinary remedies, both general and local, will be exhibited without question.

There is one other condition which seems to claim a place here, and that is ail affection of the throat where there is an even blush diffused over the fauces and pharynx and even the mouth, of' more or less intense redness; sometimes the tongue will be fiery red, with none of the usual coating, all appearance which is shared by the interior of the mouth and throat to a less degree. Arsenical poisoning must here be borne in mind, especially if it is found that the patient is better away from his ordinary dwelling as in vacation time, or that he has the usually ravenous appetite, with perhaps the malaise of this condition. Perhaps he is given to the deleterious habit of putting things into the mouth, as in one case which came under the writer's observation, where in reading a book the patient tore off the corner of each page after finishing it and put it into his mouth. With this throat it is well to institute the usual investigation to find out the source of the poison, including the examination of the urine, to see if it is present in the system, or to clear up at least that possibility. General treatment only call here be indicated.

The various forms of paralysis come under this general head, among which may be mentioned paresis of the palate in greater or less degree in post diphtheritic paralysis, or in the early stages of tabes dorsalis; the laryngeal crises in later stages of this last distressing disease; or vagus paralysis on one side in aneurysm of the arch, or of the innominate, or from pressure of mediastinal glands, etc.

There are doubtless other states of the, system which have their manifestations prominently in the throat, but those mentioned are the most prominent which have come under the writer's observation. Figures are not at hand and probably have not been collected to enable us to judge of the proportion of such cases; but it is doubtless true that a Very large percentage are much better treated by general measures than by local treatment alone, and it is also obvious that general treatment is only assisted by the local in their management.

Before leaving the general part of the subject, it may be well in this place to note certain hygienic measures which may offer suggestion in preventive therapeutics or preventive medicine, in which such vast strides have been made toward the comfort of humanity in our modern times. An ounce of prophylaxis may be worth a pound of surgical or pharmaceutical interference.

In general, it may be asserted that nothing is more conducive to the maintenance of a proper condition of the mucous membranes of the upper air passages than the avoidance of colds ; for to colds may be attributed the beginning of most of the common inflammatory states of these membranes. Their initial congestions are due principally to three causes: 1, a sluggish skin; 2, a state of the blood best called lithemia, in our present knowledge of the subject; and 3, to the action of atmospheric micro organisms and dust.

1. If the skin is active i. e., if, after being chilled, it will again take up its quantum of blood on returning to warm surroundings the internal congestion, called cold, will not remain. To keep the skin active is one of the problems in the prophylaxis of catarrh. This raises the question of clothing, bathing, ventilation, and heating.

The clothing should be adapted to the weather; and in a changeable, climate like that of New England and the Atlantic coast, also of the Southern shore of the Great Lakes, should be of such material that sudden chills may be avoided. The layer next the skin should be such that it will conduct the perspiration, both sensible and insensible, into the next layer, so that the skin may not be in a damp envelope. To this end cotton should be avoided because it does not hold the body heat if dry, and when wet with perspiration allows rapid evaporation and so chilling of the surface. Wool is almost universally recommended because it retains heat: it is, however, irritating to sensitive skins, and, having the property of absorbing moisture slowly, also gives it of slowly. Hence the skin is damp before the moisture is absorbed and enclosed in a damp envelope afterward, which may keep up evaporation and abstraction of body heat for a long time, until the gar¬ment has become dry again. This would be an advantage to the laboring man who is constantly manufacturing heat; but is a disadvantage to those who have long periods of rest between those of exercise. The material, however, which seems theoretically to answer the purpose best is a new one now bidding for public favor, viz., a linen mesh. This is smooth, unirrita¬ling and absorbent; it carries the moisture from the skin, and quickly dry¬ing, maintains a layer of warm air next the surface of the body. It remains to be seen whether, its advantages will enable it to win recognition against the popular prejudice in favor of wool.

In general it may be said that clothing for the house should not be too heavy, but that sufficient addition should be made on going out in wintry weather. The fashion of wearing furs, except in the most rigorous weather, is doubtless conducive to dampness of the skin and should be avoided. Woollen outer garments are much more to be recommended than the heavy impervious pelts through which there can be no ventilation; like the rubber boot, the latter tend to keep the skin in a bath of perspiration, which is destructive of its activity and allows the rapid loss of heat on their removal.

Bathing, both for its stimulating and cleansing purposes, is rightly considered not only a prophylactic but a therapeutic measure of great service in the treatment of catarrh of the upper air passages. Rosenberg' recommends daily cool baths, and it is well known that they who take the cool morning dip are less troubled with colds; doubtless because the vaso motor system is toned up to better control of the vascular supply of the nose.

Little need be said on this subject except to caution that the skin should never be left in a slightly moist state after a bath. Hence, the cold or hot bath is much better than the tepid one which is not stimulating enough to produce a reaction. As a therapeutic measure the very hot bath (103' to 1081 F.), used within the first forty eight hours of a cold, followed by a cold dash (600 to 80'F.), and this followed by vigorous friction till the skin is perfectly dry and of a pink color, is one of the best means which can be suggested to break up a cold. The hot soak should be continued fifteen to twenty minutes; the cooling off from two to ten minutes; and after the drying of the skin the bed clothing should not be heavier than usual.

In this connection may be mentioned that hyperidrosis pedis with its .accompanying cold feet is a prolific cause of catarrh, not only of the hypertrophic, but of the atrophic variety as mentioned by Kretschmann, quoted by Jacobson.' This author recommends very stimulating treatment for the feet, and states that cure may be brought about even in atrophic rhinitis without local treatment.

The necessity, therefore, of keeping the feet warn and dry is obvious. Foot wear in cases of catarrh should be as carefully attended to as possible: in the damp winter and spring weather the ordinary leather sole, especially of ladies' shoes, is probably never thick enough to keep dampness from the sole of the foot, and should always be supplemented by rubber.

Shampooing the head is also sometimes a cause of obstinate inflammatory conditions, most often, perhaps, because of insufficient drying, which allows .of chilling of the surface by evaporation and hence congesting of the interior. This may take place even in some cases where drying is properly done. It is a question whether the long hair of our lady patients can be dried so as not to work evil in some catarrhal cases. At all events, the evil is sufficient to make the practice always a subject of inquiry.

Ventilation. This is a matter of no small importance, especially as regards that of the chamber at night in the winter season. The popular craze for fresh air during sleep is often carried too far. To live in a room artificially heated to 70' to 80' F. during the day, and then to retire with the windows open, so as to be practically out of doors with uncovered head when the body resistance is reduced in sleep, would seem to be wholly irrational. The sonless, chill night air, blowing in steady draughts or only in gentle gusts upon the unprotected bead, must do much injury in catarrhal cases, and should be strenuously avoided. The night caps of our grandparents, relegated to the past with their unheated chambers situated remote from the warm living rooms, would still be useful articles of night clothing for those who must sleep with open windows.

Heating. In our northern climates this should receive careful attention from the throat specialist. The physiological functions of the Dose in respect of the supplying of moisture to the inspired air should point out to US the Cause Of much of the engorgement and hypertrophy of the interior of the nose and throat which manifest themselves in winter colds. The air below the freezing point is deprived of much of its moisture: brought into our houses and raised to 70' or 80' F., or drawn in as breath and raised to 98' F., it must take tip its quota of moisture. Hence, a more or less increased function of the mucous coverings of the turbinals and in mouth breathers, of the throat which results in an obstructive engorgement or in chronic inflammatory thickening. These evils may be avoided by proper saturation of the indoor atmosphere with moisture much more important when the heating is by steam or hot water. It is obvious then that cauterization of such engorged noses may be productive of evil, and painting of such hyperemic throats with astringents only a source of discomfort and Dot of cure; and that both may be more rationally treated by proper attention to indoor atmospheric conditions. Here the hygrometer comes to be a much more important instrument of observation than the thermometer. And it may be said that houses are much more comfortably heated when this instrument registers 65' to 800 than when below 50' F.

2. State of the Blood. It often happens that patients complain of colds which they say come on without cause i. e., without known exposure or carelessness in dress etc., this may often be due to a lithemic condition, as lately pointed out by Dr. L. Duncan Buckley. A cold may thus be, as it were, a uric acid explosion. On investigation it may be found to follow the ingestion of a heavy meal, or of a quantity of malt liquors, or of tea or coffee which Haig' has shown to contain large quantities of the xanthin group or to neglect of proper exercise or bathing.

Buckley's method of cure has been found in certain cases to be very efficacious, and is as follows: Twenty grains of bicarbonate of soda are given every one quarter hour for four doses; if there is not sufficient relief after waiting two hours, the same series is repeated. The five grain soda mint tablets are a convenient means of administration.

3. Atmospheric Micro organisms and Dust. Probably the presence of colds in a large part of the community at any one time, so as to seem like an epidemic, is due to this cause. The prevalence of epidemics of influenza, of hay fever, of diphtheria, or tonsillitis is often accompanied by great frequency of colds, or at least of irritable states of the upper mucous membranes. At other times, when the graver forms are not so pronounced as to show evidence of the above named diseases, colds may be the lesser expression of their influence.

The mechanically and chemically irritant effects of atmospheric dust are a prolific cause of inflamed mucous membranes. Hence during the windy months in our cities it is often almost universal to see cases of inflamed noses and throats due solely to surface irritation. Certain classes of the community also are frequent sufferers from this state of the mucous lining of their upper air passages among which may be mentioned gentlemen who assume personal care of their furnaces, teachers who make much use of the blackboard, workers in dusty shops, and tinsmiths and plumbers who inhale the acid fumes inseparable from soldering. For these people some of the various nasal respirators are of service to clear the inhaled air (or even a small tuft of absorbent cotton introduced into the orifice of each nostril), and bland or protective sprays may be frequently used with advantage to cleanse the irritated surface. Schech and others recommend that sufferers from bacteria laden or dust laden atmospheres in larynx or nose be removed from the city into the cleaner air of the country or the woods.

Mouth breathing. This is a habit which should be interdicted in toto from the very earliest moment of life; and it is the duty of every physician to impress upon the young (or old) mother that nasal respiration must be insisted upon at the outset with every infant. The parts are so small that if the nose is deprived of its proper air currents, the engorgement of the parts soon closes it. The accoucheur attends to the funis, the bowels, and even the eyes of the infant, but habitually omits to call attention to the importance of nasal respiration. It is not improbable that this may be one factor in the early occurrence of obstructive nasal engorgement which results in adenoid vegetations.

Diet. This must usually be left to the family physician; but at times even the throat specialist may find it convenient to interfere. When the trouble is due to the lithemic state and its congeners, as mentioned above, it may be necessary to proscribe sweets and starches in some cases, or nitrogenous foods in others: highly spiced foods may keep up a congestion of the fauces and pharynx. Alcoholic beverages probably act in two ways, as local irritants and as vaso motor dilators. To avoid the first effect, the stronger liquors should be diluted; to obviate the second, excessive use should be prohibited. In the writer's experience the most uniformly reddened and thickened mucous membranes of all visible parts of the upper air tract above the bifurcation of the trachea was in a man who complained not of pain but only of some discomfort, who confessed to habitually having taken about fifty drinks of whiskey per them for several years; miscellaneous libations of the vinous and malt liquors were not counted.

Tobacco undoubtedly exercises more or less of an irritating effect on the mucous membranes, especially when, as Rosenberg' even finds it well to say, the smoke is blown through the nose. The inhalation of cigarettes probably is the worst form of the use of tobacco; but there is a vast difference in the irritating effect of tobaccos. Those which contain saltpeter in appreciable amounts, whether natural to the leaf or introduced in the curing, should be avoided by patients whose throats are irritable, or by those whose tongues or lips show a tendency to leukoplakia. The presence of the nitrate of potash is easily seen when the fire causes a flashing as it progresses down the leaf and leaves minute white dots of the hydrated carbonate of potash on the ash. This drug is probably introduced to carry the fire in moist tobaccos such as, plug and cigarettes, as well as in some cigars designed to be used “green," and is chosen because it has no objectionable flavor, but only adds pungency to the smoke. But in the decomposition by combustion, nitric acid is given off to be added to the smoke, which can but be irritating to the mucous surfaces with which it comes in contact.

Rest. Schech lays great stress on the importance of rest in inflammatory and ulcerative conditions especially when, in the vocation of the patient, use of the voice is necessary. He even goes so far as to send the patient away to a quiet place or resort, according to the severity of his condition.

Use of the voice should be interdicted in inflammatory states of pharynx and fauces, and especially of the larynx; and in the former the use of some drug, as belladonna or atropia, to diminish the secretion and so diminish the necessity of swallowing, may be of service. In cases of singers' nodes (pachydermia tuberosa), both acute and cbronic, absolute rest of the voice is the most efficient method of treatment, and should be insisted upon also with any other mode Per contra, in paralytic affections, especially those depending On the hysteric or neurotic state, diphtheritic paralysis, etc., exercise should be employed rather than rest according to the same author.'

After this somewhat lengthy but, it is to be hoped useful consideration of the general therapeutics and hygiene of the subject, we come to that of the local manipulative treatment, which too often assumes a greater importance than it really deserves. And at the outset it is well to lay down a principle that whatever is to be done should be done with strict attention to the physiological function of the parts that their efficiency should be by no means impaired, but facilitated.

Local Treatment. In local treatment there are employed various means and procedures, as follows:

Gargles. It is a universal custom to prescribe gargles for almost every affection of the throat, but it is obvious that in laryngeal and naso pharyngeal affections they are, as a rule, wholly useless unless a method is employed which requires a great deal of' practice for its proper performance. It is possible by half swallowing the fluid to reach the top of the larynx, and by suddenly throwing the head forward in its ejection to wash the naso pharynx, as elucidated by Swain and others; but in the most common use of the gargle it probably does not reach back of the posterior pillars of the fauces. “Made up” gargles have deservedly fallen into disrepute, and, although tannin and some other astringents are sometimes used in acute congestions, they are of doubtful value. Astringent and stimulating remedies must necessarily be irritating, and, therefore, in painful and inflammatory states are apt to aggravate rather than cure.

Gargles are of more value, probably, because of their temperature than of their composition. The most useful gargle is, in the writer's opinion, hot water, to which may be added simple substances such as bicarbonate of soda or borax, or even salt, which have cleansing and stimulating or soothing properties and are easy of access. In the inflammatory states the extremes of heat and cold are of greatest value, and in such affections as acute inflammation of the fauces or tonsils, probably extreme heat as a gargle, or better, as advocated by Smith of Cleveland, pressed upon the inflamed area in the form of a large tampon soaked in hot water, has much antiphlogistic power. The universal use of chlorate of potash as a gargle is probably of most value as a placebo.

Sprays. The forcible and voluminous spray recommended by Mackenzie is doubtless of great value as a cleansing agent and should be used warm in the nose : the solution should be of the strength of two thirds of one per cent. of alkali (as Dobell's or Seiler's solution) to give a bland, unirritating wash for the nasal mucous membranes. It should be a rule that no liquids which cause smarting should be used in the nose; and that liquids should be used principally when there is secretion. to be washed away. The nose is made for air and not for water; and it is probable that much evil is produced by the routine employment of sprays and washes on the Schneiderian membrane. In inflammatory states soothing sprays may be used, such as those exhibited in an oily menstrumn; but even these are suspected of doing evil after long continued use, since they tend to cause a feeling of dryness and discomfort, probably affecting the secreting power of the mucous membrane unfavorably. In sluggish states of the secretion, or in atrophic states, stimulating sprays may be employed, such as those containing iodin or alcohol in various proportions. Rectified spirit is used by Miller of Edinburgh in cases of polypi, and by Creswell Baber in hypertrophic rhinitis (McBride).'

Cold sprays should not be used, lest by producing a hyperemia they may produce a chronic engorgement. The spray apparatus most highly to be recommended is that which has a nasal tip in the shape of an acorn or cone, which should be introduced only into the orifice of the naris, pointing backward parallel with the septum, the fluid being propelled by a force of not more than ten to fifteen pounds pressure, lest the mucosa of the turbinates and septum be abraded. The straight pointed tips often sold for nasal use are to be avoided, except in the hand of the physician, since the tender mucous surface of the septum anteriorly near the columna may be so wounded by contact that an eroding ulcer may be started and kept up. It is not infrequent to see an area a centimeter in diameter, with a crust more or less bloody, under which is an ulcer of the septum which will produce a perforation if allowed to continue. This may also be brought about by improper use of the handkerchief or finger nail, as well as by the end of the spraytube; hence, the acorn or cone shaped tip is the one which should be used by the patient himself in his own nostril, the shaft being held parallel to the median line.

An atomizer which forces considerable fluid should be selected, since the use of the finest sprays is usually most inefficacious and tedious. Sprays may be used with greater force in the fauces; but the turned up tip for the naso pharynx is of doubtful value, since its contact with the mucous membrane of he throat may often produce irritation. Sprays used in the larynx for cleansing or soothing purposes are of great value in the hands of the physician, and if used during phonation probably can be made to reach all supraglottic parts of the larynx; and with a forcible stream, perhaps under pressure of twenty pounds or more, with a spray tube capable of delivering a large volume, the interior of the trachea can sometimes be cleansed, during deep inspiration, of the inspissated secretion of a dry inflammation of its membrane. In the larynx at first but a small amount of the fluid should be sprayed in quickly, lest the patient be embarrassed by unpleasant spasm and cough. Vapors formed by very fine comminution of fluids are of doubtful value in the upper air passages, since only an exceedingly small amount of the medicament can come into contact with the membranes, especially if coated with secretion; and it is hardly possible that such mild applications can be of much service, since it is the function of mucous membranes to throw off all foreign substances. Thus, in all these uses of sprays it is well to bear in mind that the solution should be of sufficient strength to accomplish its object before the mucous secretion can wash it away, except where cleansing only is desired, when this eliminating property of the membrane is more or less in abeyance.

The use of the nascent chlorid of ammonium vapor caused by the union of the fumes of strong hydrochloric acid and ammonia water by means of an apparatus devised by Vereker, Lewin, or Kerr is doubtless of considerable value: the way in which it acts is probably not yet determined, but the membranes assume a more normal condition after being well bathed with its white dense cloud.

Doucher,. Douches are of great value when properly used, but are liable to be exceedingly dangerous. The introduction of a solid stream of water by whatever means is antagonized perhaps overmuch by aurists, because of the liability to force the fluid into the middle ear. There is no doubt, however, that intelligent patients may be able, under explicit directions and by experience, to so use the douche that it may be of greatest value, especially in cases of atrophic rhinitis or other less offensive purulent conditions. The very hot douche may be of use in its poultice action to reduce inflammations in the nose which cause such inflammatory states of the accessory sinuses, as recommended by Bosworth ; but the rule should be laid down that the douche should always be introduced through the narrower nostril and that the act of swallowing should not be performed during the passage of the stream ; and after its use that the fluid should be hawked away from the naso pharynx before blowing the nose; and, of course, that the Politzer air douche should not be used until a considerable time has elapsed. It is probable, however, that after the membranes have been soaked by the use of the douche, the patient may be more susceptible to cold in going out into the open air in the colder weather. The solutions to be used in the douche are usually those, such as Dobell's and Seiler's, which have alkaline and antiseptic properties. They should be of such strength as Dot to produce smarting or tingling of the membranes and should be at the body temperature or higher; about two thirds of one per cent. is the proper strength. The small elevation of the reservoir is important; the bottom of the reservoir should not be over six or eight inches above the orifice of the nose. The patient should also be cautioned never to use the douche carelessly or in haste; for one lapse might destroy the middle ear for life.

The external application of cold and heat is often serviceable in inflammatory states of the nose or of the throat. After injury an extreme cellulitis may be kept under by cold compresses on the nose. Acute tonsillitis maybe aborted by holding an ice bag behind and under the angle of the jaw. Acute laryngitis, even to the extent of inflammatory edema, may also be aborted or kept under by the ice bag or by Leiter's coil (cold) around the front of the neck. The application of beat to the tonsils and throat, in the form of the poultice or coil, is often very grateful to the patient, and requires no comment.

Powders. The use of these agents in the nose is not physiological, because of its function to get rid of foreign bodies by sneezing, hypersecretion, and the action of the ciliated epithelia. Hence, the general use of snuffs because they " clear the head " is calculated to entail congestion and hypernutrition, especially in the common form of catarrh of which patients complain, which is generally that of a slight hypertrophy or engorgement; they should be forbidden, since they tend to increase the evil. Bland antiseptic powders, however, can often be used to advantage after operations or in cases, where there is superficial loss of substance in the nose, or even where only the cilia seem to be absent. Such substances as iodoform, dermatol, aristol, and their congeners, which have become so numerous of late, may be of value in these cases, either pure or diluted with starch or bismuth or even compound stearate of zinc. It must be borne in mind, however, that, as in the ear, all insoluble powder sometimes hinders the proliferation of the mucous membrane to cover a defect. In these cases, therefore, insoluble powders should not be used; but they should be of such material that by the heat and moisture of the nose they will be melted into an oil or syrup.

The use of powders in the larynx probably does not in most cases compensate for the discomfort which they cause; but the antiseptic powders and those having a specific action, such as iodoform and its congeners, are valuable in ulcerative conditions of this organ. The best powder blower for the nose is one manufactured by the David son Co., known as No. 192.

Pigments. The name of these substances is legion and is continually being added to but the one substance which has lasted through many periods of antagonism, and which is now probably the most universally used, especially in Germany, is the solution of nitrate of silver in various strengths ; this has a slightly astringent strongly antiseptic, and somewhat stimulating action. It can be applied except in the nose to all the parts of the upper mucous membranes. It is best applied to the naso pharynx and larynx in strength from 2 to 8 per cent. and may be used even to 12 per cent. in the larynx and on the tonsils. It is best, of course, to begin with mild solutions and work up. It is to be borne in mind that the nitrate of silver sometimes produces ceruleanism; and the writer has seen at least one case where a deep brown pigmentation of the membranes and a dull coloration of the skin was attributed to the use of nitrate of silver in the throat; fortunately these cases are of extreme rarity.

Where an astringent effect is sought for, as in pharyngitis, solutions of tannin 60 grs., to the oz. of glycerin ; of the subsulphate of iron, 40 grs. to the oz. of water; of sulphate of zinc, 10 to 30 grs., to the oz. of water (also, used as a spray), may be mentioned among others as of considerable value. It is probable that the use of astringents in the nose, such as tannin or iron, even in their strong solutions, are productive of more discomfort to tile patient than of benefit to his condition much better results may be obtained by the use of caustics As stimulating pigments may be mentioned tincture of iodin from 10 to 50 per cent. in glycerin, which may be of value in various states of the pharynx characterized by sluggish secretion. Some have recommended a saturated solution of iodoform in ether in such conditions. The pigment selected should be applied by a brush; various kinds are recommended, but probably the most efficacious is that made by twisting a pledget of cotton on the roughened end of a metallic applicator. In all manufactured brushes there is the element of uncleanliness, and the shoulder of the part containing the hair is apt to injure the membrane with which it comes in contact. In Germany a form of forceps, such as Baginsky's, is frequently used to hold the saturated pledget of cotton ; but they are unwieldy and have no advantages over the cotton firmly wound upon a roughened stilet. One of the great disadvantages of the brush is that the hairs, one or all, may be left in the throat of the patient. This can never occur with a cotton applicator properly made.

Tampons. In atrophic rhinitis the Gottstein tampon, either dry or saturated with a stimulating solution, has been very much advocated. It produces its effect by extreme irritation, which brings on a hyperemia and, therefore, greater nourishment of the parts. The principle is doubtless correct. The small pledget of cotton or tampon soaked with a 4 to 10 per cent. solution of cocain (to which has been added 4 or 5 grs. of rescreen to the oz.which not only preserves the fluid but seems to prevent constitutional effects) and accurately applied to the atrophied turbinals is also of great value in these states. The first effect of the cocain is to exsanguinate the parts; the second is to paralyze the vessels and so to induce a passive hyperemia which lasts a considerable length of time and increases the nourishment of the parts without the disagreeable effect of the Gottstein tampon.

Cocain. To this drug the rhinologist is indebted for the opening of his whole field ; but on account of its secondary action and its constitutional effects its use should be restricted to diagnostic purposes. It should not be prescribed for the patient's personal use, and may be said to have no therapeutic value except in cases of atrophic rhinitis, as mentioned above. When, however, in the later stages of tuberculosis, or of malignant disease of' the larynx, deglutition becomes excruciatingly painful, it may be used to enable the patient to eat with more comfort and so keep tip his nourishment. Tile formation of the cocain habit, which is doubtless one of the worst of the drug habits, must always be borne in mind, although fortunately it does not seem to be very common among patients.

In the first congestion of a cold it may be of use to establish nasal respiration ; but if the result is not permanent after one or two trials its use should not be continued. It is without doubt true that the continued use of cocain produces a state of engorgement and hypertrophy which is most intractable. The great advantage of' cocain in producing anemia and shrinking of the nasal structures as well as anesthesia does Dot seem to be shared by the new drug lately brought to notice, eucain. The fact that the latter produces engorgement and hyperemia will probably prevent its Coming into general use in the nose. Menthol has a mildly anesthetic action e.g., in 5 to 10 per cent. solutions in oily menstrua, and may be useful in some cases of painful deglutition, but cannot take the place of cocain.

Lozenges and Troches. Certain substances are with advantage put into this form : the drug makes a solution or mixture with the saliva and accomplishes the object desired. For stimulating purposes, when the throat feels rough and uncomfortable, the various combinations of chlorid of ammonium are very useful; among these may be commended those made after the formula of the London Throat Hospital Pharmacopeia, with black currant paste; and those compounded with cubebs and licorice or with guaiacum, made by various pharmaceutical chemists, may be mentioned. Antisepsis is by this method often carried out most efficiently in cases of foul mouth or lacunae tonsillitis, or even in mild cases of streptococcus or diphtheritic throats by use of tablets of the bichlorid of mercury 1/1000 to 1/200 gr., as made by Fraser, Wyeth, and others. Tablets of these strengths are not disagreeable to the taste, and should be dissolved in the mouth every one to four hours, thus converting the saliva into an antiseptic solution of more or less strength. In acute tonsillitis may be recommended here the small tablet, made by Fraser and others, called " tonsillitis tablets," containing aconite and belladonna to influence the circulation, and the red iodid of mercury as ail antiseptic; probably this iodid of mercury is more powerfully antiseptic than the bichlorid, and 1/100 0 gr. in each tablet is not too much to be given every two to four hours. In mild inflammatory conditions where there is considerable annoying irritation of the fauces, the tablets of "red gum" or other astringent drugs may be used with advantage. After the irritation produced by smoking, chlorid of ammonium and red gum have been often given to advantage.

The almost universal remedy in this form is chlorate of potash, which, given in all states of the throat, is almost as often given erroneously. This drug is supposed to be taken into the circulation and eliminated by the salivary glands and mucous glands of the fauces and pharynx; it therefore increases the activity of the blood supply of these regions, and hence should not be given in acute inflammatory states. In cases, however, of dry pharyngitis, where there is more or less lack of secretion the chronic inflammatory thickening producing an 'engorgement and, therefore, sluggish action this drug generally finds its rational therapeutic use.

It may here be mentioned that some drugs seem to have a specific action on the membranes of the upper air passages: for example, the iodids increase their circulation and glandular action; belladonna diminishes their secretion, and may be used when, as in an early coryza, it is desirable to stop the mucous flow. Quinin, arsenic, nux vomica, and other toni es are of value in those cases of engorgement of the nasal mucous membranes where the vaso motor system seems to have lost its tone. lodids seem also to increase the secretion of the larynx and trachea, so that they may be given where an expectorant effect is desirable.

Massage is recommended, notably by some German authors. In atrophic rhinitis a stroking or vibratory massage has been recommended (by M. Braum) and much claimed for it; but Rosenberg' considers it of doubtful value, although some good effects have been observed. A probe tipped applicator is wound with cotton which is saturated with a solution of tincture of iodin in glycerin, I part to 4 or 8, or in an ointment containing iodin, and applied to the membrane in this manner. The object here is an increased blood supply, as in the case of the tampon. Laker recommends a similar procedure in dry laryngitis. In paralysis, muscle weakness, and neuralgia, massage is recommended by M. Schmidt and others.

Electricity is doubtless of greater value in these conditions, either used as the faradic, induced vibratory current, or as the interrupted constant galvanic current. Electricity may be used, by means of the double electrode of v. Ziemssen, on the muscles of the velum palati, fauces, or in the larynx; or more comfortably by the ordinary single electrode, the kathode (9) being placed on the area to be treated, and the anode (P) by a sponge electrode at the outside of the throat or back of the neck. In diphtheritic paralysis, in the weak muscular action of the late persisting puerile voice, in the fatigued larynx of singers, especially after a cold, these procedures are of great value, the strength of the current being regulated by the sensations of the patient. Faradization of the whole larynx may also be accomplished by pressing a small electrode deep at each side of the larynx, or by placing the negative pole in front of it and the positive pole at the back of the neck. This procedure is of much service in atonic states characterized by weak voice, caused by cold, overuse, or vocal strain, and similar conditions.

The combination of massage and electricity to the outside of the larynx is, often very useful. This is accomplished by clamping the negative pole to the right hand or wrist of the operator, so that the current will flow through the fingers, and placing the positive pole at the back of the neck, as before mentioned.

Caustics. In the use of these destructive agents the greatest caution is to be advocated, since they are to be used principally in the nose and larynx. It is very easy to remove by their means redundant tissue; it is not so easy to remove just enough and still preserve the functions of the parts. It should be the rule to do a little less than enough rather than a little more, since it is easy to burn more, but not to restore that which has been too zealously destroyed.

In the nose first was used glacial acetic and fuming nitric acids, but being liquid, their action was difficult to control and they have deservedly been relegated to the past. Next comes 'Chromic acid, which could be fused on a metallic applicator and drawn in lines along the turbinal bodies. Its disagreeable odor, its active deliquescence and too powerful action, causing a deep wound and a troublesome slough and slow healing, have been disadvantages which have led to its disuse. It is, however, the best agent to close the little bleeding vessels in the septal ulcers before mentioned, which are the frequent cause of epistaxis.

The best acids for caustic action are without doubt the monochloracetic and the trichloracetic acids. These act practically in the same way to produce condensation (Bosworth) of the tissues subjacent to the area of' their application, the former having a little more powerful effect than the latter. These acids come in crystals and can be readily fused on the applicator ; or, being slowly deliquescent, the thick liquid can be taken up on a probe very finely wound with cotton (the excess being shaken off), and this will have almost the same caustic value as the former method and is easier of preparation. These acids have the great advantage that the slough becomes hygroscopic and remains on the site of the application as a protective covering, like a, piece of wet chamois skin, leaving a smooth surface On removal. After the effect of the cocain has subsided, there is apt to be some pain; but it is not lasting, and is far less than after the use of chromic and glacial acetic acids.

The most efficient and most accurately controllable agent in this class is, the galvano cautery ; and now it is the most reliable, Since the rheostat has been perfected and the Edison street current can be brought to our hand, enabling US to discard the ever troublesome and expensive battery.

This powerful agent should not be used on turbinals presenting a transient engorgement from atmospheric irritation or vaso motor relaxation, but only upon those showing true hypertrophy: the distinction is made manifest. by cocain. If the whole turbinal shrinks down to a minimum, it is not hypertrophy; but if some remains, especially if it is pale, flabby, and less easily compressible, then it is a true hypertrophy and will permit the Use of these agents. The galvano cautery tip can be used in two ways in these cases : the point being heated to a cherry red color, a line can be drawn on the lower edge, and on one or two parts of the face of the third turbinals or along the middle, or one or both sides of the second or middle turbinals; or one or more lines may be drawn along that swelling of the septum so often occurring over the suture between the ethmoid plate and the triangular cartilage. Some have decried the cauterization of the second turbinal, fearing meningitis by extension of inflammation or other evils. But this fear is probably not well grounded unless the operation were done where there was so much swelling in the lower parts of the nose as to make drainage poor or nil. For this reason the lower parts of the nose should be treated first, and after healing has taken place it will be safe to treat the upper parts.

This "lining" of the surface of the intranasal swellings, however, causes much destruction of the ciliated epithelium and of the glandular laver under this; healing is then sometimes rather tedious, and there is danger of synechie if the lumen is narrow. Hence, it is at times better to puncture the anterior part of the swelling and to carry the heated point backward as far as is necessary in the cavernous layer parallel to the outer surface. For this purpose the platinum part of the point may be made longer than usual, say three fourths of an inch in length. In this way only a small round point of the surface is destroyed and healing is more rapid. A flow of blood is apt to follow the extraction of the point, but can be controlled by withdrawing it slowly and then sealing the aperture with the still glowing point. A white heat is not hemostatic.

The best handle is that of Sehech, and be has also probably brought the points to the greatest perfection as to their form. If the copper part of the electrode is too small, it will get disagreeably hot before the operation is finished ; this adds much to the nervous apprehension of the patient if it is felt. The copper part should, therefore, be large enough to keep the platinum heated without itself getting hot. This principle is carried out in points made by the Edison Company.

The use of the galvano cautery on hypertrophied tonsils is advocated by many. In the opinion of the writer, however, it is irrational and dangerous'. The inflamed tonsil (especially in the lacunal variety) is large because of morbid processes and products in the crypts. Unless the electric point is carried to the bottom of these crypts and the whole of the interior treated, some of the materies morbi is left after the adhesive inflammation has sealed the outer part of the lumen (there is the same objection to the ordinary amputation with the guillotine); and if it is carried to the bottom it comes too near the capsule and the large vessels lying just to the outside. Enucleation or discission (as first advocated by Hoffman and elucidated by the writer, Boston Medical and Surgical Journal, Oct. 12 and 19, 1893) seems much more rational. Moreover, the galvano caustic method of reduction requires several sittings, and thus keeps the throats of most patients in a state of painful inflammation longer than does discission, which may Deed but one or two sittings.

The use of the galvano cautery or of other caustics is fortunately not often required in the larynx, but may be indicated in some cases of tumefactions. For example, lactic acid (40 per cent. to 100 per cent.) has been very highly praised in tubercular nodules and ulcers; and nitrate of silver, fused on Shrotter's concealed applicator, in papillomata or pachydermia among others. But the use of the galvano cautery for singers' nodes (pachydermia tuberosa) as advocated is, in most cases, entirely uncalled for, since absolute rest will cause their disappearance in a very few weeks, with much less danger to the delicate edges of the vocal cords.

PROGNOSIS.

The question is often asked of the specialist, "Can my catarrh be cured?" or "Can it be cured permanently?" The first of these questions can generally be answered in the affirmative, except in some very bad cases of atrophic nasal catarrh or of destructive specific ozena; and the second also in the affirmative, as truly as in any other affections of the mucous membranes. Recurrences are to be expected or to be guarded against in most ills to which human flesh is heir except perhaps death or those which can be permanently shut out by surgical measures, such as enucleation of an eye, or amputation of a limb, or removal of the appendix vermiformis: then why not a recurrence of catarrhal conditions to be brought on by the same means as previous attacks? But it is altogether probable that if all contacts are abolished in the nose by removal of extraneous growths and by reduction of abnormal swellings of normal structures without destroying the functions of the parts, so as to establish the habit of nose breathing; if purulent cavities are drained and allowed to Ilea], whether of the accessory sinuses or other sources of' pus emptying into tile nose; if caries or necrosis of hard or soft parts can be stopped and their products removed so as to be no longer the source of irritation as foreign bodies; if bad habits are corrected and the daily life brought into rational physiological channels; if troublesome or deleterious dyscrasia and diatheses can be eliminated or held in abeyance then probably the symptoms of catarrh can be abolished. So that in most cases the patient may be promised that he can be cured or, if not cured, made so much better that he will consider himself cured, till by his own carelessness or misfortune causes operate to induce a new manifestation of his trouble.

These same questions are almost always asked by anxious parents when hyperplasia of the pharyngeal tonsil has been discovered in their children. .It seems to the writer that an affirmative answer can always be given, provided the nares are unobstructed and the habit of nasal respiration is immediately established. No statistics are at hand ; but it is probably true that habit and hypertrophic nasal obstruction are the great factors operative in cases of recurrence. Per contra, given an obstructed nose and adenoid vegetations, it is often safe to give the prognosis that the latter may wholly disappear or cease from troubling, provided they are not too old and hard, if the former is restored to normal caliber and mouth breathing stopped. This desirable result has been attained in the practice of the writer more than once; and the cases of recurrence which have formerly come under his observation were in children with obstructed noses or whose parents did not insist on nasal respiration.

In closing this article, a word as to the danger of too much or too radical surgical interference in the upper air passages deserves a place. Destruction of tissue in the nose should be limited to the hard parts as much as possible. It is a great mistake to remove the lower turbinals except for necrosis, although much of their covering may be redundant. The posterior ends may be amputated, the middle an anterior ends may be prodded and scored with the cautery and any excrescences removed, but not enough to shrivel them into cicatricial masses without function. The whole body even may be bent downward and outward on its attachment like a hinge, but it is protested that it should not be destroyed nor removed. Atrophic rhinitis, dry, crusty, malodorous catarrh, pharyngitis sicea, and chronic inflammation of the surfaces lower down threaten the victim of such mistaken zeal, if not immediately, surely in the near future. The middle turbinal is functionally less important and may even be removed with less danger of future evil when it suffers edematous mucous degeneration (socalled) or caries, or becomes cystic and enlarged, causing painful disturbance of the fifth nerve by pressure. Twere better to reduce its size by the various means suggested, but even then its ability to keep its surface clean should not be impaired.

It is significant, as Chapell and others have shown that even by ordinary operations in the nose in certain individual’s reflex neurosis may be set up, producing exaggerated nervous symptoms especially as to the nose itself, inability to apply the mind, and even melancholic depression. Perhaps in no branch of surgery' then, is there more need of caution than in this region.

It is obvious also that the mucous membrane of the naso pharynx should not be removed with the pharyngeal tonsil, nor the pillars of the fauces with the faucial tonsil, nor in the larynx should the delicate edges of the vocal cords be injured, nor other part wounded so that cicatricial bands may impair its shape or movements. In fine, in all this region of the upper airpassages, the operator should have ever in mind the inflexible rule that if he cannot reach the perfection of his ideals, lie certainly must make the patient no worse in any particular.

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