A retrospect of Laryng-Otology

98 IRISH JOURNAL OF MEDICAL SCIENCE

A RETROSPECT OF LARYNG-OTOLOGY. '~

By SIR ROBERT WOODS,

I T was suggested to me that at this, the first meeting of the Section of Laryngology and Otology of the Royal Academy of Medicine in Ireland, it would be of interest if I reviewed

the progress made in our speciality during the years that have elapsed since I began practice. So, with your permission, like pioneers who pause from their labour to look around and con- template the ground already cleared, we shall cast a glance behind us in the hope of finding sufficient satisfaction in what we have already achieved to inspire us with hope and encouragement for what lies before us.

Judged by the life of art and science in general, laryngology is still in its infancy. I have shaken hands with the inventor of the laryngoscope, Senor Manuel Garcia, a teacher of singing whose hundredth birthday I helped to celebrate about thirty years ago. He devised the instrument about 1855 as an aid to him in his profession, but for many years it remained a toy suitable only for musical conversaziones. I t was not until the '80's that Tiirck of Vienna and Morell Mackenzie of London brought it into daily use as a serious contribution to the equipment of the physician. Its success was rapid, for by its means a flood of light was thrown on conditions that theretofore had been only guessed at. Tumours, ulcerations and paralyses, that had previously only been suspected or discovered post mortem, were opened to view, and a beginning was made at the clinical study of the pathology and treatment of disease affecting the throat. As might be expected, the chief progress lay at first in the recognition of the grosser changes brought about by aneurysm, syphilis, cancer and tubercle. But there remained a host of ailments less severe in character whose causation was misunderstood, whose pathology was explained on traditional creeds, and whose manifestations were treated on traditional lines. When patients complained of persistent discomfort a persistent cause was naturally, and indeed properly, assumed; but the difficulty lay in blaming the true cause. Occupations have always had their ailments; and, if housemaid's knee and painter 's colic, why not clergyman's sore throat? The most fantastic theories were formulated to fit the assumption. Pharyngitis was held by Lennox Browne in 1893 to be due to faulty respiration and voice production, and the aid of elocution masters and singing teachers was invoked in its treatment. The following dates from 1891.

Pathogeny of Speaker's Sore Throat. There can be no doubt that the malady commences as fatigue of the muscles and motor nerves, in fact as myalgia; and this is continually maintained by repeated efforts. As

* Being the President's Inaugural Address to the Section of Laryng- otology of the Royal Academy of Medicine in Ireland, delivered on January 16th, 1931.

R E T R O S P E C T OF LARYNG-OTOLOGY 99

muscular exertion is always attended by arterial dilatation, it necessarily occurs that the muscular paresis is soon associated with arterial pares~s~ and a state of active hyper~emia is established in the part. Some slight, n o x a converts this into actual inflammation, the parietal corpuscles of tl~e Vessels and the leucocytes undergoing hyperplasia, and outwandering into ~he tissues, where they form or exaggerate adenoid growths.

One can only indulge in the hope that our speculations of to-day will not sound quite such rubbish to our successors !

Tobacco was a favouri te scapegoat, and a fa i r ly safe one, for i t seldom happened that a devotee of the so-called pernicious habit of smoking, would, by giving up the pipe, submit to the only test that could prove the doctor wrong. Gout was in thos~ days a convenient limbo to which every complaint not susceptible of a handier explanation was relegated. I t had the ines~timable advantage, too, which it shared with certain diseases of the skin, tha t patients cheerfully submitted to t reatment without an y illusion about the prospect of a cure. Such diagnoses became almost stereotyped owing to the difficulty of applying crucia| tests. That we hear little or nothing of them nowadays is a proof tha t more satisfactory explanations have taken their places.

Chronic laryngitis was for many years regarded as a p r imary affection and, once the diagnosis was made, the only question that remained was by what local astringent it should be treated. When I was s tudying in Vienna in 1891, laryngology consisted largely in examining patients and talking about what we saw. A polypus on a vocal chord was a godsend to a clinic, for the pat ient underwent a month 's t raining in allowing instruments to be passed into his la rynx without coughing. The arrangement was satisfactory to everyone, for the man got four weeks' lesson in toleration, and the students an equal practice at instrumentation. The therapeutics of chronic ailments were vir tual ly confined to chromic acid for the nose, and solutions of n i t ra te of silver in various strengths and powdered alum for the pharynx and larynx. I t was astonishing to see the regular i ty wlth which patients came to the clinic to have their throats brushed, with no obvious result beyond the " gra t i fy ing feeling that thei r du ty had been done . " A fixed i, dea is a t ru ly terr ible thing. I once allowed myself to paint a woman's throat with chloride of zinc, not because I could see anything to account for the " tightness " of which she complained, but as a placebo to her conviction that there was something wrong, and as a, perhaps weakminded, concession to her importunity. My punishment fitted my crime, for though that was over th i r ty years ago, she still, if able to stagger, comes to the dispensary for the purpose, and by no amount of argument have I ever been able to dissuade her from presenting herself for the treatment, which she always receives with the utmost satisfaction, rehearsing each time the first article of her creed, tha t only for it she would be dead!

The effect of uncer ta in ty as to the causation of troubles led to the most exaggerated importance being attached to small depar tures from the normal or from the average, and irregularit ies


in such variables as lymphoid tissue in the pharynx were credited with sinister influences. As long ago as 1868, Mayer described adenoids, and recommended their removal as a cure for deafness, but his work only bore sporadic fruit until about 1890, when surgeons began to treat it seriously. The operation as performed to-day took a long time to develop. Many operators at first used the index finger nail, which they allowed to grow long for this purpose; and this was improved on by an artificial nail fitted to the top of the finger. Such operations were generally done without an anaesthetic, or with cocaine, and accidents sometimes happened, apparently from poisoning by that drug. Recur- fences, which one suspects might more truly be called perslstences, were frequent, and doub|e spoons of various shapes were devised, but the curette devised by Gottstein drove all other devices from the field. Hmmorrhage was the bugbear of the operation, and it was the custom to plug the naso-pharynx with tannic acid on a sponge. Tonsillotomy was a much older procedure, but tl.e two were not commonly associated until the '9C's, when the use of Rose's position with the extended and dependent head becam~ popular in most places, though many men adhered to the sitting or half-lying posture. The choice of an anaesthetic gave rise to the most acute and even angry dissension, and even to this day there is no compleW, consensus of opinion, though the tendency is, I gather, more and more towards ether. This has been our ex- clusive practice here for many years, and to this I attribute the fact that we, in Dublin, do not lose patients under the anaesthetic. I t is now more than thirty years since I permitted an anaesthetist to use chloroform in such cases. I have observed that at inquests in England, where the status lymphaticus has been blamed, chloroform has without exception been either the sole anaesthetic, or a constituent part. While on this subject I may remark that, though avoiding chloroform on all possible o(~casions, we can still hardly dispense with its occasional use. Under such circumstances my practice is to use ether alone first, and only to employ chloro: form for maintaining the anaesthesia. By this means the early and most dangerous stage of the narcosis is tided over. I f asked how this helps, I would suggest that most patients when being an~esthetised have a certain degree of apprehension, which in some amounts to fear. That fear is a cause of syncope, and when to that emotional influence chloroform is added, dangerous depression of the heart's action is not far off. Suppose, however, that, in spite of our precautions, collapse occurs, what pr~edure gives the best prospect of resuscitation? I am convinced, both by reason and experience, that it lies in artificial respiration by direct in- suffiation, or the mouth to mouth method, which had been practised from time immemorial until the middle of the eighteenth century. In a paper read before this Academy in 1906, I pointed out' that the reason for changing to the newer and worse method of Sylvester was because Black in 1756 discovered the presence of CO~ in expired air. The physiological wiseacres therefore

RETROSPECT OF LARYNG-OTOLOGY 101

rushed to the quaint conclusion that " to pour the exhaled breath of one human being into another human being was to commit a grave physiological error, and to intensify the bad condition already present ." This plausible childishness may have suited the rudimentary knowledge of that day, but is it not astonishing that it should still be tacitly accepted after the lapse of a century and three-quarters?

Up to almost the end of the last century the care of the mouth was regarded in the same light as cosmetics. Fastidious people kept their teeth and gums in order, others left them to chance, unless pain developed. With few exceptions, dentists took the narrowest view of their business. I f their patients could smile without embarrassment, and eat without discomfort, that was enough. Their fixed and moveable devices might cover any un- cleanness. The practice of cutting off stumps level with the gum and covering them with plates was common, and defended stoutly; and in many cases a denture once put in place remained 1here in- definitely. The credit of pointing out the danger of oral sepsis is largely due to Dr. Hunter, whose articles in the British Medical Journal from 1896 onwards focussed attention on that important subject, and proved once again the close connection that usually subsists between dirt and danger.

The influence of dental disease on the throat and nose was soon suspected and confirmed. Carious molars were found associated with antral disease. But before antral disease could at that time be recogzfised, some exaggerated sign had to be presenu As late as 1896 it had to be remarked that for its diagnosis examination of the nose, and not palpation of the face, was the important thing, and that distention of the canine fossa was not so common ~n the disease as was generally supposed. Trans-illumination was invented at this time. Treatment consisted in washing out the cavity through the hiatus semilunaris, and though successes were claimed for that method, it is perhaps doubtful if they would pass for cures nowaaays. At any rate a sufficient number were believed to be cured to excite the hope that irrigation per vias naturales was suitable for every case.

In the following year, 1897, the alveolus was perforated by dentists, to whom such cases were sent by leading specialists, and tubes attached to neighbouring teeth or dental plates were inserted. I t was expected, and indeed assumed, that the principle of drainage, so successful with purulent collections elsewhere, would be equally applicable here. Indeed, it is still so generally assumed that I venture to say there is not a text book or publication on the subject that does not put it forward as all- important in the treatment of sinusitis, thus missing the heart of the problem. It is now more than a quarter of a century since I pointed out in this Academy 2 that an abscess and a purulent sinus have nothing in common except the pus. An abscess is a collapsible cavity lined with granulation tissue, whose walls are forced apart by the pus, and which only needs an outlet for that


pus in order that it should collapse and obliterate itself by fusion of its walls. A sinus, on the other hand, is a rigid natural cavity lined by epithelium, and its treatment when diseased depends entirely on what changes that epithelium has undergone. An early infection may well be cured by drainage, just as an acute cold may be regarded as being cured by drainage, but once polypoid degeneration has taken place, recovery can no more happen in a sinus than in the nose. where drainage conditions are much more favourable, and where we can see for ourselves that it does not happen.

The question then arises, should even an acute antrum be drained? I should have no objection, if it could be done without sacrifice of part of the turbinal, and if an equally good result could not be obtained by a few punctures and washings through the inferior meatus, a method that I find most effective. But for my part, even if I were assured that intranasal drainage would cure my antrum, I would cheerfully submit to the radica! operation, rather than allow the sacrifice of any portion of my precious turbinal.

Drainage and irrigation however, even though they may have failed to cure, were helpful in so far as they kept the disease in check, and prevented the consequences, local and general, that are known to follow the secretion and ingestion of pus. The sins laid to the charge of a purulent antrum are many, and most of them too well known to need recapitulation, but ther.~ is, I lhink, one not usually mentioned and fortunately not common, which should be included in the list, viz., carcinoma of the upper jaw. I t has fallen to me to operate on many cases of this fell disease, but never to my recollection without finding the antrum, or what was left of it, purulent and degenerated exactly as in an ordinary chronic empyema. I t can hardly have been mere coincidence.

As an improvement on the tube through the gum which was too easily blocked by food particles, the drain was inserted through the canine fossa. When this was done without a free incision being made into the soft tissues at the site of puncture, it sometimes resulted in a cellulitis which took the patient to death's door, if not through it! a risk which was not run in the casc of the alveolar route, where the tissues are so dense that infection does not readily spread.

At length the radical cure by removal of the degenerated membrane was introduced. The operation at first consisted in making an opening in the canine fossa large enough to permit curetting of the pyogenic membrane, the cavity was plugged and dressed and made to heal from the bottom. Skin grafting was sometimes resorted to. Results were good, but the time between the operation and the patient's dismissal was too long, and when the Caldwell-Luc operation was introduced it was welcomed as a tremendous shortening of convalescence. In this procedure, after removal of the diseased membrane, a large opening was made in the nos~ by taking away a portion of the inner antral wall,


and the wound in the canine foa~a closed finally at the time of operation. By this means true granulations grew from the denuded wall until they either fused or were covered by epithelium from the nose. This process, though not always rapid, happened sooner or later, and meantime the patient was to all intents cured within a week of the operation. Notwithstanding that the radical operation was so satisfactory, many operators persisted, and indeed still persist, in their efforts at cure by intranasal methods, by removal *of the anterior end of the turbinal and cutting a window in the subjacent antral wall, being still dominated by the drainage theory, and only resort to tile radical method when these efforts fail, as they are always bound to fail in old-standing cases. Unfortunately, it happened too often in performing the radical operation that operators, in their anxiety to make the opening into the nose free enough4 did not confine their attentions to the inferior fossa, but cut the inferior turbinal completely away, thus quite unnecessarily depriving the patient of the advantage of that most important structure. Abnormal nasal patency and its attendant discomforts resulted. Even as late as 1907 illustrations of the radical operation re- presented ablation of the turbinal as one of its features. This want of respect for the turbinals constitutes, in my opinion, one of the gravest reproaches to our speciality. I t found its cul- mination in the operation of turbinectomy for the relie~ of nasal obstruction, which had such a vogue in England in the first two decades of this century. It aimed at nothing less than the complete removal of the inferior turbinal and all that belongs to it, by means of an instrument called a spokeshave. The operation conferred nasal respiration on the patient by depriving him of the structure which of all others renders it worth having. It is my opinion that the turbinals, both middle and inferior, are generally speaking still treated with too little courtesy.

The radical antrum operation was soon followed by that of the frontal sinus. But a dozen cases had not been treated before it was clear that while the antrum was very safe, the frontal was highly dangerous. The mortality at first was appalling, and is still far too high. The commonest cause of death was osteomyelitis of the skull. I am sure that faulty operative methods were, and are, to blame for nearly all bad results. My own mortality has been less than 1%, and I ascribe this entirely to McEwen, who pointed out the danger of the slightest scratch on the bones of tho skull. No instrument should be employed in removing the lining membrane of a sinus; this should always be done with gauze. Healing should always take place within ten days.

Nasal patency in its severest form is found in so-called chronic atrophic fcetid rhinitis or oz~ena, a condition long familiar to physicians, and whose pathology has been the cause of much speculation among rhinologists. Ever since the microbial origin of disease was established efforts have been constautly made to find its specific organism. But among the multitude of varieties


always present, it is little wonder that none has yet been con- victed of its causation. Oz~ena used to be, and indeed still is by many authorities, regarded as a progressive disease, and the belief was widely held that atrophy was the end stage of hyper- trophic rhinitis. I have never subscribed to these views. I do not regard atrophic rhinitia as progressive. I think it is cataclysmal, and due to a single attack whose severity determines once for all the damage done. I further think that those attacks occur in the course of measles, and that the impairment or de- struction of the delicate nasal membranes results from the ful- minating inflammations that accompany that fever in its severer forms, and which cause parallel effects in the middle ear. The want of success that has invariably attended efforts to cure that distressing malady is thus easily explained.

The problem of how to treat nasal obstruction when caused by septal fractures and deformities met no satisfactory solution until it was tackled by Killian. Before his time spurs and de- flections were sawn off, or turbinal tissue was sacrificed to make room for the air current, with varying success; but his elegant device of submucous resection of the septum enabled us to correct deformities and restore symmetry without sacrificing physiological tissue and leaving scars behind. The comfort that this operation has brought to sufferers can only be appreciated by those who have experienced it.

During my student days diphtheria was rare in Dublin, but in the early '90's it became quite prevalent. The first ease I saw in consultation was a severe one, and it was debated among three of us whether antitoxin should be given. The remedy was new, severely eriticised, and hard to procure. I t was not administered and the patient died. Koch's much boomed tuberculin treatment was at that moment in disrepute, and it was predicted with confidence and even assurance that antitoxin, which seemed a similar sort of thing, would be found worthless, if not injurious. A very short trial convinced most of us of its value. I saw many cases in consultation, not a few of which needed tracheotomy, an unpleasant operation before the days of head- lights in a private house with only a paraffin lamp. Antitoxin was given in many cases according as the patient seemed to need it, and no general rule was followed. I never saw any harmful effects from its use, and it came as a surprise to find that there was such a thing as anaphylaxis. Of no less importance than cure is prevention. My belief is that most of the cases I saw were distributed by infected milk. I feel that at any rate it is food born, and that it does not ordinarily pass directly from patient to patient, though no doubt it does sometimes happen. In those days, once the diagnosis was confirmed by the microscope or culture, the bacteriologist was not further troubled about the case. When the patient's recovery was clinically complete, he mixed with his neighbours as usual, and no one seemed one penny the worse. I feel sure I am old fashioned, but waiting until the


patient's throat is germ-free, and regarding him as a carrier and a danger to the community until that moment arrives, has always seemed to me wasteful and ridiculous excess. I believe that if all the throats in Grafton Street were examined, a high pro- portion of the owners would be classed as carriers, and it seem.~ absurd to confine a child to a room for weeks at a time whose danger to the public is no greater.

I wonder why it is that nasal diphtheria is always so mild. I have never seen a case with severe constitutional disturbance, and many I have happened on quite accidentally in the dispensary. It must, I think, be a common thing for children to acquire, and recover from, without any suspicion that it was more than a cold in the head.

The discovery of cocaine and its anaesthetic effect on mucou~ surfaces is certainly the most important in rhinology. With it, in fact, rhinology may be said to have been born. Before its introduction people would not stand the irritation of nasal instrumentation, and until examination by whatever instruments are necessary becomes a routine, the signifiance of what is seen can hardly be understood. Up to that time only the most distressing o r dangerous conditions of the nose came under treatment. As a student, I only saw polypi removed, and the method adopted was enough to deter all but the brave. The operator stood beside the seated patient, facing in the same direction. With his left hand he steadied the victim's head, and with his right introduced forceps into the nose. Whatever the jaws happened to catch was pulled out with groans and bloodshed. The snare, though an oM invention, was harder to use, and therefore less popular.

In 1899 Bates made his famous observation on suprarenal ex- tract as a h~emostatie, and in the following year the active principle of the gland, under the name of adrenalin, appeared on the market. The discovery was second only to cocaine in its importance to rhinology. Its chief benefit lay in rendering a higher accuracy of workmanship possible by providing a bloodless field, but hardly less advantageous was its effect of lessening the quantity of cocaine necessary for anesthesia by the virtual stoppage of the local circulation. Cocaine syncope, from being unpleasantly frequent, became rare after the use of adrenalin.

I suppose there is no drug but will have a different poisoning effect on different people, and I can record an extreme illustration from my own experience of cocaine. In the first case, in 1891 or 1892, I assisted at a minor operation on the dorsum of the foot in a man aged about 30. The surgeon injected three grains of cocaine round the seat of operation. I need hardly say complete local anmsthesia resulted. When asked if he noticed any effect, the patient replied that he felt as if he had had a good glass of sherry. The second ease was that of a barrister, aged about 40, in 1894, on whose nose I wanted to do something trivial. I applied a swab or two of cocaine to the turbinal body, when he complained of being ill, and forthwith developed all the symptoms of


poisoning, including pallor, fainting, profuse sweating, tingling at the hands and feet, feeble pulse, etc. I applied restoratives, and he came round, but it was some hours before he could be moved home. Some days later he came again, and this time in order to make assurance sure, I took a tabloid of one eighth of a grain of cocaine from my hypodermic case, and with that dis- solved began my painting of the turbinal. To my astonishment the same symptoms developed, to almost the same degree, and for about the same length of time. The man was no coward, and I cannot see my way to dismissing his collapse as being entirely emotional. My experience of fainting from emotional causes is that the effect is much more transitory than in this case. But I have always found that the man who leads the intellectual life is much more easily affected by toxic influences than he " that holdeth the plough and whose talk is of bullocks."

Cocaine, in spite of its rivals, remains in my opinion incom- parably the best local anaesthetic for the nose, and~ when used with reason and ordinary care, perfectly safe if combined with adrenalin and applied superficially. I t is not So safe when injected, even in great dilution. The patient should have had a reasonably full meal, for an empty stomach is twin brother to a faint heart. At the British Medical Association Meeting in 1913 I advanced the paradox that a strong solution of cocaine is safer than a weak one. My argument was that in order to produce anaesthesia a certain quantity of the drug must be absorbed per unit of area. That if a weak solution is used, the bulk of the fluid being greater, we are more likely to have it slopped over places where it is not needed, and by the time anmsthesia is in- duced at the field of operation, the total quantity of the drug introduced will be needlessly large, and that from the general toxic point of view it is this total quantity that matters and not the strength. Therefore let the concentration be high and the volume small. This view now meets, I think, with general acceptance.

On its first introduction adrenalin suffered the fate of most good things and was abused. The relief it afforded to a choked nose tempted people to use it in acute inflammatory cases, forget- ful of the consideration that inflammation is a protective process, whose suppression is likely to be followed by a rise in the severity of the attack. The comfort of nasal freedom may be bought at too high a price, and the use of blanching agents in the treatment of acute rhinitis should certainly be discouraged. This is one reason why most commercial " cold cures " are so pernicious.

One of the most difficult and interesting problems that can confront a rhinologist is the decision as to what can properly be described as a normal nose, and following closely on the heels of this question comes the more practical one of to what extent one is justified in interfering with small departures from the ideal. The answer cannot be learnt from textbooks; it can come, if it ever does come, only from prolonged observation aided by a well


balanced judgment. An operator who takes too rigid a view ef the importance of symmetry will be kept busy. I t must always be remembered that an unsymmetrical nose, if not anatomi- cally normal, may be in perfect health and perfect function. The physiological tissues of the nose have a marvellous faculty of com- pensating for minor irregularities such as are invariably, or almost invariably, found in all but prognathous races. A turbinal will feel after and grow towards a depression in the septum, in much the same way as a plant will towards light. No one expects to find a plane unbiassed septum in a white man. The fact that the septum is out of t ruth is no reason, therefore, for interfering with it. Nor are we always helped in our decision by the patient's cries for relief; for some of the worst cases of distress have nothing pathological as their cause, but are due to a false notion of what is correct. An introspective and credulous individual reads an advertisement for some nostrum and concludes that he suffers from catarrh, and at once the beautiful process by which the nose cleanses itself becomes in his eyes degraded to a disease which he regards with the same disgust and apprehension as he would a urethritis. I t is only necessary for a nasal wash to be prescribed by a well-meaning practitioner to have his views endorsed and his fears confirmed, and by this declension he gravitates into a state of despondency, for of course the discharge never stops, and he looks on himself as incurable. This is no fancy picture; I have seen scores of them. Reasonable people will sometimes learn to change their views, but a minority will go away unshaken, convinced that you have sadly misunderstood their case; and it has on occasion happened to me to get a letter in a most Christian and forgiving spirit, pointing out how the disease that I had overlooked was discovered by someone else. Needless to say that before one arrives at a decision that nothing is physically wrong, the most painstaking and exhaustive examination is pre-supposed; for the rule is that the less there is wrong, the harder to find it.

In the late '90's RSntgen discovered x-rays. In a relatively short time they were successfully employed in the location of opaque foreign bodies in the gullet. Though helped to this extent by this information, the treatment remained very crude. I t consisted in passing a sponge in the hope that the substance would either go before it, or come up entangled with it. Much harm has resulted from the use of this instrument. In the case of coins the prospect was somewhat better, for the old coin-catcher, a most ingenious and generally harmless instrument, was usually successful. I f the object swallowed was large, o~sophagotomy had generally to be undertaken.

Towards the end of last century, inventors, taking the tip from swordswallowers, began to make cesophagoscopcs, but they were mostly impractical devices until Killian and his pupil Briinings produced their elegant instrument at the Vienna Congress of Laryngology in 1908. The beauty of the instrument, unfortunately, does not make it easy to use without considerable practice.


To Killian's fertile and ingenious mind we are also indebtecT for suspension laryngoscopy (1913) whereby the weight of the patient's head is used to draw forward the tongue and epiglottis, and so permit a direct view of the larynx, leaving the operator with both hands free for manipulation. The method is occasionally valuable, but will never supplant the old indirect method of operating which, if harder to acquire, is much more comfortable to the patient.

When the difficulties in the way of learning anything about the organ of hearing are remembered, the lateness of the birth of otology as a science and its slow development during its early years need cause no surprise. The pioneers, under the name of aurists, were thought a fair target for the witticisms of their brethren the physicians. A London clinician used to say to his class: " A little wax, gentlemen, a little wax is a godsend to an aurist ." Diseases of the ear in those days were divided into two, those that could be cured by syringing, and those that could not. Thus our predecessors had to submit to being a source of innocent merriment to their brethren of the stethoscope and the splint.

Ever since Valsalva's time, at the end of the seventeenth century, his plan of inflating the middle ear by holding the nose and trying to blow was known to relieve deafness. When the normal process of ventilation of the tympanic cavity is interrupted and the balance of pressure inside and outside the drum upset by absorption of air, the method of course gives relief, and the number of eases where it was applicable was at one thne much greater than now, since gross obstructions are now cleared away without ceremony. But its success in those suitable cases, for which there was then no other remedy, led to its being preseribed in all cases of deafness. Defective aeration of the tympanic cavity thus became the dominant theory of deafness, even where there was no obstruction, and interest centred around the ways of overcoming it. At the end of the '80's, adenoids, which had been described by Mayer in 1868, were recognised as playing a part of the first importance i-n deafness. Their removal had the most satisfactory results, and the obstruction theory received con- firmation. Where adenoids were not present, or their removal effeeted no improvement, efforts were directed to the Eustachian tube, where the obstruction was supposed to be. Politizer devised his rubber bag so that a higher pressure might succeed where Valsalva failed, and from this it was an easy transition to the Eustachian catheter and bougie, whereby the air could be directly forced into the middle ear, and its entry recognised by a tube connecting the patient's and aurist's meatuses, to which the absurd name of " otoscope " was given.

The popularity that the Eustachian catheter, as a treatment for chronic deafness, has enjoyed for the past forty years is to my mind one of the most amazing things in the whole history of medicine. The product of the obstruction theory, it outlives its parent, and, perhaps for want of a more demonstrative rival, is


~till employed with an optimism so buoyant as to need no encouragement from success. I f the tympanic membrane is normal in shape and position there can be no blocking of the tube, and what there is to be gained by catheterisation, even for diagnostic purposes, in such a case, passes my comprehension. And yet the practice is so widespread to-day that the pat ient seeking relief f rom chronic deafness of any kind is for tunate if he escapes f rom a " course " of such futile fiddling every second or third d a y for weeks, or even months at a time.

The catarrhal theory of chronic deafness held the field for decades, and indeed still has its adherents. I t accounted satis- factor i ly for Eustachian obstruction, but even in the absence of obstruction, and with no trace of flow of any kind, the theory was equal to the occasion, and people spoke of " dry ca t a r rh , " a most perfect contradiction in terms. The suspected origin of the catarrh was, of course, the nose, and the theory was that if not due to adenoids it must come from some other nasal condition, and could therefore be mitigated or cured by nasal surgery. E v e r y structure, no mat ter how sound, and every deviation from the normal, no matter how trivial, has been ]aid under suspicion, and the amount of unnecessary and even injurious surgery that has been p e r f o r m e d - - I had almost said commit ted- - in con- ~equence of this blunder, can only be surmised.

Otitis media for ty years ago was not taken very seriously. I f in the young it was only due to teething, and the child would grow out of it. I f chronic, and affecting only one ear~ the pat ient had the good one to hear with, and was near ly as well off for hearing as if he had two. Nor was the connection between the acute and chronic forms known. In 1896, as a result of investigation and observation of over 300 cases in an epidemic of measles and scarlatina, I arr ived at the conclusion that the essential difference is bacterial, viz., that acute otitis is always due to a single, and chronic to multiple infections. I still believe this to be broadly true, and quite t rue if allowance be made for tuberculosis, which, though a single infection, is f rom its nature chronic f rom the first.

I t was recognised, however, tha t occasionally intracranial complications supervened, and it was observed that when this happened i t commonly had as a prelude the cessation of the discharge. Hence arose the belief that as long as the ear ran all was well, and that it was therefore dangerous to stop the discharge. I t seems odd nowadays, but not so many years ago a proposal to cure otorrhcea, even by medicinal means, used often to be met by the objection that such and such an author i ty said that the discharge should not be arrested. I t is certain that this was sometimes the pat ient 's garbled version of what the doctor had said, bu t in other cases it certainly was not.

The mechanism of extension of ear infections has always in- terested me. There can be little doubt that spreading can take place by direct continuity of tissue, or along a clot ~ in a blood


vessel, even when there is no gross obstructien to the outlet of inflammatory products, but there is still le~ doubt that if such an obstruction exists the likelihood of such complications is in- creased, for the law is inexorable that fluids will always tend to go from a place of high pressure to one of low pressure. For this reason it has always seemed to me that the commonly recommended practice of treating otitis whether acute or chronic by hydrogen peroxide is highly risky, for, when the gas develops, pressure is exerted equally in all directions, and will push matter in as cheerfully as out. Of course it is impossible to say in any given instance that no complication would have arisen if peroxide had not been used ; but it is my firm belief that I have seen many cases that would not have come to operation but for its employ- ment. I have the less hesitation in speaking so strongly, since I ean see no possible advantage from its use.

For similar reasons I regard the practice of inflating the middle ear with the catheter in acute otitis Jn order to blow the secretion out through the perforation as meddlesome. The ear has a very perfect way of disposing of whatever is left ~ of the discharge when the inflammation subsides, and help of this kin~ is therefore gratuitous, if not mischievous.

The old mastoid operation was as a rule undertaken only wher~ extensions of the disease acute or chronic rendered it imperative, and though good results were often attained they were sometimes far from ideal. I t was a great advance when the complete mastoid operation was introduced in 1899, whereby the tympanic cavity, external meatus, antrum, and ablated mastoid cells were alI thrown into one cavity, the malleus and incus removed and the walls grafted. I t rapidly gained the popularity which it stil| holds; but the necessity for being quite so radical was sool~ challenged by Heath and others 'who contended that as good results could be obtained, and with better hearing, by not removing the ossicIes. I lhink there is a great deal to be commended in this view. Chronic suppurative otitis commonly has its focus in the antrum or mastoid cells, the middle ear being then only the channel through which the discharge must necessarily pass. Removal of the focus cures such cases. The difficulty then is to know how far the middle ear is really involved. Whenever I determine to try the conservative method I generally state the case to the patient in this way: " The operation is urldertaken primarily to remove a danger to life. This being accomplished, care will be taken to conserve as much as possible of the hearing, and should some slight discharge persist it will not meau that the danger of complicati,Jns persists also."

Intracranial complications of chronic otitis received uo ~ystenmtie investigation until in 1893 McEwen of Glasgow published his great work on Py~genic Diseases of the Brain and ,~pinal Cord,. It came on us like a sunburst dispelling fog. His masterly elucida- tion of the subject has never been excelled, nor has his wonderfu! series of cases ever been equalled. One can pay no higt, er tribute


to this great pioneer than to say that though' now fo r ty years old. his book is still the best. I t is worth recalling tha t at the bondon Meeting of the Brit ish Medical Association in 1893, McEwen drew at tent ion to a remarkable passage in a speech of King Richard I I , f rom which it might well be argued that Shakespeare had in his m i n d ' s eye a picture of the intracranial complications of otitis media.

The passage runs : -

for within the hollow crown That rounds the mortal temples of a King Keeps Death his court; and there the antic sits Scoffing his state and grinning at his pomp-- Allowing him a breath, a little scene, To monarchize, be fear'd and kill with looks; Infusing him with self and vain conceit, As if this flesh which walls about our life Were brass impregnable, and hmnour'd thus Comes at the las~ and with a little pin Bores through his castle wall, and farewell King!

I t is now just a century since phys]elogists began to investigate the funct ion of the labyrinth, but B a r a n y ' s work published in 1910 marks the beginning of the interest taken by otologists in this subject. The association of deafness, giddiness and subjective noises had long been remarked , and it was with grea t sat isfact ion tha t a single physiological basis was found for the syndrome. Pa t ien t s who suffer f rom this distressing tr io often, and not un- natura l ly , suspect it to be a prelude to insanity, and sr~ffe- as much f rom apprehension as they do f rom the disease itself. One cannot help regret t ing tha t there was no authori ta t ive voice to a l lay Swi f t ' s fears when he was attacked with what appears to have been a labyrinthi t is unconnected with any central nervous disorder. There is no evidence whatever tha t Swif t was insane. He dr i f ted into dementia of the senile type, helped perhaps b~" the depression to which his malady gave rise.

A great deal of good foundat ion work has been done on the physiology of the labyrinth, but we can only be said to be on the threshold of tha t vas t subject .

We should be ungra te fu l if we did not acknowledge the debt we owe to advances in the principles of medicine and surgery in general. Unfortunately, there has not been the same room for the explorat ion of asepsis in the operative t rea tment of the throat, nose and ear, that there has been in other par ts of the body. This is, of course, direct ly due to the fact tha t the organs in question are not often in an aseptic state under any circumstances, and are a l ready chronically infected in all but a very small percentage of the cases where surgical work is called for. We have, a t all events, learnt the importance of clean instruments, and the danger of superposing other infections on those tha t a l ready exist. When I s tar ted practice in 1892, I had a small boiler worked by gas on m y ins t rument table. I t was looked on as a great joke, and m y colleagues asked m a n y amusing questions as to whether the brew was tea, coffee, or punch. Even as late as 1898, in m y


Presidential Address to the Dublin University Biological Associa- tion, I thought it necessary to put in a plea for cleanliness. I quote the following paragraph : - -

A speculum or probe once used in a chronic case may, a s the bee carr ies pollen, be the means of g ra f t ing on to an acute case the microbe dest ined to conver t i t in to a chronic one. The use of a speculum, unless recently submi t t ed to a reliable cleansing process, is as g rea t a surgical cr ime a8 the use of a d i r ty knife. Ster i l izat ion by boiling is so simple, so effectual and so cheap t h a t i t should be used by everyone w h . examines an ear , and i ts general adopt ion would incidental ly ge t r id of t h a t abominat ion the vulcani te speculum.

At that time, and indeed much later, vulcanite instruments were common, but that they existed at all showed the need for saying what I said.

Our ,~peeiality has been an equal sharer with medicine and surgery in the advances made in general therapeutics through chemistry and physics. The most outstanding example that I can call to mind is Ehrlich's discovery of Salvarsan. We had here at last, beyond any doubt, a weapon for use against syphilis of a quite different and very superior order to anything we had possessed up to the date of its introduction. This was proved definitely to my satisfaction by a single case. An unfortunate boy, a congenital syphilitic, who should in all humanity have been chloroformed at birth, and who very early in life developed ulceration and necroses in the nose, palate, and throat, and who in spite of the most careful treatment could never be kept more than a few months without some fresh outbreak, was after many years of suffering, cured, at least from further attacks, by one dose, the first, I think, that was administered in Ireland. The subject of congenital syphilis is an interesting and important one. From cases such as the one just mentioned there is a perfect gradation by insensible shades to those who, though the children of infected parents, have no discoverable syphilitic manifestation. I t is towards, but not quite at, this latter end of the series that the taint when it exists is in danger of being overlooked, and I am persuaded that many of the chronic ulcerative affections of the nose that appear after puberty have syphilis as the sole, or if not the sole, the chief cause. Malformations of the teeth, rhagades at the angles of the mouth, and dermisation of the lips, afford the most reliable evidence of the heredity, but even when the evidence from these sources is clearest, we rarely in such cases get a positive blood test. Still, they will be found to respond often enough to anti- syphilitic treatment.

How is this apparently never ending dilution of the virulence of syphilis to be accounted for? I cannot say. I t may be some form of attenuation such as has been accomplished artificially in the case of rabies; a kind of domestication of the spirochaetal wolf into a dog that will sometimes snap at or bite his host.

Chronic ulcerative diseases of the nose are in great need of further investigation. When a specimen of tissue is sent to a histologist for identification he naturally puts it into one or other

R E T R O S P E C T O F L A R Y N G - O T O L O G Y 113

of the classes a l r e a d y recognised . A n d y e t the re m a y be such a c l in ica l c o n t r a s t be tween two cases h i s to log ica l ly iden t i ca l , as to cons t i t u t e a d i f ference in k ind . I m a y t ake as a n i l l u s t r a t i o n m a l i g n a n t g r a n u l o m a of t he nose, which I d e s c r i b e d 3 in the B~it ish Medical J o u r n a l of 1921. H e r e we have a d isease p u r s u i n g a wel l m a r k e d a n d d e a d l y course, c l i n i ca l ly qu i te un l i ke a n y other , a n d y e t i t s on ly h is to logica l f e a t u r e consists in g r a n u l a t i o n t issue, wh ich m i g h t as well have come f rom a w o u n d in process of k i n d l y hea l ing . I t m u s t neve r be fo rgo t t en t h a t the c l in ic ian comes be fo re the pa tho log i s t ; t h a t i t is f rom the work of the c l in ic ian t h a t a d isease is r ecogn i sed as be ing a d i sease ; a n d t h a t the r e s p o n s i b i l i t y of c lass i f ica t ion res ts wi th him. I be l ieve t h a t in the case of these chronic n a s a l u l ce ra t ions t h e r e is room for f u r t h e r divis ion, a n d t h a t on th i s wil l d e p e n d t h e i r more efficient t r e a t m e n t .

References. 1. Trans. Roy. Acad. Med. Ireland, 1905, xxiii, 182. 2. ibid., 1906, xxiv, 136. 3. Brit . Med. Jo., 1921, ii, 65.

POSTGRADUATE WORK AT PARIS.

During the Easter recess a special course in the Medical Treat,q~ent o~ Diseases of the Intestinal Tract and Liver will be held at the Necker Hospital under the direction of Prof. ViUaret. The course will commence on Monday, April 20th, and will run regularly (three sessions daily) until May 3rd. The fee for this course is 300 francs.

During the summer vacation a new departure is announced by the A.D.R.M., in which postgraduate courses will be given in English, in the following s e r i e s : -

Diseases o] Throat, Nose and Ear. Operative course (dog and cadaver), 12 sessions, commencing June 29th, at the School of Anatomy, under the direction of Prof. Lemaitre. Fee, 500 francs.

Surgery o! Digestive Tract and Liver. Six sessions, commencing June 29th, under direction of Prof. Gosset, at the Salpetriere, 500 francs.

Pediatrics. Two series of lectures will be given by Dr. Armand-Delille a t the Hospital Herold, from June 29th to July l l t h , daily at 10 a.m. Fee, 1,000 francs. The first week's course will deal with general medicine in childhood; the second week will be devoted to tuberculosis in infancy.

Clinical Medicine. A ten days' course on diseases of the lungs will commence on July 6th, under the direction of Prof. Sergent, a t the Charite. Foe, 500 francs.

Orthopvedic Surgery. One week's course, daily at the Hospital Trousseau, under the direction of Dr. Sorrel. Fee, 500 francs.

Clinical Radiology. Daily, from 3 to 6 p.m., commencing July 20th, a t the Salpetriere, under the direction of Prof. Ledoux-Lebard. 500 francs.

Urology. Six lectures by Prof. Chevassu, from July 6th to l l t h z at 10.30 a.m., with afternoon sessions at 2.30 p.m., at the Cochin Hospital. Fee, 500 francs.

Full information may be had from the A.D.R.M., Salle Beclard, Ecole de Medicine, Paris, 6e.

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A retrospect of Laryng-Otology

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