Diseases of the nose and throat

Front matter

HARVARD UNIVERSITY

The Warren Library

Dr. John Warren 1753-1815

Preface

The object of this book is to guide the student or practitioner of medicine in his clinical work, by giving him a ready reference to the important details of examination, diagnosis and treatment of the upper respiratory tract.

A small manual is no longer able to contain all of the information which the student must occasionally seek in books of reference, but it should be useful in presenting the different subjects in their proper perspective. With this in view, established facts and well-authenticated theories have been accentuated, and as far as possible unproved statements and superfluous treatment have been avoided. The anatomy and physiology of the different regions are briefly reviewed as far as it is important to bear them in mind in examination and treatment. The etiology and pathology of the different diseases are somewhat fully taken up when they are of practical importance or theoretical interest.

There are many things which can only be learned by clinical experience, but also much that is overlooked if this practical work is not accompanied by a reasonable amount of didactic study. The examination of patients, the choice of instruments and the technique of operations vary so much in detail in different clinics and with different operators, that the student should expect to get only general principles from his text-books. To become skilful his training must be with patients, but to acquire good judgment in the interpretation of symptoms, and in the question of operation in doubtful cases, the subject must be studied from all sides. For this reason considerable space is given to arguments for and against the more common operations, and other methods of treatment.

4 PREFACE

The illustrations are intended to help the text in places where a diagram can be used to make a point clear. Cuts of instruments have been almost entirely omitted, because the student seldom lacks the opportunity of a much better study of them in a clinic or in the catalogues of manufacturers. A. Coolidge.

September, 191 5.

Chapter I Page

Methods of Examination n

Historical, n; Illumination, 12; Examination of the Fauces, 15; Examination of the Anterior Nares, 16; Examination of the Posterior Nares, 18; Examination of the Larynx, 20; Examination of the Trachea, 22; Direct Laryngoscopy, 22; Transillumination, 25; Diagnosis by X-ray, 27.

Chapter II

Nasal Obstruction and Secretion, 31; Hoarseness, 32; Cough, 32; Obstruction to Breathing, 3^': Pain, 34.

Chapter III

The External Nose, 35 ; The Profile, 35 ; The Nasal Vestibules, 37; The Nasal Septum, s^'y The Nasal Cavities, 39; The Accessory Sinuses, 42; The Maxillary Sinus, or Antrum of Highmore, 45; The Frontal Sinuses, 45; The Ethmoid Cells, 46; The Sphenoidal Sinuses, 47; Physiology of the Nose, 47; Physiology of the Accessory Sinuses, 51.

Chapter IV

Fracture of the Nasal Bones, 53; Deformities of the External Nose, 59; Lateral Deviations, 59; Saddle-back Nose, 62; Diseases of the Vestibule, 63; Eczema of the Vestibule, 64; Furunculosis, 64; Lupus, 65; Erysipelas, 65; Anterior Fissure, 65; Collapse of the Alae, 66.

Chapter V

Erosion of the Septum, 68; Perforation of the Septum, 69; Abscess of the Septum, 70; Ulceration of the Septum, 71 ; Sep-

CONTENTS tal Adhesions, 71; Deviations of the Nasal Septum, 72; Submucous Resection, 81; Other Operations, 84; Epistaxis, 86.

CHAPTER VI Diseases of the Nasal Cavities qt

Acute Rhinitis, 9 1 ; Colds, 9 2 ; Chronic Rhinitis, 99 ; Catarrhal Rhinitis, 100; Intumescent, Hyperplastic and Hypertrophic Rhinitis, 101; Turbinotomy, 104; Hypertrophy of the Posterior End of the Lower Turbinate, 105; Chronic Rhinitis with a Tendency to Atrophy, 106; Atrophic Rhinitis, 106; Syphilis of the Nose, no; Tuberculosis of the Nose, 112; Lupus, 112; Vasomotor Rhinitis — Hay Fever, 113; Nasal Asthma, 121; Nasal Neuroses, 123; Reflex Coryza, 124; Neuroses from Contacts, 124; Sphenopalatine Neuralgia, 125; Anosmia, 126; Nasal Hydrorrhea, 127; Nasal Mucous Polypus, 128; Foreign Bodies in the Nose, 134; Narrow Nasal Cavities, 135.

Chapter VII

Acute Sinusitis, 137; Chronic Sinusitis, 138; The Maxillary Antrum, 139; Acute Maxillary Sinusitis, 139; Chronic Empyema of the Antrum, 140; The Frontal Sinus, 145; Acute Frontal Sinusitis, 145; Empyema of the Frontal Sinus, 147; Killian's Operation, 149; Diseases of the Ethmoid Cells, 151; Removal of the Middle Turbinate, 153; Operations to Open the Ethmoid Labyrinth. 154; Diseases of the Sphenoidal Sinus, 155; Acute Sphenoidal Sinusitis, 155; Chronic Empyema, 155.

CHAPTER VIII Tumors of the Nasal and Accessory Cavities 157

Angioma of the Septum, 157; Dentigerous Cyst, 157; Tubercular Tumors, 158; Bullous Middle Turbinate, 158; Mucocele, 159; Malignant Tumors, 160; Carcinoma, 160; Sarcoma, 160; Nasopharyngeal Polypus, 161; Fibroma of the Nasopharynx, 161.

CHAPTER IX Anatomy of the Pharynx 165

The Nasopharynx, 165; The Soft Palate, 167; The Uvula, 167; The Pharynx, 168.

CONTENTS

Chapter X

The Physiology of the Tonsillar Ring, 172; Adenoids, 174; The Faucial Tonsils, 180; Acute Tonsillitis, 185; Subacute Tonsillitis, 189; Peritonsillar Abscess — Quinsy, 190; Enlarged Tonsils, 194; Retained Secretion, 196; Chronic Tonsillitis, 197; Removal of the Tonsils, 199; Tonsillectomy, 201 ; Hemorrhage after Tonsillectomy, 204; Keratosis Tonsillaris, 206; Foreign Bodies in the Tonsil, 208; Concretions, 208; Bone in the Tonsil, 208; The Lingual Tonsil, 208.

Chapter XI

Diseases of the Nasopharynx, 210; Acute Nasopharyngitis, 210; Chronic Nasopharyngitis, 210; Acute Pharyngitis, 211; Chronic Pharyngitis, 213; Granular Pharyngitis, 214; Elongation of the Uvula, 214; Acute Erosions of the Pharynx, 216; Herpes of the Fauces, 217; Membranous Pharyngitis, 218; Vincent's Angina, 219; Ludwig's Angina, 220; Syphilis of the Pharynx, 220; Tuberculosis of the Pharynx, 222; Lupus of the Pharynx, 223; Retropharyngeal Abscess, 223; Tumors of the Pharynx, 225; Papilloma, 225; Angioma, 226; Fibroma, 226; Cysts, 226; Lipoma, 226; Accessory Thyroid Gland, 226; Sarcoma, 227; Carcinoma, 227.

Chapter XII

Diphtheria, 228; Scarlet Fever, 233; Measles, 233; Chickenpox, 234; Glanders, 234.

CHAPTER XIII Chronic Infiltrating and Ulcerating Diseases 235

Syphilis, 237; Tuberculosis, 243; Lupus, 244; Leprosy, 246; Scleroma, 247; Actinomycosis, 248.

CHAPTER XIV The Cartilages, 250; The Thyroid Cartilage, 250; The Cricoid

CONTENTS

Cartilage, 251; The Arytenoid Cartilages, 251; The Epiglottis, 252; The Cavity of the Larynx, 253; The Ventricular Bands, 253; The Vocal Cords, 253; The Ventricles of the Larynx, 254 ; The Blood Supply, 254; The Mucous Membrane, 254; The Muscles of the Larynx, 254; The Cricothyroid Muscles, 255; The Posterior Crico-arytenoid Muscles, 256; The Lateral Crico-arytenoid muscles, 256; The Arytenoideus Muscle, 256; The Thy ro-arytenoid Muscles, 256; The Nerves of the Larynx, 256; The Superior Laryngeal Nerve, 256; The Recurrent Laryngeal Nerve, 257; Physiology of the Larynx, 258; Speech, 259.

Chapter XV

Acute Laryngitis, 261; Croup, 263; Subglottic Laryngitis, 263; Laryngismus Stridulus, 265; Edema of the Larynx, 266; Chronic Laryngitis, 268; Chronic Atrophic Laryngitis, 269; Perichondritis of the Larynx, 270; Syphilis of the Larynx, 270; Tuberculosis of the Larynx, 271; Lupus of the Larynx, 277; Stenosis of the Larynx, 277; Singer's Nodes, 279; Pachydermia of the Larynx, 281; Congenital Laryngeal Stridor, 282.

Chapter XVI

Sensory Disturbances, 284; Motor Disturbances, 285; Abductor Paralysis, 286; Complete Paralysis of the Recurrent Nerve, 287; Spasm of the Glottis, 288; Laryngeal Vertigo, 289; Hysterical Aphonia, 289; Defects in Speech, 291; Backwardness in Speech, 292; Stammering, 293; Falsetto Speech, 293; Defects in Speech of Peripheral Origin, 293.

Chapter XX

Acute Erosions, 323; Aphthae, 324; Stomatitis, 325; Scurvy, 327; Thrush, 327; Noma, 328; Pemphigus, 328; Acute Glossitis, 329; Leucoma, 329; Geographical Tongue, 331; Hairy Tongue, 332; Tongue Tie, 332; The Salivary Glands, 332; Ranula, 334; The Teeth, 335; Epulis, 336; Cleft Palate, 336.

Chapter XXI

Sprays, 339; Gargles, 340; Douches, 341; Mouth Washes, 342; Inhalations, 343; Insufflations, 343; Lozenges, 343; Ointments, 344; Caustics, 344; Cocaine, 345; Substitutes for Cocaine, 347; Adrenalin, 348; Nitrate of Silver, 348.

Index .351

MANUAL OF DISEASES OF

THE NOSE AND THROAT

Chapter I Methods Of Examination Historical

In the medical literature of a hundred years ago there is occasionally recorded a successful attempt to see the inside of the larynx. Bozzini in 1807 used a little mirror at the end of a double canula, one to carry down the light, the other to bring up the reflected rays. Cagniard de la Tour in 1825 and Babington in 1829 saw the vocal cords by reflected light. The possibility of doing so appears to have been periodically recognized, but without exciting any general interest, until Manuel Garcia in 1855 made his laryngoscope, and drew attention to its importance. Ttirck two years later started the first laryngologic clinic. About the same time Czermak introduced the perforated head-mirror, which was an essential addition to the development of laryngoscopy. Beginning thus with a device for seeing the larynx, the specialty of laryngology has been growing for the past fifty years. By turning the reflecting mirror upward the nasopharynx was seen. The examination of the nasal cavities from the front became easy with the introduction of the perforated head-mirror. One by one different operations were devised, made possible by laryngoscopy.

The laryngoscope shows the larynx by reflection in a mirror but it is also possible to see it directly. The first practical speculum for this direct inspection was made by Kirstein in 1890 and called by him an autoscope. It resembled an elongated tongue-depressor. Later Killian modified this into a closed tube with a lip at the end, the tube-spatula, which he developed into his bronchoscope by elongating the tube.

ILLUMINATION

In order to see clearly into the different cavities of the body it is necessary that the line of vision should coincide with the direction of the illuminating rays. This can be done by the simple expedient of reflecting light from a mirror with a small hole in the center, through which hole the eye follows the illuminating rays, and sees the same point that is illuminated. To look around a corner a small mirror at the proper angle is placed at this corner. Thus the interior of the larynx is seen by reflecting the light downward, and the posterior nares by directing it upward from the oropharynx. In order to get as much light as possible into a cavity it is obvious that the illuminating rays, instead of being parallel, should be concentrated at the narrowest point through which they must pass. In the case of the nasal cavity, for instance, only as much light as enters the nostril is of use inside the cavity, all that illuminates the external face is wasted. The head-mirror, therefore, is made concave to condense the light into a focus at the external nose, or upon the laryngeal mirror held in the pharynx. This focusing of light is only to increase its brilliancy at the point where it is most needed, and consequently does not demand fine adjustment. The distance from the concave mirror at which the light is most concentrated will depend upon the degree of concavity and the distance of the source of light, the farther away the lamp is placed the nearer parallel will be its rays and the sooner they will be brought together by the mirror. The focal distance of the mirror should be that at which the observer can best see and work. For the ear and anterior nares a mirror of shorter focal distance than for the larynx and posterior nares is theoretically advisable, but one that will focus parallel rays at from six to eight inches is practical for all purposes. A mirror which focuses parallel rays at seven inches will focus the rays of a light placed just behind the patient at twelve inches.

An excellent light is obtained by gas and a Welsbach mantle. Electric light will generally throw an uneven reflection on account of the filament, although this can be avoided by proper appliances. A kerosene lamp can be made efficient, whereas a candle is generally unsatisfactory. A metal covering letting the light out only in one direction through a lens adds much to the clearness of vision. In many respects no light is so good as direct sunlight; this, however, is often difficult to regulate, and so strong that care must be taken not to focus it if a concave head-mirror is used.

The direction of the light should be such that the angle of reflection is as acute as possible, generally from just behind and above the patient's ear. The head-mirror is adjusted so that in looking through the hole, the examiner sees the center of the circle of light upon the patient's face.

Instead of a reflecting head-mirror a small electric lamp is sometimes attached to the head-band, so near to the eyes that its rays are nearly enough parallel to the line of vision to enable the examiner to see well into a cavity which is not too narrow or too deep, such for example as the pharynx; or a combination of this small lamp with a perforated reflecting mirror brings the illumination and the vision into line so that any cavity may be inspected. This has the great advantage of allowing the observer to move his head about without throwing his illumination out of adjustment. It has the disadvantage of being a more elaborate and delicate apparatus, and generally that of giving less light.

The necessary instruments for examination are a head-mirror with a focal distance of about seven inches, a set of small mirrors, of which one of a diameter of seven-eighths and one of one-half inch will be the most frequently used, a tongue-depressor, a nasal speculum, nasal forceps, probe and applicator. These instruments should be boiled after use to avoid all danger of infection. Some mirrors are made to withstand boiling, if not they should be carefully washed and cleaned with alcohol.

EXAMINATION OF THE FAUCES

As the faucial cavity is broad in proportion to its depth, reflected light is not necessary. If the head-mirror is used it may be turned up onto the forehead so that both eyes are used simultaneously. In most cases the arch of the tongue obstructs the view and must be depressed by pushing it downward and somewhat backward. A tongue-depressor with a right angle bend is better than a straight one, as it takes the hand out of the line of vision. The principal obstacle is reflex gagging on the part of the patient, which varies much in different cases, but which is always greater if the tongue-depressor is put too far back on the tongue. It is better to keep the depressor on the anterior half of the tongue even if more force is necessary to keep it down. The patient should not hold his breath, and should make no muscular effort except to open his mouth.

Having depressed the tongue we see the lower surface of the soft palate, with the dependent uvula, and the pillars of the fauces, two folds of mucous membrane on each side running from the sides of the uvula, the anterior to be inserted into the side of the tongue, and the posterior merging into the lateral walls of the pharynx. The anterior represents the free edge of the palatoglossus and the posterior the palatopharyngeus muscle. On each side between the two pillars is seen the tonsil, when it is not hidden behind the anterior pillar. The background of the picture is formed by the posterior wall of the oropharynx.

Fig. 2.— The fauces. HP, Hard palate; SP, Soft palate; U, Uvula; AP, Anterior pillar; PP, Posterior pillar; T, Faucial tonsil; PW, Posterior pharyngeal wall.

EXAMINATION OF THE ANTERIOR NARES

This includes as much as can be seen through the anterior nasal openings. The patient sits upright in a chair, the observer either directly in front of him or on his right side. The light from the head-mirror is focused upon the patient's nose, and the nasal speculum introduced so as to lift the ala, and open a straight passage for the admission of light. There are different forms of specula but as a rule a self-retaining speculum for routine examination is unsatisfactory. As one hand must be given up to holding the speculum the instrument should be large enough to be seized by the hand instead of by the ringers only. It is important that the physician should learn to use it in either nostril, with the left hand, so that the right hand may be

Fig. 3. — Diagram of the anterior nares. MT, Middle turbinate, IT, Inferior turbinate; MM, Middle meatus; IM, Inferior meatus; S, Septum.

free for other instruments. Many patients throw the head back when the speculum is introduced so that the lower part of the nasal cavity is not seen until the head is brought forward again. With the head forward the septum is seen to the inner side, the anterior end of the lower turbinate to the outer side, the nasal floor below, and sometimes in case the septum is straight and the turbinates small, the nasopharynx in the background. The latter may be recognized by asking the patient to speak the word "can," when the upper surface of the soft palate will be seen to rise and fall. The patient's head is then thrown back, so that the upper part of the cavity can be examined.

1 8 DISEASES OF THE XOSE AND THROAT

Here the anterior and lower border of the middle turbinate is seen unless hidden by a spur or deviation of the septum or an enlarged lower turbinate. Having examined the cavity it is well to spray into it a small amount of a weak solution of cocaine, which will in a short time contract the turbinates and give a much better view of the field.

In nearly ail cases there will be found irregularities in the septum and the turbinates, which should be carefully noted, and compared with any symptoms of which the patient complains. Experience will show that many of these irregularities which are obvious to the eye have been fully compensated for by nature and have no pathological importance. Also it must be borne in mind that the turbinates, especially the lower, are covered with erectile tissue, the engorgement of which may be a functional and not a pathological process, and that a large turbinate does not often mean a hypertrophied one.

EXAMINATION OF THE POSTERIOR NARES

For this a rhinoscopic mirror of about one-half inch diameter is necessary. In order to see the post-nasal space it is essential that the tongue should be depressed giving a clear view of the fauces with sufficient room between the uvula and tongue, that the mirror should be well illuminated, and that the soft palate should be relaxed. The latter can not be obtained by force, and will often require considerable skill and patience. It is useless to attempt to introduce a rhinoscopic mirror until there is a place in which to put it and until that place is well lighted. This having been attained the mirror is warmed, or immersed in a half per cent solution of lysol, and carried without touching the tongue or palate into the pharynx, behind and to one side

Fig. 4. — The posterior nares as seen in the rhinoscopic mirror. S, Septum; MT, Middle turbinate; LT, Lower turbinate; EP, Eustachian prominence; E, Opening of the Eustachian tube; FR, Fossa of Rosenmueller; P, Soft palate; U, Uvula.

of the uvula. By slightly rotating the handle and moving the mirror as much as possible without touching the pharyngeal wall, the different parts of the region above the palate are brought successively into view. In the median line the funnel-shaped posterior edge of the septum should be sought and from this the other structures are found. On each side are the choanae, or posterior openings into the nasal chambers. In each choana the posterior and lower edge of the lower turbinate appears, in greatly varying size, in the lower quadrant. External to the choanae are the orifices of the Eustachian tubes, and above the septum an extensive field which is the vault of the pharynx. If a pharyngeal tonsil or so-called adenoid is present, as is usually the case in children, it will be seen above the septum, or if it is of sufficient size, it will overlap the choanae from above and cut off more or less of the view of the septum and posterior nares.

EXAMINATION OF THE LARYNX

The position of the patient is the same as for the examination of the posterior nares, except that his head is thrown somewhat farther back. The principal obstacle to the

Fig. 5. — Diagram of the larynx as seen in the laryngeal mirror, during inspiration. BT, Base of the tongue; E, Epiglottis; VB, Ventricular band; C, Vocal cord; AE, Ary epiglottic fold; A, Arytenoid; I A, Interarytenoid fold; PS, Pyriform sinus; T, Trachea.

view of the larynx is the epiglottis. In order to get this as far forward as possible the tip of the tongue is held with a napkin between the thumb and finger of the observer's left hand, care being taken not to pull the frenum against the patient's lower teeth. The upper part of the uvula is then visible above the dorsum of the tongue and the light from the head-mirror is thrown upon it. The laryngeal mirror, seven-eighths to an inch in diameter, is warmed or immersed in lysol, passed down above the tongue and held either just in front of the uvula or with the latter resting on its back. If this does not bring the lower pharynx and larynx into view the patient is asked to say "ah" which by opening the pharynx allows a better position for the mirror. The palate is generally fairly tolerant as compared with the sides of the pharynx or the tongue, but if gagging occurs, the mirror must be withdrawn and another attempt made, touching the fauces as little as possible.

Fig. 6. — The same during phonation.

It must be remembered that the reflected image is an inverted one, and that what is seen at the top is really anterior, and at the bottom posterior. At the top is seen the base of the tongue, below it the epiglottis, on each side the aryepiglottic fold extending from the epiglottis above to the arytenoids below. The arytenoids and the vocal cords are easily identified by their motion, coming together in phonation, and separating in deep inspiration. When the glottis is open the tracheal rings may be seen in the space between the cords. To the outside of each aryepiglottic fold is the pyriform sinus, the lowest part of the pharynx before it merges into the esophagus.

EXAMINATION OF THE TRACHEA

Often much may be learned by a careful examination of the trachea in the laryngeal mirror. Sometimes in the routine examination of the larynx the whole tracheal column to the bifurcation can be seen through the glottis, but in most cases with the patient in the best position for laryngoscopy, with the head thrown back, only the upper part of the anterior wall of the trachea is visible. In order to see the bifurcation the patient's head must be brought forward, while the observer changes his position accordingly, until the whole length of the trachea comes into view. A strong light is essential, preferably sun rays. The bifurcation should then be easily distinguished, and the upper portion of the two bronchi.

Normally the tracheal rings appear distinctly lighter in color than the mucous membrane between them. In cases, however, of acute or chronic inflammation the contour of the rings is lost and the increased redness of the mucous membrane is evident. Secretion if present is seen adherent to the tracheal wall, and changes its position after coughing. The presence of secretion or blood on the tracheal wall is good evidence that it has come up from below.

DIRECT LARYNGOSCOPY

The lower pharynx and larynx may be seen directly by straightening out the angle at the base of the tongue. The speculum used for this purpose is a tube held firmly by a handle and ending in a lower lip, the tube-spatula of Killian or some modification of it. The tube-spatula of Jackson contains near its distal end a small electric lamp, by which the field is illuminated at close range. The

Fig. 7. — Direct laryngoscopy.

spatula of Mosher is open on one side, allowing much more space for inspection and the use of instruments.

The patient may be seated on a low chair with the observer in front of and above him, or he may lie on his back with the observer behind his head. The epiglottis and neighboring parts must be well cocainized, and even with a general anesthetic the interior of the larynx should be cocainized before attempting any manipulation within it. The patient's head is extended as far as necessary and the lip of the spatula carried over the base of the tongue and behind the epiglottis. By traction forward the whole body of the tongue is pulled out of the line of vision, and the lower pharynx and the interior of the larynx brought into view. The image in this case not being reflected, is the reverse of that seen in the laryngeal mirror. The posterior portion of the larynx can always be seen by direct laryngoscopy, and often, but not always, as far forward as the anterior commissure.

In case of infants the interior of the larynx can generally be seen without an anesthetic by direct laryngoscopy whereas by the older method of reflected light this is often impossible. The infant may be held upright on the lap of an assistant or be placed on its back with its head extended over the end of the table.

Killian's Suspension Laryngoscopy. — With the patient on his back and the speculum in place, the whole head may be raised and suspended by the speculum, which proceeding will sometimes open for direct inspection the deep pharynx and much of the larynx.

Direct laryngoscopy leads the way to bronchoscopy and esophagoscopy, and the operations founded on them, which are described in another chapter.

TRANSILLUMINATION

Transillumination consists in passing light through a sinus and noting if the light is obstructed in its passage. When a small, protected, electric lamp is put into the mouth the light finds its way through a normal antrum and is seen between the floor of the orbit and the eye as a bright crescent, the pupil often appears red and the patient perceives the light in the eye. If the antrum is inflamed or filled with pus, the light fails to go through, and the contrast between that side and the unaffected side is striking. This test is not absolute, as there may be an abnormality of structure, or thick and opaque bone, but a marked opacity on the suspected side as compared with the other, is strong evidence of trouble in the antrum. Not infrequently neither side shows definite orbital light, but this can not be considered good evidence of bilateral trouble, only the relative intensity of the light on the two sides is of value for diagnosis.

The lamp should be small and the light intense, generally close to the maximum voltage that the lamp will stand, and for purposes of cleanliness inclosed in a removable glass tube. As soon as the light is deflected even a little from the median line, the orbit of that side, in a normal case, will become markedly brighter than the other. Many cases which appear dark on both sides when the lamp is in the middle line, will light up sufficiently for a proper diagnosis when the lamp is pressed against the alveolar process-

The antrum may also be transilluminated from a point external to the alveolar process. For this purpose the lamp is placed between the cheek and the posterior portion of the alveolar process behind the canine fossa. The light is here diffused in the neighborhood of the lamp by the skin, but this can be distinguished from the light which has gone through the antrum and shines in the floor of the orbit. From this position less light is required to penetrate through the antrum into the orbit, and a positive finding can sometimes be made, when from the mouth cavity it was negative.

That evidence of disease of the antrum which is given by transillumination is always circumstantial, nevertheless it is often valuable.

Transillumination should be a part of the routine examination of every case. It takes little time, is never resented by the patient, and will more frequently than some of us realize call attention to trouble in the antrum which might otherwise be overlooked.

The frontal sinus is transilluminated by covering the lamp with an opaque cap open only at the end, and pressing the open end firmly against the roof of the orbit above the inner canthus. If it is translucent, a rough outline of a large frontal sinus appears traced in light on the forehead. This evidence is not so valuable as in the case of the antrum. Owing to the great difference in the size and shape of frontal sinuses, no good conclusions can be reached by transillumination of these cavities unless their size is previously known by x-ray plates. If the size of the cavities is known, the lack of transmission of light, where it might be expected, shows that something is wrong in the cavity.

DIAGNOSIS BY X-RAY

The x-ray plate is of great value in showing the size and shape of the frontal sinuses, and to a less extent the other sinuses. It also indicates whether a sinus is pathological. A plate taken with the face lying upon it shows the orbits, the septum, the turbinates and the hard palate. The outline of the frontals can normally be distinctly traced on the forehead. Below the orbits on each side is the antrum, and between them and the septum the ethmoid region. A relative opacity in a sinus of one side as compared with its mate on the other indicates an abnormal condition. A slight density would indicate a hyperemia, a marked difference an empyema. In empyema of the frontal the sinus may be entirely lost from view so that it appears to be absent.

A lateral plate of the head shows the length and depth of the frontal sinuses, the region of the sphenoidal sinuses, the sella turcica, and the alveolar processes. The teeth show distinctly, and disease of their roots or unerupted teeth may be discovered. These are often important in connection with the floor of the antrum.