ADDRESS ON OPHTHALMOLOGY, OTOLOGY, AND

LARYNGOLOGY.

BY DUDLEY S. REYNOLDS, M.D.,

KENTUCKY.

MR. PRESIDENT:

IN obedience to an established custom I appear to deliver the annual address as chairman of a special Section of your body. It is defined somewhere in the by-laws as the duty of chairmen of Sections to report annually upon the progress made in those branches of science, which constitute the legitimate fields of research in the several departments of medicine and surgery, into which this august assembly has been divided.

Were I to limit my remarks to those things which might be regarded in the light of discoveries during the past twelve months, I fear I should be able to afford you but a poor entertainment indeed. I beg your attention to the consideration rather of the grouping together in a new form of old and wellknown facts, the results of increased clinical facilities and extended opportunities for observation in those branches wherein specialism has had its origin, its rise, and its progress. A distinguished clinical teacher, less than a quarter of a century ago, announced organic diseases of the larynx, accompanied by loss of substance as having unmistakably a syphilitic or tuberculous origin. It was proclaimed by this distinguished authority that local medication in the so-called laryngeal phthisis should be discountenanced, for the reason that the local affection was indeed but a single manifestation of a necessarily fatal constitutional affection. Another distinguished clinical teacher announced, within ten years past, his ability to overcome and remove entirely all vestige of disease in the throats of persons who suffer œdema of the glottis. The treatment suggested was local scarification. The pathology of the affection was admitted to lie in obscurity. Extended clinical observation enables the specialist in the treatment of throat diseases to recognize most

all forms of œdema of the epiglottis not due to traumatism as constituting probable evidence of tubercular deposit in the apices of the lung.

Prof. Frank C. Wilson, of Louisville, published in the Meical Herald, 1879, a series of clinical observations of pulmonary tuberculosis, wherein the first manifestation of the disease appeared in the form of oedema of the epiglottis. In many of these cases there was observed a tendency to sloughing of the epiglottis, which resulted in the production of an oblique fissure extending throughout the whole width of the organ. In this class of cases it has been determined that death often ensues from starvation, in consequence of the inability of the patient to swallow without such great pain as to deter him from the attempt, death usually occurring within a few weeks.

Reference is made here to this matter because it seems to have escaped the general observation of the profession. Prof. Wilson says it frequently happens that the throat is the first point involved, and the changes discoverable by the laryngoscope precede the manifestations in the lungs as detected by the most careful physical examination. Familiarity with the earlier changes in the throat may sometimes enable us to detect the presence of consumption long before the condition of the lungs suggest even examination. Sloughing of the epiglottis often takes place before physical examination of the chest reveals the presence of pulmonary deposit, for the reason that in cases where the epiglottis is involved the preceding pulmonary deposit is found at the apices. It may be interesting to note that sloughing of the epiglottis takes place always in a diagonal direction, corresponding to the direction of one of the arterial twigs which supply the organ with blood, the loss of substance almost invariably corresponds to the side upon which the diseased lung is situated.

Of ten fatal cases, it was observed that death ensued in from three days to two months after the slough, the average time being about four weeks. In every case, the side upon which the slough occurred corresponded with the diseased or most diseased lung. In one case only did the fissure occur directly in the median line of the epiglottis; in this case the right lung was the one most affected. In syphilitic affections of the larynx, far too much has been expected from purely local measures on the one hand, and too little attention paid to the relief of pain

ful deglutition on the other. I am quite convinced that no other local applications in syphilitic diseases of the larynx than such as tend to ensure the easy expulsion of accumulations of morbid material, and the soothing of inflamed surfaces, are warrantable. By keeping the air-passages free from obstructing accumulations, and by soothing inflamed surfaces, patients are enabled to breathe and to swallow with less difficulty, and to that extent, aside from the relief of pain, local treatment is important. Of course, it will not be doubted that constitutional medication is just as necessary in the treatment of syphilitic disease. of the throat, as it is in syphilitic disease of the generative organs, or of other parts of the body. The iodide of potassium, as a single remedy in the treatment of syphilitic laryngitis, enjoys an unquestioned claim as a specific. I have seen persons suffering with extensive syphilitic ulceration of the larynx, enduring great pain and gradual starvation, restored fully within a few weeks to a condition of robust health and comfort. The proper method of administering the iodide, in cases of this kind, is to begin with five grains in not less than two ounces of water, repeated every four hours during the day. At the expiration of the second day, double the dose. At the expiration of the fourth day, let fifteen grains be given. At the expiration of the sixth day, twenty grains. If no improvement occur from these doses, at the end of five days, let the dose be increased to twenty-five grains, and so on, adding five grains regularly every fourth day until recovery is well advanced, or the toxic effects of the drug produced. In the event that iodism precedes any very marked abatement of the disease, let the intervals be increased; or, if necessary, the dose diminished, and maintain this state for a time: or, let the carbonate of ammonia be substituted for a few days, and disappointment will rarely, indeed, be witnessed. A little attention to local appearances will seldom leave room for doubt as to the diagnosis. The diagnosis estabtablished, the course of treatment readily suggests itself.

Another affection, which is frequently misunderstood, is the trachomatous disease of the pharynx. Mr. Marston, a long time ago, pointed out the almost certain origin of trachoma in malarious districts. Mr. Marston maintains that trachomatous deposit constitutes oftentimes the very first sign of the presence of marsh miasm, or of its influence upon the system. He, therefore, concludes that the conjunctiva offers the very best and

most delicate test of the so-called malaria. It is a matter of daily observation that trachoma of the pharyngeal membrane is vastly more common than trachoma of the conjunctiva. The small amber-colored ovoidal bodies, found here and there in the inflamed mucous membrane, constitute the essence of trachoma. Of course, after these bodies have remained for a long time, gradually aggregating in number, some inflammatory changes take place. Then the proliferating process in the connectivetissue cell contents is heightened, until such large numbers of trachomatous bodies are collected together, as to produce an appearance somewhat similar to gland substance; hence, the popular term, adenoid growths. Now, it is positively absurd to attempt the cure of this condition by purely local measures, though, in most cases, and particularly those which have become chronic constitutional measures alone are indicated. Tubercular degeneration of the turbinated bones oftentimes coexist with the true trachomatous disease of the pharynx. Syphilis sometimes invades the Schneiderian and pharyngeal membranesquite often, in fact-producing a condition resembling very closely favus of the scalp, and, in some instances, a true eczema occurs in the nose and pharynx.

It is scarcely worth while for me to attempt in this brief treatise to point out to you the differential diagnosis of these various affections, or to attempt to outline any particular form of treatment. I call attention to them merely for the purpose of directing your minds to the consideration of those matters which have but recently been illuminated by the lights of specialism.

It has been too much the custom of late to call all forms of disease affecting the nose and pharynx catarrh; to such an absurd extent, indeed, does this custom prevail that we now hear specialists maintaining that nasal catarrh often arises from deformities in the nose, particularly in the septum, which is in many persons deflected to one side or the other. A distinguished gentleman in New York, Dr. Goodwillie, called professional attention last year to a new device for removing the promontory of the projecting part of the vomer and of the anterior cartilaginous septum. Others have proposed to crush the septum narium with a tooth forceps in order to force it to occupy the median line, and this under the pretence of affording relief to an asserted nasal catarrh. Now let it be understood that catarrh

is that condition, defined by the late Prof. George B. Wood, wherein there is present in a mucous membrane an afflux of all the circulating fluids with or without serous effusion according to the intensity of the process, and this condition constituting a specific form of disease due always to some disturbance in the peripheral nerves. The precise character of the disturbing element was thought by many to have been thoroughly exposed and elucidated by Chonbein in 1851 so very conclusively by a series of experiments that Sir Thomas Watson regarded them in the light of a demonstration that ozone caused all the catarrhal affections of the respiratory mucous surfaces. The positive demonstrations of Chonbein, taken in connection with Dr. Marston's discovery, that the origin of trachoma naturally suggests a comparison of the prodromata of the so-called catarrh which has long been recognized as being in many respects identical with the influenza of the Italian writers, the "Tyler" Grippe and the epizootic of America. Now it would appear difficult to conceive how intelligent persons acquainted with the principles of pathology could ever be so misled as to suppose a tubercular rhinitis, a dry proliferous rhinitis, a parasitic or eczematous rhinitis, could by any possible chance be mistaken for the specific catarrhal form.

There is much need for extending the nomenclature of diseases, and especially of those affections which are commonly observed in mucous membranes. Now there is no doubt a catarrh which has a natural tendency to recovery, may be perpetnated for an indefinite period by the habit of breathing through the mouth instead of the nose, thus allowing an abnormally tenacious mucus to accumulate and to remain in the passages until a putrescent change occurs; i. e., it is transformed into pus. Thus a purely purulent or muco-purulent rhinitis is substituted for the more mild catarrhal form. This being neglected, abrasions of the surface occur at those points in contact with accumulated matter, or abrasions may be deepened from the influence of retained encrusted or other foreign matter, and thus we find that what was originally a plain, simple catarrhal process, at a later period an extensive ulcerative, and therefore destructive, inflammation. It is safe to say no plan of treatment which does not include the thorough removal of all morbid accumulations can possibly be successful; strong caustics are always attended. by positive damage, and in fact by no corresponding degree of