COLUMBIA LIBRARIES OI-I-&I 1 1 HEALTH SCIENCES STANDARD HX641 39581 RC941 .In4 1894 Diseases of the ches Hjii^i (^ElOS«GQil» M.D. R C74/ iil4: /8^ Columbia ZHnitier^itp intijeCttpofltogork College of $f)pgtctans anb burgeon* Hibrarp Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/diseasesofchesttOOinga DISEASES Chest, Throat NASAL CAVITIES INCLUDING Physical Diagnosis and Diseases of the Lungs, Heart, and Aorta, Laryngology and Diseases of the Pharynx, Larynx, Nose, Thyroid Gland, and (Esophagus; E. Fletcher Ingals, a.m., m.d. professor of laryngology and practice of medicine, rush medical college; professor of diseases of the throat and chest, northwestern university woman's medical school, professor of laryngology and rhinology, chicago polyclinic; laryngologist to the st. Joseph's hospital and to the Presbyterian hospital, etc.; fellow of the american laryngological association and american climatological association ; member of the american medical association, illi- nois state medical society, chicago medical society, chicago pathological society, etc., etc. THIRD EDITION, REVISED. WITH TWO HUNDRED AND FORTY ILLUSTRATIONS. NEW YORK WILLIAM WOOD & COMPANY 1894 Copyrighted, 1894, By WILLIAM WOOD & COMPANY TO MY PRECEPTOR, EPHRAIM INGALS, M.D., EMERITUS PROFESSOR OF MATERIA MEDICA AND MEDICAL JURISPRUDENCE IN RUSH MEDICAL COLLEGE, TO WHOSE ENCOURAGEMENT AND WISE COUNSEL I AM GREATLY INDEBTED, Gbts 3Boofc is affectionately Beoicateo BY THE AUTHOR. PREFACE TO THE THIRD EDITION. rpiHIS is not meant for an encyclopedic work, but is intended to pre- sent in convenient form the known facts relating to diseases of the respiratory tract and circulatory organs, and I have brought their con- sideration under one cover because the parts are so closely related that when one is diseased it is generally necessary to interrogate the others before a correct diagnosis or proper plan of treatment can be reached. I have not discussed questionable theories, and have not referred to methods of treatment which do not strongly commend themselves to my judgment. The favor with which the preceding edition of this work has been received leads me to believe that I have succeeded in my efforts, not only to aid laryngologists in their daily work but also to place these subjects clearly before students and a large class of general practitioners who of necessity must be prepared to meet any emergency. As it is but little over a year since the second edition was published no great alteration in the text has been necessary, but several minor changes have been made, and a few pages have been added to keep abreast of our advancing knowledge on these subjects. E. F. I. 34-36 Washington St., Chicago. PKEFACE TO THE SECOKD EDITION. TN the first edition of this work, the consideration of the diseases of the respiratory and circulatory systems was restricted to such a presentation of the diagnosis and treatment as I had formerly made in my lectures to classes of students. With the purpose of completing the work and increasing the value of this edition to both students and prac- titioners, there have been added the subjects of Etiology, Pathology, Symptomatology, and Prognosis of the diseases to which these organs are liable. The chapters devoted to physical diagnosis have been but little changed. Those treating of diseases of the lungs and heart have been amplified and modified to correspond with the present advanced line of our knowledge on these subjects, and those relating to diseases of the throat and nasal cavities have been entirely rewritten. I have endeav- ored to include all diseases of the chest, throat, and nasal passages, as well as the more important affections of the oesophagus and thyroid gland, and to give to each the consideration which its frequency and importance demand. I have carefully consulted the extensive litera- ture of these topics but have made no attempt to collate the various theories and methods suggested by different authors. I have limited the argument to that which personal knowledge of the diseases and of writers, commends to my own judgment; and I have generally confined my recommendations for treatment to those methods which have proved most efficacious in my own practice. The substance of the writings of an individual soon becomes merged in general literature which makes it impossible for me to give personal credit as I would like, to all whose labors have enriched this field, but to all such I gladly acknowledge my x PREFACE TO THE SECOND EDITION. indebtedness. I am indebted to Drs. Ephraim Ingals, Walter S. Haines, J. Edwin Rhodes, and Norman Bridge for aid in proof-reading, and to Dr. Arthur M. Corwin and James H. Blodgett for assistance in proof- reading and revision of copy, as well as to Dr. M. A. Olsen for the index. E. F. I. 34-36 Washington St., Chicago, September, 1892. PEEFAOE TO FIRST EDITION. These lectures are designed to present a complete exposition of the subject of Physical Diagnosis so far as it relates to diseases of the Chest, Throat, and Nasal Passages; to give the essential symptoms of each disease; to point out the symptoms and signs which are of most value in a differential diagnosis; and to outline briefly the proper treatment for the various affections. The anatomical characteristics and the causes of these diseases have been pointed out wherever they are of special value in enabling the reader to understand the physical signs, or to properly apply remedial measures. When these lectures were de- livered, nothing was said about treatment, but in order to enhance the value of this work to both physician and student, I have appended to the consideration of the diagnosis of each disease an outline of the treatment which I have found most satisfactory. In so doing, I have not even mentioned many methods of treatment of more or less value which have been recommended by other physicians. In the preparation of these lectures I have availed myself of every source of information at my command, and I hope that little has been overlooked which would be of value to the student or practitioner. The study of this subject for several years, in connection with my lec- tures, and a large personal experience with these affections have enabled me to discriminate as to the relative importance of different signs and to detect numerous exceptions to the general rules. These exceptions, some of which are extremely rare, are of little importance to the general practitioner, and the study of them is a positive injury to the student unless their true significance is understood. Matter relating to them has, therefore, been set in small type, so that it may be omitted until the student has become thoroughly familiar with the facts that are essential. The nature of these lectures, which contain information gathered from many different sources by study and by personal observation, and xii PREFACE TO FIRST EDITION. the fact that much of which they treat has long since become public property, renders it impossible for me in every instance to give the credit to individual authors which I desire, but I freely acknowledge my indebtedness to all who have preceded me in this field. I am in- debted to the courtesy of Doctors J. Solis Cohen, of Philadelphia, and Lennox Browne and Morell Mackenzie, of London, for permission to use some of the cuts which illustrate their works. I take special pleasure in expressing my obligation to my clinical assistants, Doctors Philip Leach, W. H. Taylor, and J. T. Eggers, for valuable aid in the revision of my notes. Messrs. Sharp & Smith, of this city, have kindly furnished electro- types for the illustrations of instruments. E. F. I. CONTENTS. PAGE Preface, vii List of illustrations, .......... xxiii DISEASES OF THE CHEST. CHAPTER I. Physical diagnosis, 3 Divisions of the chest 3 Methods of examination, 9 Inspection, . . . „ , 9 Palpation, . 14 Mensuration, 16 Succussion, . 20 CHAPTER II. Physical diagnosis, continued, ......... 21 Percussion, 21 In health, ° ..... 21 In disease, .28 The Plessigraph, 31 Auscultatory percussion, 32 CHAPTER III. Physical diagnosis, continued, . 34 Auscultation, ............ 34 In health, 39 In disease, . . . . . . . . . . .41 CHAPTER IV. Physical diagnosis, continued, 48 Adventitious sounds, .48 Vocal sounds, . 54 CHAPTER V. Pulmonary diseases, . . . . . 60 Pleurisy, 60 Acute pleurisy, 61 Subacute pleurisy 72 x i v CONTENTS. CHAPTER VI. PAGE Pulmonary diseases, continued 76 Chronic pleurisy or empyema 76 Peculiar local forms of pleurisy, 82 Hydrothorax 84 Pneumothorax, 84 Pneumo-hydrothorax, 85 CHAPTER VII. Pulmonary diseases, continued, 89 Bronchitis, 89 Acute and subacute bronchitis, 89 Chronic bronchitis, 90 Capillary bronchitis, 95 Plastic bronchitis 99 Dilatation of the bronchial tubes 100 Asthma, 102 Pulmonary emphysema, 107 CHAPTER VIII. Pulmonary diseases, continued. ......... 113 Pneumonia, 113 Lobar pneumonia, . 113 Lobular pneumonia. .......... 123 Peculiar forms of pneumonia, ........ 128 Abscess of the lungs, ........... 129 CHAPTER IX. Pulmonary diseases, continued, . 132 Pulmonary hyperaemia, .......... 132 Brown induration, 134 Pulmonary hemorrhage, 134 Pulmonary apoplexy. 137 Pulmonary thrombosis and embolism, 138 Pulmonary collapse, ........... 139 Pulmonary oedema, ........... 142 Pulmonary gangrene, . . . . . . . . . .144 Pulmonary cancer. ........... 146 Pulmonary tumors, . 148 Hydatid cysts of the lungs, 148 Distoma pulmonale, 150 Syphilitic diseases of the lungs. • . 151 Enlarged bronchial glands, ......... 152 Pertussis or av hooping-cough, . . 153 CHAPTER X. Pulmonary diseases, continued, 156 Pulmonary phthisis, ........... 156 Pulmonary tuberculosis, .156 Acute miliary tuberculosis, ........ 165 Fibroid phthisis, 167 CONTENTS. xv CHAPTER XI. PAGE The heart, 177 Anatomy and physiology of the heart, 177 Physiological action of the heart, 180 Physical examination of the heart, ........ 183 Cause of the heart sounds, 190 Modification of the heart sounds by disease, 191 CHAPTER XII. The heart, continued, 195 Abnormal heart sounds, cardiac murmurs, . . . . .195 Anomalous heart sounds . . . . 205 Subclavian murmurs, 206 Venous signs, .......... . 206 The sph3 T gmograph, „ 208 CHAPTER XIII. Cardiac diseases, 212 Pericarditis, 212 Pneumo-hydropericardium, 218 Hydropericardium, . 218 Endocarditis, . . . 219 Acute endocarditis, . . . . . . . . . . 219 Ulcerative endocarditis, . 222 Chronic endocarditis, valvular disease of the heart, . . . 223 Myocarditis, . . . . 231 CHAPTER XIV. Cardiac diseases, continued, .......... 234 Simple cardiac hypertrophy, 234 Hypertrophy and dilatation of the heart, 236 Dilatation of the heart, . 239 Atrophy of the heart, 242 Fatty heart, 242 Aneurism of the heart, .......... 245 Rupture of the heart, 245 Syphilitic disease of the heart, 245 Tumors of the heart, 246 Morbus cseruleus, 246 Neurotic or functional disease of the heart, . . . . - . . 247 Tachycardia, ............ 249 Bradycardia, .....' 250 Angina pectoris, 250 CHAPTER XV. Diseases of the thoracic arteries, . . . . . • . . . . 254 Aortitis, 254 Atheroma of the aorta, 254 xvi CONTENTS. PAGE Aortic or thoracic aneurism, 256 Aneurism of the sinuses of Valsalva, 257 Aneurism of the arch of the aorta 257 Aneurism of the descending aorta, 257 Coarctation of the aorta 266 Solid mediastinal tumors, 267 DISEASES OF THE THKOAT. CHAPTER XVI. The throat, .... Examination of the fauces, Laryngoscopy, . Obstacles to laryngoscopy, . Infra-glottic laryngoscopy, 271 271 272 289 292 CHAPTER XVII. The throat, continued, . 293 The larynx and rhinoscopy, ......... 293 Examination of the trachea 300 Rhinoscopy, 301 Anterior rhinoscopy, 301 Posterior rhinoscopy 302 Obstacles to posterior rhinoscopy, 304 Vault of the pharynx and posterior nasal cavities, 307 CHAPTER XVIII. Diseases of the fauces, 311 Acute sore throat 311 Erysipelatous sore throat, 314 Rheumatic sore throat, 316 Acute rheumatic sore throat 316 Chronic rheumatic sore throat, 318 Sore throat of small -pox, . 321 Sore throat of measles, ... , 322 Sore throat of scarlet fever, ......... 323 Simple membranous sore throat, 324 CHAPTER XIX. Diseases of the fauces, continued 328 Diphtheria, 328 CHAPTER XX. Diseases of the fauces, continued, 339 Acute follicular pharyngitis, 339 Chronic follicular pharyngitis, ......... 340 Acute follicular glossitis, 347 CONTENTS. XV1.1 Chronic follicular glossitis, Scrofulous sore throat, - . Acute tubercuar sore throat, Syphilitic sore throat, Syphilitic sore throat in infants, CHAPTER XXI. Diseases of the fauces, continued, Diseases of the uvula, ...... Acute inflammation and oedema of the uvula, . Chronic inflammation and elongation of the uvula Malformation and new growths of the uvula, Leucoplakia buccalis, . Acute tonsillitis, Phlegmonous tonsillitis, Hypertrophy of the tonsils, Concretions in the tonsils, Mycosis of the throat, Tubercular ulceration of the tonsils, Cancer of the tonsil, . CHAPTER XXII. Diseases of the pharynx, . Foreign bodies in the pharynx, Retro-pharyngeal abscess, Tumors of the pharynx, Cancer of the pharynx, Neuroses of the pharynx, . Anaesthesia of the pharynx, Hyperassthesia of the pharynx, Paresthesia of the pharynx, Spasm of the pharynx, Paralysis of the pharynx, Scalds and burns of the pharynx, Swallowing the tongue, Diseases of the valeculse and pyriform sinuses. PAGE . 347 . 348 . 350 , 353 . 356 358 358 358 358 359 360 362 368 370 375 376 378 380 382 382 383 386 386 388 388 388 889 390 391 392 392 393 CHAPTER XXIII. Diseases of the larynx, 394 Acute laryngitis, . 394 Subacute laryngitis, *. . 397 Traumatic laryngitis, 398 Chronic laryngitis, 398 Trachoma of the vocal cords, 408 Phlebectasis laryngea, 409 CHAPTER XXIV. Diseases of the larynx, continued, 411 Membranous croup, 411 XV111 CONTENTS. CHAPTER XXV. Diseases of the larynx, continued. ..... Phlegmonous laryngitis, Erysipelatous laryngitis, Abscess of the larynx, (Edema of the larynx, ...... Chondritis and perichondritis of the laryngeal cartilages Tubercular laryngitis, Syphilitic laryngitis, Syphilitic laryngitis in infants, PAGE , 427 , 427 . 428 . 429 . 430 . 433 . 434 . 443 . 449 CHAPTER XXVI. Diseases of the larynx, continued, 451 Lupus of the larynx, 451 Lepra of the larynx, 454 Hypertrophy of the larynx 455 Laryngitis of small-pox, . . . . . . . . . 455 Laryngitis of measles, 455 Laryngitis of scarlet fever, 455 Chronic stenosis of the larynx 456 Stenosis of the trachea, . 460 Tracheitis, 460 CHAPTER XXVII. Diseases of the larynx, continued, . Morbid growths in the larynx, . Benign tumors of the larynx. Malignant tumors of the larynx, E version of the ventricle of Morgagn Tracheal tumors, Post- tracheotomy vegetations, . Involution of the trachea, . Tracheocele, . ... Syphilis of the trachea, 463 463 465 476 483 483 485 485 486 487 CHAPTER XXVIII. Diseases of the larynx, continued, . 489 Fracture of the larynx, 489 Dislocation of the larynx. .......... 490 Foreign bodies in the larynx, . 490 Foreign bodies in the trachea, 492 Spasm of the glottis, . 496 Spasms of the larynx in adults, 497 Irritative cough, ........... 498 Nervous cough, ............ 498 Anaesthesia of the larynx, .......... 499 Hypereesthesia, paresthesia, and neuralgia of the larynx, . . . 500 Chorea laryngis, 501 CONTENTS. xix PAdiS Spasm of the vocal cords, 502 Falsetto voice, 503 Laryngeal vertigo, . 504 CHAPTER XXIX. Diseases of the larynx, continued, ...... Paralysis of the thyro-epiglottic and ary-epiglottic muscles, Paralysis of the crico-thyroid muscles, .... Paralysis of the thyro-arytenoid muscles, Bilateral paralysis of the lateral crico-arytenoid muscles, Unilateral paralysis of the lateral crico-arytenoid muscles, Paralysis of the arytenoid muscle, ..... Bilateral paralysis of the posterior crico-arytenoid muscles, Unilateral paralysis of the posterior crico-arytenoid muscles, Ancli3dosis of the arytenoid cartilages, .... Atrophy of the vocal cords, . . . 505 505 506 507 508 510 511 511 514 514 515 DISEASES OF THE NOSE CHAPTER XXX. Diseases of the nasal cavities, . . 519 Influenza, 519 Rhinitis, . . . 522 Simple acute rhinitis, 522 Traumatic rhinitis, 526 Chronic rhinitis, 527 Simple chronic rhinitis, 528 CHAPTER XXXI. Diseases of the nasal cavities, continued, Rhinitis, continued, .... Chronic rhinitis, continued, Intumescent rhinitis, . Hypertrophic rhinitis, . Submucous infiltration at the sides of the vomer Atrophic rhinitis, . . . , 531 531 531 531 540 '547 547 CHAPTER XXXII. Diseases of the nasal cavities, continued, 553 Hay fever, 553 Furunculosis of the nose, 558 Epistaxis, 559 CHAPTER XXXIII. Diseases of the nasal cavities, continued, Nasal mucous polypi, Nasal fibrous polypi, 564 564 569 XX CONTENTS. PAGE Nasal papillary tumors, ... 569 Nasal vascular tumors, . 570 Nasal osseous cysts, . 570 Nasal cartilaginous tumors, 571 Nasal bony tumors, 571 Nasal malignant tumors, 572 CHAPTER XXXIV. Diseases of the nasal cavities, continued, 574 Syphilis of the nose, 574 Congenital syphilis of the nose, 577 Tuberculosis of the nares, . 578 Empyema of the antrum, . 579 Empyema of the sphenoidal sinuses, „ 583 Inflammation of the frontal sinus 584 Chronic suppurative ethmoiditis. 585 Lupus of the nares, .... 587 Ehinoscleroma, . 588 Glanders 589 Nasal affections in acute diseases 591 Perverted sense of smell, . 591 Parosmia, 591 Anosmia, 591 CHAPTER XXXV. Diseases of the nasal cavities, continued, Congenital deformity of the nose, Fractures of the nose, .... Dislocation of the nasal bones, . Deflection of the nasal septum, Ecchondroma and exostosis of the nasal septum, Perforation of the nasal septum, Haematoma of the nasal septum, Abscesses of the nasal septum, . Foreign bodies in the nose, Rhinoliths, ...... Myasis narium or maggots in the nose, 593 593 593 594 594 597 601 602 603 603 604 605 CHAPTER XXXVI. Diseases of the nasopharynx, . 607 Rhino-pharyngitis, 607 Throat deafness, 610 Hypertrophy of the pharyngeal tonsil, 613 Retronasal fibrous tumors, . 620 Retronasal fibro- mucous tumors, 624 Retronasal cartilaginous tumors, 625 Malignant tumors of the naso-pharynx 625 Cystic tumors of the naso-pharynx, ........ 626 CONTENTS. xxi DISEASES OF THE THYROID GLAND AND (ESOPHAGUS. THE CHAPTER XXXVII. Goitre, Exophthalmic goitre, Oesophagitis, Acute oesophagitis, Chronic oesophagitis, Stricture of the oesophagus, Compression of the oesophagus, Spasm of the oesophagus, . Paralysis of the oesophagus, Foreign bodies in the oesophagus, Parsesthesia of the oesophagus, PAGE . 629 . 632 . 632 . 632 . 633 . 634 . 637 . 637 . 638 . 640 . 642 APPENDIX. Formulas for prescriptions, .......... 645 Gargles, . . 647 Sedatives, . 647 Astringents, 647 Stimulants, 647 Antiseptics 3 647 Trochisci or lozenges, 647 Sedatives, 647 Demulcents, 648 Astringents, 648 Stimulants, ............ 648 Antiseptics, = 649 Vapor inhalations, „ 649 Sedatives, . 650 Antispasmodics, 650 Mild stimulants, 650 Strong stimulants, 651 Spray inhalations, 651 Sedatives, 651 Astringents and stimulants, 652 Haemostatics, . . . . . 653 Antiseptics, 653 Dry inhalations, . 654 Sedatives, . 654 Stimulants . . 654 Fuming inhalations 654 Sedatives, 655 Stimulants, 655 Pigments, 655 Local anaesthetics 655 xxn CONTENTS. PAGE Astringents, 655 Stimulants and caustics, 656 Antiseptics, 656 Insufflations, 656 Sedatives, 656 Antiseptics and stimulants, 657 Astringents and stimulants . . 657 Nasal douches, 658 LIST OF ILLUSTRATIONS. FIG. PAGE 1. Kegions of the chest, 4 2. Begions of the chest, 5 3. Outline of the chest, 10 4. Quain's stethometer, .17 5. Carroll's stethometer, . .17 6. Flint's cyrtometer, . . 18 7. Sph'ometer, 18 8. Allison's stethogoniometer 18 9. Hammond's haernadynamometer, 19 10. Flint's hammer and pleximeter, . 21 11. Camman's stethoscope, 32 12. Ingals' emballometer, . 33 13. Solid wooden stethoscope, . - . . . . . . .36 14. Knight's stethoscope, .36 15. Allison's differential stethoscope, 37 16. Phthisis, 47 17. Bronchial rales, 49 18. Acute pleurisy, 53 19. Curved line of flatness in pleurisy, posterior view, . . . .64 20. Curved line of flatness in pleurisy, anterior view, 65 21. Subacute pleurisy, 73 22. Cabot's drainage tubes, .79 23. Strong's drainage tubes, .......... 79 24. Ingals' flat trocar, 79 25. Ingals' drainage tubes, 81 26. Pneumo-hydrothorax, .......... 86 27. Pneumonia, . . 117 28. Tubercle, 157 29. Tubercle bacilli, colored plate, ........ 168 30. Globe nebulizer, . 174 31. Physiological action of the heart, 181 32. Rhythm of the heart, 183 33. Areas of endo-cardial murmurs, ........ 198 34. Auricular systole, • 201 35. Ventricular systole, 202 36: Marey's sphygmograph, 208 37. Normal radial pulse, tracings, ........ 208 38. Normal radial pulse, tracings, 208 39. Aortic obstruction, 209 40. Aortic obstruction, ............ 209 41. Mitral regurgitation, 209 XXIV LIST OF ILLUSTRATIONS. FIG. 42. 43. 44. 4.-). 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65. 68. 69. 70. 71. 72. 73. 74. 75. 80. 81. 82. 83. 84. 85. 86. 87. 88. 89. 90. 91. 9-2 Aneurism. ........ Aortic regurgitation. ...... Aortic regurgitation and obstruction, Cardiac hypertrophy in Blight's disease. Tracing of the senile pulse, ..... Mitral constriction, tracing, ..... Mitral constriction and aortic regurgitation, tracing, Mitral hypertrophy and dilatation, .... Turck's tongue depressor, ..... Pocket tongue depressor, ...... Bosworth's tongue depressor, ..... Throat mirrors for laryngoscopy, . . . Sc-hrotter's head band with nasal rest, Krishaber's illuminator, ...... Modified Mackenzie's rack -movement bull's-eye condenser, Modification of Mackenzie's illuminator, Laiyngoscopic reflector, ...... Position of the head giving the best view of the larynx, Position of the head giving a poor view of the larynx, Lai yngoscopic mirror in position, .... Brim's pincette, ....... Infra-glottic laryngoscopy, ..... Relative relations of the larynx and its image, Normmal larynx in respiration, .... Pitcher-shaped inter-arytenoid fold, Lapping of arytenoid cartilages in phonation, Cushion of epiglottis, ...... Pointed epiglottis, ....... Jews' -harp epiglottis, ...... Larynx of a woman in respiration, .... View of left side of larynx, ..... Normal larynx of woman in formation of head tones, View of posterior wall of trachea, .... View of anterior wall of trachea, .... Ingals' nasal speculum, ...... Jarvis' nasal speculum, ...... Sajous' nasal speculum. ...... Cross section of head showing ethmoid cells and nasal cavities. Fraenkel's rhinoscope, ...... Position for rhinoscopy, ...... Rubber palate retractor, ...... Porcher's self-retaining uvula and palate retractor, Palate retractor, ....... Rhinoscope with uvula holder, .... Rhinoscopic image, ....... Adenoid tissue at vault of the pharynx, Pharyngeal bursa, ....... Chronic follicular pharyngitis, Modification of Shurly' s battery, Ingals' cautery electrodes, ..... Perforation of the palate, syphilitic, LIST OF ILLUSTRATIONS. xxv FIG. PAGE 93. Scissors for amputating the uvula, 359 94. Mathieu's tonsillitome, 372 95. Mathieu's tonsillitome, oblique fenestra 372 96. Ingals' tonsil forceps, 373 97. Fibroma of pharynx, 386 98. Superficial ulcers of the vocal cords, 395 99. Superficial ulceration of the epiglottis, 395 100. Mackenzie's laryngeal lancet, . . . . . .. . . 397 101. Catarrhal ulcer of the vocal cord, 399 102. Chronic catarrhal laryngitis, with deformity, 399 103. Chronic catarrhal laryngitis, 401 104. Catarrhal laryngitis, with deformity, 401 105. Subglottic oedema, . 401 106. Davidson's atomizers, set No. 66, 405 107. Ingals' laryngeal applicator, ......... 405 108. Davidson's atomizer, No. 59 old style, . 406 109. Trachoma of vocal cords, . . 408 110. Ingals' chromic acid applicator and handle, 409 111. Ingals' galvano- cautery handle, 409 112. O'Dwyer's intubation instruments, 418 113. Henrotin's gag, ........... 419 114. Waxham's gag, 419 115. Allingham's gag, 419 116. O'Dwyer's extractor, . . . " . . . . . . 420 117. Abscess ' of the larynx, 429 118. Infra-glottic abscess of the larynx, ....... 430 119. Infra-glottic abscess of the larynx, twelve hours after opening, . . 430 120. CEdema of the larynx, 432 121. Tubercular laryngitis, .......... 435 122. Tubercular laryngitis, pyriform swelling of the arytenoids, . . 435 123. Tubercular laryngitis, pyriform swelling of the arytenoids, . . 435 124. Tubercular laryngitis, 435 125. Incipient tubercular laryngitis, . 436 126. Tubercular laryngitis, 436 127. Tubercular ulceration of the vocal cords, 437 128. Tubercular ulceration of the vocal cords, 437 129. Tubercular ulceration of the ventricular bands, 438 130. Tubercular ulceration of the ventricular bands and vocal cords, . . 438 131. Tubercular laryngitis, sluggish action of the vocal cords, . . . 438 132. Tubercular ulceration of the larynx, 440 133. Tubercular laryngitis, with syphilis, 440 134. Condyloma of the epiglottis, ....... . 444 135. Gumma of the larynx, .......... 444 136. Multiple gumma of the larynx, 444 137. Syphilitic laryngitis, . • . 444 138. Syphilitic laryngitis, ........... 446 139. Syphilitic ulceration of the epiglottis, ..*.... 446 140. Syphilitic ulceration, 446 141. Lupus of the larynx (Ziemssen) , 451 142. Lupus of the larynx (Tiirck) , ....:... 452 143. Lepra of the larynx, 454 XXVI LIST OF ILLUSTRATIONS. FIG. 144 Syphilitic laryngitis, 145. Syphilitic stenosis of larynx, . 140. [Mackenzie's laryngeal dilator, 147. Whistler's cutting dilator, 148. Tube for laryngotracheal stenosis, 149. Mount Bleyer's tongue depressor, 150. Papilloma of right vocal cord, 151. Papilloma of the larynx. 152. Papilloma of vocal cords, 153. Papilloma of vocal cords, 154. Papilloma of the larynx. . 155. Fibroma of left vocal cord, 156. Fibro-cellular tumor of the larynx. 157. Cystic tumor of the larynx, 158. Cystic tumor of the larynx, 159. Cyst of the epiglottis, 160. Adenoid tumor of the larynx, 161. Adenoid tumor of the larynx, 162. Cartilaginous tumor of the laryi 163. Vascular tumor of the larynx. 164. Vascular tumor of the larynx, 165. Laryngeal forceps. . 166. Mackenzie's tube forceps, 167. Stoerk's laryngeal instruments, 16s. Tobold's laryngeal knives, 169. Cancer of the larynx, 170. Cancer of the larynx, 171. Cancer of the larynx, 172. Cancer of the larynx, 173. Cancer of the larynx, 174. Cancer of the larynx, 175. Mixed sarcoma of larynx. 176. Cancer of the larynx, 177. Tumor in the trachea, 178. Ingals' punch forceps, 179. Syphilitic laryngitis, 180. Seller's tube forceps, 181. Bilateral paralysis of the cricothyroid muscles, 182. Acute laryngitis, 183. Paralysis of the thyro-arytenoid muscles, 184. Paralysis of the lateral crico-arytenoid muscles, 185. Mackenzie's laryngeal electrodes, 186. Unilateral paralysis of the lateral crico-arytenoid muscles, respiration, 187. Unilateral paralysis of the lateral crico-arytenoid muscles, phonation, . 188. Unilateral paralysis of the crico-arytenoid muscles, .... 189. Ziemssen's laryngeal electrodes, ........ 190. Bilateral paralysis of the posterior crico-arytenoid muscles, inspira- tion, ............. 191. Bilateral paralysis of the posterior crico-arytenoid muscles, expiration, 192. Unilateral paralysis of the posterior crico-arytenoid muscles, inspira- tion, 512 512 514 LIST OF ILLUSTRATIONS. xxvn FIG. 193. 194. 195. 196. 197. 198. 199. 200. 201. 202. 203. 204. 205. 206. 207. 208. 209. 210. 211. 212. 213. 214. 215. 216. 217. 218. 219. 220. 221. 222. 223. 224. 225. 226 228. 229 230 231 232 233 234 235 236 237 238 239 240 bodies Unilateral paralysis of the posterior crico-arytenoid muscles, phona- tion. Anchylosis of the arytenoid cartilages, . Powder blower, ..... Davidson's oil atomizer, No. 50, Flat nasal probe and applicator, Hypertrophy of the inferior turbinated body, Hypertrophy of the posterior ends of the inferior turbinated Ingals' nasal scissors, .... Nasal burrs, Nasal trephines, ..... Submucous infiltration at sides of the Tomer, Ingals' nasal syringe, .... Nasal douche, ...... Nasal douche, traveller's, Galvano-cautery handle with ecraseur, . Ingals' snare, ...... Cotton applicator, ..... Hypodermic syringe, long silver nozzle, Ingals' nasal dressing forceps. Cross section of head looking from behind forward, Ingals' electric lamp, Brainard's bone drill, Ingals' drainage tubes for antrum, Cross section of head, Curtis' ethmoid-cell wash-bottle, Ingals' septum forceps, Ingals' septum knife. Ingals' right-angle cutting forceps, Exostosis from the septum, Sajous' knife, Nasal spud, Ingals' nasal saw, Ingals' flat nasal saw, and 227. Sajous' saws, Ingals' heavy bone scissors, .... Ingals' nasal bone forceps, .... Ingals' nasal spatula. ..... Gross' instruments for removing foreign bodies, Post-nasal syringe, Curtis' Eustachian tube vaporizer, . Rhinoscopic view of post-nasal vegetations, . Mackenzie's, John N. , post-nasal forceps, Ingals' post-nasal snare applicator, Retro-nasal fibro-mucous polypus, Sand's oesophagotome, Flexible resophageal forceps, Bristle extractor, 514 514 536 536 537 541 542 545 546 546 547 550 551 551 567 567 568 568 576 579 581 582 583 584 586 596 596 597 598 599 599 599 599 599 600 600 600 604 609 612 614 617 623 624 636 641 642 Diseases of the Chest OHAPTEK I. PHYSICAL DIAGNOSIS. » Iisr this work I shall first describe the methods for detecting disease which are based upon the pathological changes in the organs affected ; next point out the characteristics and significance of the various signs; and finally consider the individual diseases. The term physical diagnosis is used to designate the methods re- ferred to, whether used in the examination of the chest or in the exam- ination of any other part of the body; but as it is in the exploration of the chest that such methods have yielded the most brilliant results, it is now customary to apply the term physical diagnosis simply to the ex- amination of the thorax. It is in this limited sense that We shall generally use it, though it will also be applied to the examination of the upper air passages. DIVISIONS OF THE CHEST. To simplify the study, and to enable us to fix accurately in mind the position of the intra-thoracic organs, the chest has been divided into a number of regions which are purely arbitrary, and their boundaries vary with different authors. J. M. Da Costa divides the chest into the anterior, the posterior, and two lateral regions, and subdivides these into upper and lower regions. He locates signs present in these regions by certain fixed marks which may be found on the surface of the chest. For instance, anteriorly, a sign may be located in a certain intercostal space, or beneath a rib or the clavicle, at a given distance from the sternum. Posteriorly, a sign may be located in a similar manner with reference to the spinous proc- esses, or to the angles and the borders of the scapula. Such a division is well enough for the record of cases, but it does not aid us in remem- bering the location of the intra-thoracic organs. The division here adopted is similar to one quite commonly taught, with only such changes as make it plainer and more easily remembered. "While learning these boundaries, one should fix in mind the exact position of the intra-thoracic organs. We divide the chest primarily into anterior, posterior, and lateral regions, and subdivide as follows. 4 PHYSICAL DIAGNOSIS. Upon the anterior surface on either side, from above downward, we have the supra-clavicular, clavicular, infra-clavicular, mammary, and infra-mammary regions : between these two lateral groups we find the supra-sternal above the line of the clavicles, and the sternal region sub- divided into the superior-sternal and inferior-sternal. The posterior portion of the chest, on each side, is subdivided into the supra-scapular and the scapular regions, between these the inter-scap- ular region, and below the scapulae the infra-scapular regions (Fig. 2). Laterally we have the axillary and the infra-axillary regions. I ....... * \ F9 4 I I 1 Fig. 1. — A, Supra-clavicular region; B, clavicular region ; C, infra-clavicular region ; D, mam- mary region ; E. infra-mammary region : F, superior-sternal region ; G, inferior-sternal region. The wavy lines represent the borders of the lungs and the pulmonary fissures. The dotted lines correspond to the outlines of the various organs, viz.. trachea, aorta, bronchial tubes, heart, liver, spleen, and stomach. The very dark shading over the solid viscera shows the normal areas of flatness, and the shading next lighter over the upper part of the liver shows the hepatic dulness. The black rectangular spots near the third rib correspond to the position of the valves of the heart. The supra-clavicular region corresponds to that portion of the pleural cavity which extends above the clavicles. It is triangular in form, with its base internal, its apex external. It is bounded above by a line drawn from the upper ring of the trachea outward to the junction of the middle with the external third of the clavicle. The inferior boundary of this region corresponds to the tipper margin of the inner two-thirds of the clavicle. The internal boundary corresponds to the sterno-cleido-mastoid muscle. This region contains, on either side, the apex of the lung and portions of the subclavian artery and vein. • The clavicular region corresponds to the inner two-thirds of DIVISIONS OF THE CHEST. 5 the clavicle and is bounded above and below by the borders of the bone. It contains lung tissue. Upon the right side, externally we find the subclavian artery, and at the inner extremity the arteria innominata and the recurrent laryngeal nerve as it passes up to supply the muscles of the larynx. Aneurisms in this locality, by pressing upon this nerve, give rise to serious symptoms due to paralysis or spasm of the glottis. Upon the left side, at the inner end of this region we find the carotid and the subclavian arteries, deeply seated and running almost at right angles with the clavicle. The infra-clavicular region is bounded above by the clavicle, internally by the margin of the sternum, and externally by a straight 6'cix/i it la r ; UX & -i nX e r Fig. 2.— The wavy lines correspond to the borders and fissures of the lungs. The dotted line across the scapular region indicates the position of the spine of the scapula. The dotted lines and shaded areas in the infra-scapular regions indicate the position of the liver and spleen. line let fall from the outer extremity of the clavicular region, and pass- ing about an inch externally from the nipple. It is bounded below by the lower margin of the third rib. This region contains lung tissue on either side. On the right, close to the border of the sternum, we find portions of the ascending aorta and of the descending vena cava. Just beneath the second costal cartilage, we find the right bronchus as it passes into the right lung. Upon the left, in the second intercostal space, close to the margin of the sternum, the pulmonary artery is located. In the same space is found the left bronchus, which inclines more downward, and is located lower than the main bronchus on the opposite side. A portion of the base of the heart occupies the internal inferior angle of this region. The mammary region, which lies immediately below the preced- ing, is bounded internally by the margin of the sternum, externally by 3 PHYSICAL DIAGNOSIS. a continuation of the line which bounds the infra-clavicular region, and inferiority by the lower margin of the sixth rib. We may easily remem- ber the boundaries of tne infra-clavicular and the mammary regions, by recollecting that Ave have three ribs in each. The inferior border of the third rib forms the lower boundary of the upper region and the lower margin of the sixth rib bounds the lower region inferiorly. This region contains lung tissue on both sides. On the right, the thin margin of the lung, which overlaps the liver, reaches to the sixth interspace, and ex- tends even lower in full inspiration. Deeper seated we find the upper convex surface of the liver, carrying the diaphragm above it, as high as the fourth intercostal space. The nipple is usually located in the fourth intercostal space; therefore, we expect to find the upper border of the liver beneath it. A small portion of both the right auricle and the right ventricle extends into this region. In the upper part of the left mam- mary region, the lung tissue is in front as low as the fourth rib. Here the border of the lung jjasses outward and downward to the fifth rib, leaving between it and the median line a triangular space in which the heart and its investing membrane are superficial. The ixfra-mammary region is bounded externally by a continua- tion of the outer boundary of the mammary region; above by the lower margin of the sixth rib, and internally and inferiorly by the margin of the sternum and the lower borders of the false ribs. This region con- tains, on the right side, the liver, and occasionally the inferior margin of the lung during full inspiration. On the left side, near the sternum, we find a portion of the left lobe of the liver; a little farther outward, near the middle of the region, we have the stomach; in the outer third is a portion of the spleen. The stomach and the spleen usually extend as high as the sixth rib. The mammillary or nipple line is a vertical line drawn through the nipple, and, according to some authors, it forms the external boundary of the infra-clavicular, mammary, and infra-mammary regions. The regions between the lateral portions of the anterior surface of the chest are three in number. The supra-sterxal regiox, the first counting from above, is bounded inferiorly by the- upper end of the sternum, or inter-clavicular notch; laterally by the sterno-cleido-mastoid muscles; and above by the first ring of the trachea. The most important organs in this region are the trachea and the thyroid gland, the lobes of which lie on each side of the trachea and are connected by the isthmus in the upper part of this region. Here are also found certain small veins and arteries which are of interest to the surgeon. In the lower right angle of this region the innominate artery is found, and in the inter-clavicular notch we can frequently feel the arch of the aorta. The superior-sternal regiox, next in order, is bounded below by a line connecting the lower margins of the third ribs, and lat- DIVISIONS OF THE CHEST. 7 erally by the borders of the bone. This region contains lung tissue. Superficially, the inner or anterior margin of each lung reaches the median line. Deeper, we find the descending vena cava, the ascending, the transverse, and a part of the descending portion of the arch of the aorta, and at the left a portion of the pulmonary artery. At a point opposite the second costo-sternal junction is the bifurcation of the trachea. » The infeeioe-stee^al eegiox, known also as the sternal region, has for its boundaries the borders of all that portion of the sternum lying below the third rib. In it the anterior margin of the right lung corresponds to the median line, and is superficially situated. But the corresponding margin of the left lung recedes from the median line at the level of the fourth rib, passing outward and downward, leaving a triangular space between it and the margin of the right lung. In this space the right ventricle of the heart is superficial. In the upper part of this region we find a large portion of the right auricle and the origin of both the aorta and the pulmonary artery. The portions of the left side of the heart which present anteriorly lie to the left of this region. In this region we find jDortions of the four sets of valves which guard the orifices of the heart (Fig. 1). At the left edge of the sternum, under the third rib, are the pulmonary valves ; a trifle lower, beneath the centre of the sternum, are located the aortic valves; lower yet, at its left border in the third intercostal space, we find the mitral valves. We locate the tricuspid valves beneath the middle of the sternum on a line with the fourth costo-sternal articulation. These valves lie so closely that a circle scarcely more than an inch in diameter will include all of them, and a circle of half that diameter will embrace a portion of each. At the lower part of this region we have a portion of the liver and of the attachment of the pericardium to the diaphragm. The mesosternal line is an imaginary line passing down the centre of the sternum. The sternal lines of the right and left sides correspond to the borders of the sternum. Posteriorly are the supra-scapular and the scapular regions on each side, extending from the second to the seventh rib and corresponding very nearly to the outlines of the scapula when the patient's arms are hanging loosely by his sides (Fig. 2). The sttpea-scaptjlae ' eegiox corresponds to the supra-spinous fossa. It is occupied by lung tissue. The scapulae eegiox corresponds to the infra-spinous fossa. It is occupied by lung tissue. The inter-scapulae eegion lies between the borders of the scapulae divided by the spinous processes of the vertebrae, and extends from the level of the second dorsal vertebra to the level of the seventh. It con- tains lung substance, the main bronchi, and the bronchial glands. The 8 PHYSICAL DIAGNOSIS. descending aorta runs along the left of the spinal column, beside the oesophagus. The trachea bifurcates opposite the third dorsal vertebra. In the three preceding regions the chest walls are very thick. The INFEA-SCA.PULAB REGION on either side is bounded internally by the spinous processes of the vertebra-: externally by a vertical line let fall from the inferior angle of the scapula: above by the lower mar- gin of the scapular and inter-scapular regions,, which corresponds to the seventh rib; and below by the inferior margin of the false ribs. This region contains lung tissue on either side, extending to the tenth or to the eleventh rib. Below the margin of the lung, on the right side, we have the liver; on the left side, the intestines are superficial near the middle jDortion of the region, and externally we find the spleen (Fig. 2). The kidneys are located near the spinal column on either side. The left kidney extends an inch higher than the right, and its upper extrem- ity is frequently found in this region. Laterally we have two regions, the axillary and the infra-axillary. The axillary region is bounded below by a line drawn from the lower margin of the mammary region backward to the inferior angle of the scapula: above by the axilla; in front by the outer boundaries of the infra-clavicular and the mammary regions; and posteriorly by the axillary border of the scapula. This region contains lung tissue on each side and, deeply seated, the main bronchi. The infra-axillary region is bounded above by the axillary; posteriorly by the outer margin of the infra-scapular region; anteriorly by the external margin of the infra-mammary region ; below by the margin of the false ribs. On either side we find the lower border of the lung running from near the upper anterior angle of this region downward and backward. Below this, on the right the liver, and on the left the spleen, and a portion of the stomach, are superficial. Pulmonary Fissures. — On each side at a point about three inches below the apex of the lung, corresponding very nearly to the inner end of the spine of the scapula, we find the beginning of the pulmonary fis- sure which separates the upper from the lower lobe. These fissures run obliquely downward and forward to the sixth rib near the mammillary line. On the right side at a point on this fissure, four or five inches from the sternum, we find the commencement of another fissure, which - inward to the margin of the lung near the fourth costal cartilage. By this fissure a small triangular portion is cut off from the lower part of the upper lobe to form the middle lobe of the right lung. The posi- tions of these fissures necessarily change considerably with inspiration and expiration. It is a common error with students to suppose that the interlobar fissures run in the opposite direction; that is, downward and backward from the upper part of the anterior margins of the lungs. METHODS OF EXAMINATION. METHODS OF PHYSICAL EXAMINATION. The principal methods of physical examination, six in number, are: Inspection, Palpation, Mensuration, Succussion, Percussion, and Auscul- tation. Unfortunately the majority of physicians rely for their diagno- sis almost exclusively upon auscultation. There are many cases in which it will be necessary to use every method and to scrutinize every symptom before one can arrive at an accurate diagnosis. The evidences of disease which these methods furnish are known as signs or physical signs. There is a marked difference between symptoms and signs. Sub- jective symptoms, which are chiefly derived from the statements of the patient, may be called presumptive evidence of disease, while objective signs are considered positive evidence. The value of these signs will depend upon a knowledge of the altera- tions which produce them. The early students of physical diagnosis noted the various character- istics of a sign accurately, and located it upon the surface of the chest; then at the autopsy they sought to ascertain its causes. At present we only need to study the sign clinically, for its causes may be learned from text-books; however, it will be of great advantage, when possible, to study at the autopsy, lesions the evidences of which we have discovered by physical diagnosis. INSPECTION. By inspection we learn the general appearance of the patient, the color of the integument, the presence or absence of subcutaneous em- physema, oedema, or tumors, and the size, form, and movements of the •chest. Whatever method of physical diagnosis is employed, it is necessary, first, to be familiar with the healthy conditions which it would reveal. The healthy chest has a generally rounded or convex appearance; the shoulders are level, the clavicles are horizontal, and the two sides are almost perfectly symmetrical; however, in many cases more or less depression will be observed in the supra-clavicular and infra-clavicular regions, and not infrequently the pectoral muscles are better developed on one side than on the other. In men a deep furrow just below the fifth rib marks the lower bor- der of the pectoralis major muscle. At the borders of the sternum, about an inch below the clavicles, we often notice rounded prominences about an inch in diameter, which mark the position of the second costal cartilages. These are frequently mistaken by students for abnormal swellings. In some patients the ribs and the intercostal spaces are 10 PHYSICAL DIAGNOSIS. very distinct, while in others they are hidden by adipose tissue. The obliquity of the inferior ribs varies greatly in different individuals. In the fifth intercostal space, about two inches to the left of the sternum, we observe the impulse of the chest walls caused by the apex beat of the heart. Occasionally we find local bulging or depression, independent of dis- ease of the internal organs. The prominent sternum known as pigeon- breast, usually due to violent cough or obstructed respiration, as from catarrh or enlarged tonsils in childhood : the pear-shaped chest, due to rachitis, and the long, narrow, and flat chest, which often results from rapid growth, are all found independent of intra-thoracic disease. There is often bulging of the prgecordial region, especially in chil- dren. Deep depressions of the lower sternal region, and of the ribs in Fig. 3.— Transverse Outlines of Certain Forms of the Chest (Thompson'). rare instances, occur in healthy individuals. I have a cast taken from life, which shows a depression of the lower sternal region from an inch and a half to two inches in depth; yet the individual from whom it was taken enjoyed perfect health. Most deviations from symmetry in the two sides are due to slight curvatures of the spinal column. In the examination of a large number of patients, not more than one in seven will be found with a perfectly symmetrical chest. In health, the respiratory movements are repeated sixteen to twenty times a minute in adults, and from twenty to twenty-five or even thirty times in children. Considerable difference in the form and in the movements of the chest exists in persons of different ages and sexes. In women the upper INSPECTION. 11 portion is more prominent than in men. The respiratory movements vary accordingly, being more marked at the upper part in women, at the lower part in men. This disparity is most conspicuous in rapid res- piration. In children of either sex, the chest walls often hardly move at all; and respiration seems to be performed by the abdominal muscles. The respiratory movements in these three localities are named superior- costal, inferior-costal, and abdominal breathing. The movements of the chest may be altered considerably, irrespective of pulmonary or cardiac disease. In health, the respiratory movements are readily accelerated by active exercise, and in hysterical patients they are nearly always rapid and superficial, being confined mostly to the upper part of the chest. In persons suffering from some diseases of the brain the respiratory movements become slower and slower until they may not exceed three or four per minute. In hemiplegia the respiratory move- ments are incomplete or wanting, on the affected side of the chest. Pregnancy, ascites, or large abdominal tumors cause pressure on the diaphragm, and consequent interference with respiration. The pain of peritonitis compels the patient to restrain the movements of the abdom- inal muscles, and thus confines the respiratory movements to the. chest and renders them deficient and consequently more frequent. Often among the first signs noticeable on inspecting a patient with disease of the infra-thoracic organs are pallor, cyanosis, icterus, pityria- sis, dropsy, and subcutaneous emphysema. Pallor of the surface and emaciation are seen in chronic pulmonary disease. Pallor also results from fatty degeneration of the heart, and, in some cases, from mitral disease. Cyanosis, more or less marked, indicates incomplete oxidation of the blood, due to obstruction of the air passages or to diminution of breath- ing surface ; also to affections of the heart, such as congenital malfor- mations or valvular disease. Occasionally this sign results from inter- ference with the descent of the diaphragm by disease of the abdominal organs. Icterus is found in bilious pneumonia and in the later stages of those cardiac diseases which cause congestion of the portal circulation. Pityriasis is often found with phthisis pulmonalis, but it also occurs with other diseases, and sometimes even in apparently healthy indi- viduals. Dropsy due to recent renal disease usually shows itself first in the lower eyelids, and subsequently disappears from this locality, to appear in the lower limbs and in the backs of the hands. Dropsy due to car- diac disease usually appears first over the instep, and gradually extends upward, involving the limbs, trunk, and serous cavities. Subcutaneous emphysema may be caused by internal or external in- juries of the larynx, the trachea, or the lungs. Air escaping from the 12 PHYSICAL DIAGNOSIS. larynx or the trachea causes emphysema in the region of the throat. Rupture of the air cells from over-distention, as in croup, diphtheritis of the larynx, whooping-cough, bronchitis in children, and emphysema in the aged, causes subcutaneous emphysema, which appears first in the areolar tissue of the neck, and subsequently extends to the chest. The air in these cases finds its way into the mediastinum, and thence to the neck. Subcutaneous emphysema from external injury appears first on the ches Alterations in the form and in the movements of the chest may be most advantageously studied when grouped together as they occur in different thoracic diseases. First, let us consider the modifications found in pleurisy. Pleurisy is divided into three stages: first, a dry stage; second, a stage of liquid effusion into the pleural sac; third, the stage of resolu- tion or absorption. In the first stage we find decubitus upon the sound side; respiratory movements rapid, short, and catching. In the second stage we usually find movements of the affected side diminished, and intercostal depressions less marked than in health; im- pulse of the heart displaced to the right or to the left, according as the left or the right pleura is distended. In the third stage, the signs of the second Btage gradually subside. Sub-acute pli urisy manifests the same signs as acute pleurisy, with, excessive exudation. Chronic 'pleurisy at first manifests signs which do not differ from those of the second stage of acute pleurisy. After absorption or evacu- ation of the liquid takes place, the affected side becomes retracted and flattened; the shoulder is depressed; the inner border of the scapula pro- jects like a wing and respiratory movements are limited. In pulmonary emphysema., on first sight of the patient we notice a dusky hue of the countenance, often a sunken condition of the cheeks, marked general emaciation, and more or less turgescence of the super- ficial veins of the neck and upper extremities. The nostrils dilate on inspiration, and there is a peculiar drawing downward of the corners of the mouth. There is elevation and drawing forward of the shoulders, with anterior curvature of the spine, giving a young patient the stoop- ing appearance of old age. Inspection generally reveals the peculiar form known as the barrel- shaped chest. In this condition the antero-posterior diameter of the chest is increased (Fig. 3), its surface is rounded, and the upper ante- rior portion stands out considerably beyond its normal plane. Lat- erally, the diameter is diminished, and its inferior portion, in the region of the false ribs, is more or less retracted. The elevation and drawing forward of the shoulders cause the neck to appear unusually short. The scaleni and stern o-cleido-mastoid muscles are hypertrophied and promi- nent so that thev stand out like tense cords, resulting from excessive use INSPECTION. 13 of these muscles which elevate and fix the anterior and upper part of the thorax. Inspiration is short and quick, followed by prolonged and sometimes labored expiration. With inspiration, the anterior and superior portions of the chest are lifted as though composed of a single bone, and there is apparently no anterior or lateral expansion of the chest walls, because ihe ribs are already rotated as far as their articulation with the spinal column will permit. The ribs have less obliquity, forming with the costal cartilages more obtuse angles than in the normal chest, The intercostal spaces above are much wider than usual, but at the lower, lateral portion of the chest the ribs are closer together than in the normal condition, sometimes even to the obliteration of interspaces. In well-marked cases there is generally with inspiration retraction of the inferior ribs instead of lateral expansion. This falling in of the thoracic walls is not noticed if the disease is slight. Sometimes we meet with local emphysema, where a single lung or only one lobe is affected. In such instances we notice local bulging of the chest, with loss of motion. In extreme emphysema the anterior margin of the left lung overlaps the heart, so that the apex cannot strike the chest wall, hence no im- pulse can be seen. In milder cases the impulse may be seen closer to the -sternum than in health. Ir pneumonia, upon first glance we generally notice a dusky flush of the cheek and accelerated respiration. Inspection of the chest shows diminished motion over the diseased organ. This loss of motion may be marked, but is seldom or never complete. In pulmonary phthisis, the signs obtained by inspection are of con- siderable value. If the case is advanced the chest wall over the diseased lung will be depressed and its movements restricted, in phthisis more apt to orcur at the apex, and contrary to the general belief, quite as commonly upon the right as upon the. left side. These phenomena are due to local shrinkage and loss of pulmonary elasticity. In pneumothorax we observe distention of the chest, proportionate to the tension of the air or gas in the pleural sac, and a corresponding loss of motion. With great distention there will be no motion of the lower ribs, but prominence of the spaces between them Exceptional. — In some rare cases of this disease the upper portion of the affected side seems to move mere than the corresponding part of the sound side. This is due to the extreme efforts on inspiration by which the superior ribs are lifted directly upward as in emphysema, though there is little or no anterior expansion. HydrotTiorax presents a condition, on both sides, similar to that found in pleurisy with effusion upon one side; hence loss of motion and more or less bulging of the infra-axillary regions. 14 ' PHYSICAL DIAGNOSIS. Pericarditis, if the amount of effusion is sufficient, causes considera- ble bulging of the precordial region, especially in children; but in older patients, on account of the firmness of the cartilages, this is not so likely to occur. There is also diminution of the respiratory movements on the left side, due to pressure from the distended pericardium. Cardiac hypertrophy also occasions local bulging, most marked in young patients. The impulse, if visible, will be seen to the left, below its normal position. Its area will also be increased. Tumors within the thoracic cavity cause bulging when of sufficient size to press upon the parietes. If the tumor be aneurismal or solid and rest upon a large artery, it will usually pulsate synchronously with the contraction of the heart. An enlarged liver or spleen may occasion local bulging. In cases of pneumothorax and pleurisy with great effusion, we ob- tain valuable information by examining the impulse caused by the apex of the heart, which will be seen crowded from its normal position toward the unaffected side. In membranous croup, oedema glottidis, foreign bodies or morbid growths in the larynx or in the trachea, the amount of air entering the lung is considerably less than normal. This has the effect of prolong- ing inspiration and rendering it laborious, though expiration is not notably affected. Here the respiration is not quickened as in most pul- monary diseases, and it may be even slower than usual. This differs from emphysema in that here there is obstruction to inspiration; in emphysema, the principal interference is with expiration. When the obstruction in the larynx or trachea is considerable, we observe sinking in of the soft parts of the chest above the clavicle and in the intercostal spaces, especially at the lower part of the chest, during in- spiration. This is due to atmospheric pressure from without, as the chest walls expand more rapidly than air can enter through the ob- structed passage to fill the lungs. In chronic bronchitis the signs obtained by inspection are of little value, though we may occasionally observe prolonged expiration, and in some instances irregular expansion of the chest, in different parts, due to plugging of the bronchial tubes by secretions. PALPATION. Palpation consists of physical exploration by the sense of touch, either with the tips of the fingers or the palms of the hands. In practising palpation upon the chest, the palmar surface of the hands should be used, and in many instances it is desirable to cross the hands so that, as one sits in front of the patient, the right hand rests upon his right side and the left upon his left side. If the signs are only slight, we thus appreciate them more clearly. PALPATION. 15 By the sense of touch we appreciate slight alterations in the move- ments of the heart and thoracic walls; we sometimes detect the presence of intra-thoracic tumors which cause no bulging of the surface, and determine their nature, whether hard, soft, or pulsating; and we may differentiate between the pain of intercostal neuralgia and that of pleurodynia or pleurisy. The information regarding size, form, and movements obtainable by this method is essentially the same as that furnished by inspection. Normal vocal fremitus is a peculiar vibration which will be felt if the hand be gently placed upon the chest of a healthy person while he is speaking. It is produced by the transmission to the chest wall of the vibrations of air in the bronchi, caused by the act of speak- ing. Modifications of vocal fremitus are among the most important signs which are obtained by palpation. The normal vocal fremitus varies in different individuals. It is not usually marked in women and children. In males it will be found more or less defined in proportion to the pitch or force of the voice. Voices of low pitch cause a more distinct fremitus than those which are higher. The distinctness of this sign also depends upon the thickness of the chest walls, the diameter of the bronchi, the proximity of the bronchi to the parietesj and the distance of the point examined from the larynx. It is therefore more marked upon the right than upon the left side, and in the infra-clavicular region than in the lower part of the chest. In women, this sign may be obtained over the upper portion of the chest, but is seldom found over the lower part. In men it is usu^ ally perceptible over the whole chest. Normal vocal fremitus may be increased, diminished, or abolished by disease. As a rule, it is increased by all diseases causing consolidation of lung tissue, as phthisis, pneumonia, oedema, and apoplexy of the lungs. It is generally increased by dilatation of the bronchial tubes, in which case there is more or less induration of the parenchyma of the lungs. Exceptional. — In pneumonia, when the bronchial tubes are completely filled by the inflammatory deposit, vocal fremitus cannot be felt. Owing to the great variation of this sign in different individuals and to its mutations in disease without clearly defined causes, it is not of very much value when taken alone. Vocal fremitus is diminished or suppressed by any disease causing separation of the lung from the chest wall by the intervention of air, gas, or fluid. In pneumothorax, hydrothorax, and pleurisy with effusion, absence of vocal fremitus over the air or the fluid is a sign of great value. Exceptional. — Presence of vocal fremitus is not always a certain sign that fluid does not exist, as snown by a few rare cases. If there is but a small col- lection of air or fluid in the pleural sac, vocal fremitus may be simply diminished; and in multilocular pleurisy it remains over the bands of adhesion. 16 PHYSICAL DIAGNOSIS. In emphysema, vocal fremitus is diminished. Aneurismal or other intra-thoracic tumors cause diminution or ab- sence of vocal fremitus directly over them, providing no lung tissue in- tervenes between the tumor and the chest wall. » Vocal fremitus is principally of value in differentiating between con- solidation of lung tissue and fluid in the lower part of the chest. When lung tissue is consolidated, fremitus is increased, but when there is a col- lection of fluid, it is absent. Exceptions to this rule are unimportant. Friction fremiti's, vibration caused by rubbing together of the roughened surfaces of the pericardium or pleura, is indicative of inflam- mation, with exudation, which causes roughening of the serous surface. Bronchial or rhoncal fremitus is the term applied in acute or chronic bronchitis, especially in children, when secretion is abundant, and the chest walls are thrown into vibration by air bubbling through fluid within the bronchi. The vibrations communicate to the hand a distinct bubbling sensation, which cannot be mistaken. Fluctuation of fluid within the pleural cavity may often be felt in the intercostal spaces by the fingers while tapping at a little distance with the fingers of the other hand. MENSURATION. Mensuration is rarely used, since inspection and palpation give suffi- ciently accurate and more quickly obtainable knowledge of the signs furnished. Many instruments have been devised for determining the size, capacity, and degrees of curvature or flatness of the chest. The only measurement of special clinical value is that of the circumference, in inspiration and in expiration, which may be readily taken by means of a simple tape. A good device for this consists of two tapes joined at their extremi- ties and so padded near the line of junction as to form a sort of saddle, which rests upon the spinous processes and prevents slipping. In using this instrument, adjust the pads to the spine and carry the tapes about the chest on both sides to the median line in front. The exact amount of motion of the two sides may thus be easily ascertained. In measuring with a single tape, place the thumb nail at a certain point on the tape, the first finger about one-fourth of an inch nearer its end. Then press the tape with the thumb nail against the middle of a spinous process and press the forefinger down beside it. This enables one to hold the tape firmly in position, and, by preventing the skin from slidiug in respiration, gives a fixed point from which to measure. It is always desirable to mark the median line in front before commencing this measurement. The circumference of the chest may be taken above or below the nipples, but best on a level with the sixth costo-sternal articulation. In recording cases, always note the level of the measurement. MENS URA TION. 17 The measurement should be taken during both full inspiration and forced expiration, and the two results should be compared to determine the expansion. The two sides must be compared to ascertain whether either is distended or deficient in movement. Quain and Carroll in- vented very satisfactory instruments for taking these measurements, known as stethometers. Quain's instrument (Fig. 4) consists of a cylin- drical box with a dial and an index, moved by a rack to which is attached a cord long enough to compass the chest. Each rotation of the index about the dial indicates one inch of movement. The box is placed upon the centre of the chest in front, and the string is carried horizontally around the chest; as the patient breathes, the f~^\ index revolves about the dial, registering accurately the expansion of the chest walls. Carroll's stethometer is simple and exact (Fig. 5) a simple tape is sufficient. Measurements of the healthy chest, of course, vary in different indi- viduals. The average in men is thirty-two and one half inches. Gener- ally, the right side exceeds the left by half an inch, but in left-handed persons the reverse is true. In disease, the affected side may be distended or contracted, and its movements may be diminished or increased, conditions usually noticea- ble on inspection and by palpation, but it is not uncommon to find, upon mensuration, that a side which had the appearance of distention is Fig 4.— Quain's Stethometer. Ordinarily iy§_i Fig. 5. — Carroll's Stethometer. smaller than its fellow; frequently expansion, which has seemed com- paratively free, will be found by the tape not to exceed one-eighth of an inch. The diseases causing expansion or contraction, and loss of move- ments of the chest wails, were mentioned under inspection. The transverse diameter of the chest may be obtained by means of a pair of calipers, or by Flint's cyrtometer (Fig. 6). Gee's cyrtometer, consisting of two pieces of composition gas-pipe joined together by means of a piece of rubber tubing, is the cheapest and perhaps the best instrument for ascertaining the transverse outline of the chest. In using it, the joint is placed upon the spine, and the pieces of pipe are accurately moulded round the chest. The instrument 2 is PHYSICAL DIAGNOSIS. - is then removed and laid on paper, when an exact tracing can be made. In a well-formed chest, the antero-posterior diameter will be to the transverse diameter in men as three to four, in women as four to five (Fig. 3). Scott Allison invented an instrument, known as a stetho- goniometer, for measuring the curves or the flatness of the surface of Fig. 6.— Flint's Cyrtometer. Fig. 7. — Spirometer. the chest (Fig. 8). It has been claimed that the infra-clavicular space should always be convex in health. With this instrument the curva- tures could be accurately ascertained, but unfortunately the information is of very little value, because, in healthy individuals, this region is often flat or even concave. Spirometers are used for measuring the chest capacity. Hutchinson was, I think, the inventor of the spirometer, but many modifications Fig. 8.— Allison's Stethogoniometer. have been devised. Recently portable instruments about the size of a watch have been made. In one of these, as the patient inspires, or blows into the tube, the index revolves on the dial, registering the num- ber of cubic inches of air inhaled or expired. Hutchinson found that people five feet in height usually possess a vital capacity of one hundred and seventy-four cubic inches, and for every inch of height above five feet, eight cubic inches should be added MENSURATION. 19 to the healthy standard. There are many obstacles to the use of spiro- meters rendering them practically useless. For instance, it takes most persons some time to learn how to blow into one of these instruments. A patient may at one time expire only one hundred and fifty cubic Fig. 9.— Hammond's HjEMadynamometer. inches, and at another, without any change of health, two hundred cubic inches. Furthermore, women and men, the young and the old, all have different vital capacities, and it has not yet been possible to arrive at an accurate healthy standard. Hammond devised the hsemadynamometer, which he used for meas- uring the force of inspiration and expiration. He found that individ- 20 PHYSICAL DIAGNOSIS. uals five feet eight inches in height possess the maximum respiratory power. His instrument (Fig. 0) consists of a bent glass tube fastened to a graduated scale, and joined at each end by a rubber tube, through which the patient is to breathe. The instrument is partially filled with mercury, which rises on one side or the other as the patient inspires or expires through the mouth-piece and falls after he ceases. Hammond found the expiratory power much greater than the inspiratory, the average man being able to raise the column of mercury three inches by expiration, and only two by inspiration. This is a fact which at once explains some of the phenomena of disease. For instance, Laennec's hypothesis as to the cause of pulmonary emphysema was based upon the supposition that the inspiratory power was greater than the expiratory, a supposition clearly untenable after Hammond's demon- stration. SUCCUSSION. Succussion, the fourth method of physical exploration, was known to Hippocrates. It consists of suddenly shaking the patient's body while the ear is placed against his chest. When air and fluid occupy the pleural sac, this proceeding will cause a splashing sound. The sign is of value in pneumo-hydrothorax (Fig. 26). The succussion sound will vary more or less in quality with the density of the fluid. Thick pus will not yield the same sound as thin serum, but the quality of these sounds is not usually sufficiently distinc- tive to aid us materially in our diagnosis. Metallic tinkling, due to dropping of fluid from the upper part of the cavity into the effusion below, can usually be heard when the succus- sioD signs are present (Fig. 26). CHAPTER II. METHODS OF EXAMINATION.— Continued. PERCUSSION. PERCUSSION" IN HEALTH. Percussion is the art of eliciting sound by striking with the fingers, •or with instruments constructed for the purpose. As a means of diagnosis, it is generally supposed to have originated during the last century with Avenbrugger, a physician of Vienna, bat the works of Hippocrates indicate that he was familiar with it, to a limited extent. Hippocrates and Avenbrugger recommended immediate percussion. in which the blow is struck directly upon the chest wall. Fig. 10.— Flint's Hammer and Pleximeter. This form of percussion has been nearly supplanted by one which originated about sixty years ago, with M. Piorry, termed mediate percus- sion, in which the blow is received on some intervening substance. Before mediate permission was employed, it was quite essential to intensify the sounds ; this was accomplished by placing the patient with his back against a hollow wall. In some women the signs elicited by immediate percussion are quite distinct over the upper part of the chest, but usually this method is very unsatisfactory. In mediate percussion, a small hammer or plexor and an instrument known as a pleximeter or plessimeter are employed. The hammer in common use consists of a cylindrical rubber head attached to a light handle about eight inches in length. Metallic hammers faced with rubber, as sometimes used, are objectionable on account of their weight, which renders the blow so forcible that it is apt to cause pain. 22 PHYSICAL DIAGNOSIS. Pleximeters are made of various materials, as rubber, bone, wood, ivory, or leather. Some of them are graduated in order that they may be used in mensuration. Among the best is one which consists of a narrow oval disc of hard rubber, with large ears at each extremity. It should be narrow enough to be placed between the ribs, and should have a large projection at each end, that it may be firmly graced. I have frequently used a small cylinder of soft rubber about two inches long and half an inch in diameter. It lias the advantage of being easily adapted to the intercostal spaces, and of emitting no sounds of its own -when struck. For ordinary percussion it is best to use the middle or index finger of one hand in place of the pleximeter, and two or three fingers of the other, with their tips brought into line, as a hammer. The fingers used as a plexor should be brought as nearly as possible to a right angle at the second joint, that the terminal phalanges may strike perpendicularly upon the finger of the opposite hand. When the fingers are used, there is noticeable a certain sense of resistance which is not obtained with instruments. Often this would enable us to detect internal organic changes even with our ears com- pletely stopped. So valuable is it in intricate cases that, when there is difficulty in making an accurate diagnosis, I always employ the fingers instead of instruments for percussion. The sounds obtained by percussion are generally described as clear, dull, and tympanitic, but these terms are not sufficiently precise to aid us much in studying the method. I prefer a classification based upon acoustic properties. The elements of sound which concern us in per- cussion are intensity, pitch, quality, and duration. The intensity of a sound determines the distance at which the sound maybe heard. Other things being equal, the intensity of a sound in pulmonary percussion varies with the force of the blow, the volume of air in the lung, and the thickness and elasticity of the chest walls. It is diminished by thick layers of fat or muscle, by rigidity of the costal cartilages, and by contraction or consolidation of the lung, and it is in- creased by the opposite conditions. The pitch of a percussion sound may be high or low. Those famil- iar with music will understand this, but a common mistake is to con- found pitch with intensity. Many students suppose that the higher the pitch, the greater the intensity. The reverse of this is usually true in pulmonary percussion, intense sounds being low pitched, and high- pitched sounds possessing feeble intensity. This difference between pitch and intensity can be easily recognized by striking two notes at opposite ends of the keyboard of a piano. By striking a high note forcibly, one will obtain a sound loud enough to be heard some dis- tance ; then by gently tapping a key at the other end, one will obtain a sound heard at exactly the same distance, but of a much lower pitch. The pitch of the percussion note over a healthy lung is always low, PERCUSSION. 23 but it will vary in different portions of the chest, owing to difference in the volume of air and the position of other intra-thoracic organs. Quality of sound is that element by which we distinguish between the tones of musical instruments, or of voices of different individuals, having, it may be, the same intensity and pitch. In pulmonary percussion, we obtain a peculiar quality termed vesic- ular, impossible to describe, but always to be obtained by percussion of the healthy chest. It is soft and low in pitch, and usually seems as though coming from a point a couple of inches beneath the surface. It can be learned only by studying the healthy chest. Dttratiox of the healthy percussion note depends upon the same causes as its pitch. If its pitch is high, the duration is short; if the pitch is low, the duration is prolonged. Indeed, a definite relation exists between all these different elements; that is, intense sounds are apt to be low pitched; those which are feeble are generally short and high pitched, and, instead of the vesicular, they possess a solid character. Percussion seems very simple as practised by an adept, but accuracy is not acquired without much practice. Certain rules essential to accurate percussion should be early fixed in mind. The surface of the chest should be bare; but if for any reason this cannot be secured, have the covering soft, thin, and smooth. It is abso- lutely useless to percuss the chest of a patient who has on one or two shirts and perhaps a chest protector or corset. The patient should be in a comfortable position, whether sitting, standing, or lying upon the back, and the two sides must be relatively symmetrical. The first two positions are . preferable, but very sick pa- tients should not rise for the examination; it will be better to make a less critical examination than to endanger the patient. Persons suffering' from diseases which cause feebleness of the heart should not be asked to sit or stand. Illustrating the importance of this caution, I have seen cases of sudden death from overtaxing of a weak heart, by slight exertion, such as the getting out of bed of a patient convalescing from pneumonia or diphtheria. Do not allow the patient to twist the body or move the arms during percussion, as such motions change the relations of the muscles, and thus alter the percussion note. The physician's ear should be squarely in front of the part percussed. If he stand partially to one side, the signs obtained on that side, even though the same as those on the other, will reach the ear with a different tone. His position should be easy and unrestrained, or he will not- recognize slight differences in sound. In percussing any particular region of the chest, aim to have the chest walls as thin and tense as possible. To secure this on the anterior portions of the chest, the arms should hang at the sides and the shoulders 2i PHYSICAL DIAGNOSIS. should be thrown backward. In examining the lateral region.-, it is well to have the hands rest upon the head. If the arms are held up, the muscles stand out so prominently that they interfere with obtaining the pulmonary resonance. In percussing the posterior regions, the trunk should be bent forward and the arms crossed in front. In percussing the chest, compare corresponding portions of the two sides. If changes from the normal are slight, they can be detected in no other way. Ordinarily it is sufficient to repeat a series of strokes first on one side, then on the other, or to percuss both sides repeatedly in quick succession. However, the percussion sounds vary slightly at dif- ferent periods of the act of respiration ; therefore, whenever the changes are so slight as to require great care for their discrimination, the sides should be compared during the same stage of the respiratory act. The best period at which to make the comparison is at the close of a forced expiration. Exceptional. — In health the two sides are not always alike as regards dis- parity between the note elicited in full inspiration and that elicited in forced ex- piration. In applying the finger or the pleximeter, be careful that it presses evenly upon the surface and displaces all the air beneath it. Otherwise, the resonance of the pleximeter is obtained instead of that from the chest, and at the same time the air is suddenly forced out, causing a sound very similar to cracked-pot resonance. The force of the stroke should be moderate, never great enough to cause the patient pain, and alike on both sides. In percussing super- ficial portions of the lung, the stroke should lie very gentle, but to obtain the resonance from deeper parts it must be more forcible. Be- ginners commonly strike much too hard. The stroke should be from the wrist alone, whether made with the hammer or with the finger. When striking from the elbow, we cannot control the force of the blow. Some diagnosticians are accustomed to strike a single blow, first upon one side, then upon the other: but I get better results by making three or four taps in rapid succession. The direction of the stroke should always be perpendicular to the surface of the chest. If we percuss obliquely, instead of obtaining the resonance from the lung immediately beneath the pleximeter, we get that from a rib or from more distant tissue. In percussing near i-he sternum, in the tipper portion of the chest, We obtain resonance from the trachea instead of from the lung, unless care be taken to direct the blow toward the central portion of the apex. The stroke should be a simple tap, the finger or hammer being al- lowed to rebound instantly, instead of resting a moment on the plexi- meter, which has an effect on pulmonary resonance similar to that pro- duced by touching a vibrating tuning-fork. In percussing with the fingers, strike with their tips, instead of with the pulps. PERCUSSION. 25 As the signs in a healthy chest vary in its different regions, we must take special pains to familiarize ourselves with all the healthy sounds. There are no two healthy people whose chests are exactly alike, therefore we can take no one person as a standard for compari- son; but after percussing many healthy chests, we may form an ideal standard from which no great variation can occur without indicating disease. Normal vesicular resonance is obtained most perfectly in the left infra-clavicular region; and this, being the sound obtained over the pul- monary air vesicles, is taken as the standard for comparison in pulmo- nary percussion. In the right infra-clavicular region the percussion note is nearly the same as in the left, but is slightly harder or more tubular in quality, owing, probably, to the greater size of the bronchial tubes. In the middle of the supra-clavicular region the resonance is soft or vesicular in quality, but toward the inner part of this region it becomes harder in quality or tubular and higher in pitch. Austin Flint called this an approach to tympanitic resonance. Externally in this region the vesicular quality is diminished. In percussing over the central por- tion of the clavicular region, the sound is fairly vesicular, but it becomes less and less so toward either end of the clavicle. In the mammary regions the sounds are altered on one side by the presence of the heart, and on the other side by the presence of the liver (Fig. 1). In the upper part of the right mammary region we obtain vesicular resonance extending down to the line of hepatic dulness in the fourth interspace. Below this, where the lung overlaps the liver, dulness is appreciable on forcible percussion, gradually becoming more and more distinct as the lung decreases in thickness, until we reach the lower border of the lung at the sixth rib, the line of hepatic flatness, below which we lose all pulmonary resonance. The lines of hepatic dulness and of hepatic flatness, the first along the upper margin of the liver, the second at the lower margin of the lung, are ordinarily about two inches apart. Exceptional. — In deep inspiration the lower line may be carried an inch and a half or two inches lower, and in forcible expiration it may be elevated from one to live inches ; therefore the area of hepatic dulness, between the two lines, may vary from two to seven or even eight inches. This wide range is not common, but its occasional occurrence shows the necessity for studying - the chest in both inspiration and expiration. In the left mammary region pulmonary resonance exists over the outer part. Near the middle of the region forcible percussion elicits cardiac dulness. Near the sternum the heart is superficial, covered only by the pericardium and by cellular tissue; here there is a small, triangu- lar space yielding flatness. It is about an inch and a half wide at its base, which corresponds to the sixth rib, and extends from the fourth 26 PHYSICAL DIAGNOSIS. to the sixth costal cartilage. The apex of this triangle is located at the margin of the sternum on a level with the fourth rib. The resonance of the mammary region is modified more or less by the thickness of the muscles in men and by the mammary glands in women. In the infra-mammary region, on the right side usually, there is nothing but the liver to affect the percussion note, hence we have a sound termed flatness, like that obtained by percussing the thigh. If the colon be distended by gas, we obtain tympanitic resonance in the lower part of this region. In the left infra-mammary region flatness caused by the left lobe of the liver extends a couple of inches to the left of the median line. In the outer portion of this region we obtain a similar sound from the spleen, and between these two organs we elicit tympanitic resonance from the stomach. In the upper sternal region, as low as the level of the second costal cartilage, the sound is tubular, or, according to Flint, tympanitic. This is due to the presence of the trachea, the sounds of which are modified by the anterior borders of the lungs which are in apposition throughout this region. Below the level of the second ribs, on light percussion, pulmonary resonance may be heard, though modified by the timbre of the bone. But deep percussion gives dulness, resulting from the presence of the great blood-vessels. Over the lower sternal region, by light percussion, pulmonary reso- nance is obtained to the right of the median line, while on forcible per- cussion there is dulness. Left of the median line, the heart is super- ficial and yields flatness. At the inferior portion of this region, flatness is due to the left lobe of the liver. Over the scapula, the vesicular sound is indistinct from the thick- ness of the muscular tissue, but above the spine of the scapula it is much more marked than below, and in the upper part of this region it is quite clear. In the inter-scapular regions the sounds are hard in quality and high pitched, because the chest walls are thick. There is, however, in all cases some pulmonary resonance. The pitch is a trifle higher on the left side on account of the aorta. In the infra-scapular regions the vesicular resonance is well defined, though not quite so clear as in the infra-clavicular region. It extends downward to the tenth or eleventh rib. On the right side we find the line of hepatic dulness at the eighth rib and the line of hepatic flatness at the eleventh rib; but these vary from one to two inches during forci- ble respiration (Fig. 2). On the left side the resonance is slightly modified near the spine by the nearness of the liver. Below the tenth rib the intestinal canal, if filled with gas, causes a tympanitic sound. In the outer part of this PERCUSSION. 21 region, between the ninth and eleventh ribs, d illness is obtained over the spleen, and for a short distance abont this dnll region resonance is rendered more or less tympanitic by the stomach and intestines. In the lower part of the left infra-scapular region, close to the spinal column, dulness is found over the kidney, and it occurs in a similar position, though a trifle lower, on the right side. In the axillary regions the resonance is often more marked than in the infra-clavicular. In the infra-axillary region the resonance is modified on the right side by the liver, and upon the left by the stomach and spleen. In this region the margin of the lung passes obliquely downward and backward from the anterior boundary near the sixth rib to the pos- terior near the tenth rib. On the right side, hepatic flatness is found below this line, and hepatic dulness a couple of inches higher. On the left side, below this line, we find tympanitic resonance in front over the stomach, and dulness posteriorly over the spleen. In this locality the pulmonary resonance is often modified by the stomach, as high as the fourth rib. The size of the spleen varies considerably, even in health. The area of dulness which it causes seldom exceeds two and one-half inches in height by about four inches in width; about half of this dull space is in the infra-scapular and half in the infra-axillary region. Exceptional. — In rare cases the spleen rises as high as the lower boundary of the axillary region, or the stomach may yield decided tympanitic resonance as high as the fourth rib. In the infra-scapular region, upon the right side in children, dulness is some, times very pronounced, due to the disproportionate size of the liver in early life. This is not infrequently mistaken for the consolidation of pneumonia. The percussion sounds in different regions of the chest are modified by age, sex, and various idiosyncrasies. In old age, the chest walls are less elastic than in middle life, and the lung has undergone some change which renders the sounds harder in quality and higher in pitch. In children, the lungs are very resonant, and the costal cartilages are elas- tic; consequently we obtain a low-pitched, intense vesicular sound. In men the percussion note over the upper portion of the chest is not usually so resonant as in women, but it is more distinct over the lower portions. It will be seen, from what has already been said, that there is notable dissimilarity of the percussion sounds on the two sides in the mammary regions, as also in the infra-mammary, infra-axillary, and infra-scapular regions. In all other portions of the chest the resonance is nearly identical on the two sides, but the slight normal disparity in the infra-clavicular regions is a point of great importance. PHYSICAL DIAGNOSIS. PERCUSSION IN DISEASE. In disease, the percussion sounds may occur in every gradation from normal to tympanitic resonance or flatness. These varieties have heen variously classified. R. E. Thompson classifies them as clear, dull, tym- panitic, amphoric, and cracked-pot resonance. Flint arranged them under six heads; and A. L. Loomis under seven, as follows: Exaggerated pulmonary resonance, dulness, flatness, tympanitic resonance, vesiculo- tympanitic resonance, amphoric resonance, and cracked-pot resonance, or the cracked-metal sound. Exaggerated pulmonary resonance differs from the normal vesicular sound only in its intensity. The pitch and quality are the same as in health, but the intensity is increased. This sound is obtained over lung tissue which is receiving more air than usual, and which might therefore be said to be in the highest degree of health. The sign is therefore only negative, as it is indicative of no disease whatever in the place where it is obtained, but rather points to deficient action in some other part of the respiratory tract. Exaggerated pul- monary resonance, in adults, is very nearly the same as the normal reso- nance in children. The sign results from obstruction to the entrance of air into some portion of the respiratory tract, whether from filling up of the air cells by inflammatory exudation as in pneumonia, from nar- rowing of the bronchial tubes, or from collapse of the air cells. Pneu- monia of one lung or of a single lobe of a lung causes exaggerated resonance over healthy portions of the lungs. Compression of the lung from air or fluid in the pleural sac gives rise to exaggerated resonance on the sound side. If one main bronchus is occluded, from causes within it or external to it, resonance is exaggerated on the opposite side. In extreme anaemia exaggerated resonance occurs on both sides, due probably to a diminished amount of blood in the pulmonary circuit. As the chest is practically a cavity with unyielding walls, diminution in its fluid contents must cause a corresponding increase in the amount of air. Dulness indicates a small amount of air beneath the part percussed. It can always lie obtained in the healthy chest where the lung overlaps the liver. This sign differs from normal vesicular resonauce in having nigh pitch, hard quality, and comparatively short duration. Its inten- sity is usually less than that of vesicular resonance. Varying degrees of dulness should be carefully studied on the healthy chest. Over the liver, on forcible percussion, slight dulness is found in the fourth inter- costal space, becoming more distinct, higher in pitch, harder in quality, and shorter in duration, as examination extends downward, toward the lower margin of the lung. This sign, when obtained in a position which should yield vesicular resonance, indicates that something has occurred to diminish the nor- mal amount of air in that part of the lung. It is obtained over consolir PERCUSSION IN DISEASE. 29 dated lung, from simple inflammation or from phthisis, from com- pression of the lung or from collapse of the air cells ; over collections of fluid in the bronchi or in the air vesicles; over moderate exudations in the pleural sac separating the lung from the chest trails, but effusions of any considerable amount destroy pulmonary resonance entirely, giving flatness. Dulness is also obtained over intra-thoracic tumors, whether solid or fluid, provided a small portion of lung tissue containing air intervenes between them and the thoracic wall. It is one of the signs found in pneumonia, pleuritis, phthisis, atelectasis, and in intra-thoracic abscesses, aneurisms, and tumors. Exceptional. — Dulness results occasionally from pulmonaiy apoplexy. In such cases it is usually found at the lower angle of the scapula. It may arise from brown induration of the lung, due to a varicose condition of the pulmonary veins. In this disease it is found near the middle of the lungs on both sides. It may arise from enlarged bronchial glands, and in a few instances it is found in bronchitis over the apex of the lungs, or more clearly at the lower pos- terior part of the chest, due to a collection of secretions within the bronchi. Flatness differs from dulness in complete absence of vesicular res- onance. Dulness indicates that there is some air beneath the point at which the stroke is made; flatness, that there is none. Dulness is ob- tained over that portion of the liver overlapped by lung tissue; flatness over that portion below the sixth rib, which is superficial. Dulness occurs in pleurisy where the exudation has separated the lung a short distance from the chest wall and caused a corresponding diminution in the volume of air. Flatness will be found in the same disease, when an effusion of serum lifts the lung above it, removing all air- containing tissue from beneath the point percussed. Flatness is found in pleurisy with effusion oftener than in any other disease. Exceptional. — In rare cases of pneumonia the inflammation runs to such a height that not only the air cells, but also the bronchial tubes are filled with the exudation, and in such cases absolute flatness is found over the lung tissue. Again, when the lung- becomes completely collapsed from pressure or obstruc- tion of a large bronchus, flatness results. Tumors or abscesses within the thorax, when they rest against the chest walls, cause flatness. Tympanitic kesoxaxce is the name given to the sound which may be normally obtained over the stomach or the intestines when filled with air or gas. It indicates a quantity of air enclosed by walls thin and yield- ing and not too tense (Da Costa). Under certain conditions, this sign is met with over the thorax. Tympanitic resonance is usually described as of higher pitch than the vesicular sound. Its duration may be longer or shorter, and its quality is hollow, conveying the idea of more or less tension; it is also some- what hard, metallic, and ringing. Statements of different authors 30 PHYSICAL DIAGNOSIS. Conflict concerning the pitch of this sign. Some hold that it is high, Others that it is low. It seems to me that the discrepancy has arisen from mistaking the ringing metallic quality of the sound for a high pitch, when it may really be low. I find the weight of opinion in favor of a high pitch. R. E. Thompson, in his little work on physical examination of the chest, states that the pitch of this sign may be either high or low : high when the tension of the volume of air is great, and low when it is slight. This variety of resonance is never found in the healthy chest, unless it he transmitted from some of the organs beneath the diaphragm; it is frequently obtained below the fourth rib, on the left side from gaseous distention of the stomach or the intestines and occasionally over the infra-mammary region on the right side when the colon is distended. When obtained over portions of the chest which should yield a vesicular Bound, the sign usually indicates a collection of air or gas in the pleural sac, as in pneumothorax. Occasionally it is found over a large cavity in the lung tissue containing air. " Pulmonary cavities are generally produced by jihthisis; hence the rule, that there are only two diseases of the chest, pneumothorax and phthisis, in which this sign is found. Exceptional. — Guttman, Gee, and some others claim that this variety of 'resonance sometimes results from diminished tension of the pulmonary paren- chyma, and may be found in any condition causing partial collapse of the lung. Perfect tympanitic resonance may be obtained in that very rare condition in which air or gas collects in the pericardium. It is said to be found in some cases of emphysema and of acute tuberculosis. According to Da Costa, it is some- times found in pulmonary oedema. Tympanitic resonance from the stomach may be elicited far above its normal seat, when the luug is retracted and the stomach and intestines are correspondingly elevated. Vesiculo- tympanitic resonance is a quality of sound midway be- tween the vesicular and the tympanitic. This sign occurs in extreme emphysema, where the air cells and the chest walls are distended. Amphoric resonance is a modified tympanitic sound which may be closely imitated by tapping the cheek gently when the mouth is filled with air. but not much distended. The sound is hollow and somewhat metallic. It is obtained in very much the same conditions as cracked- pot resonance — that is, over an empty pulmonary cavity with yielding walls; but to produce this sign the cavity must communicate freely with a large bronchial tube, so that the air can be driven quickly from it by the percussion stroke. It is found also over collections of air in the pleural sac, when this cavity opens through the lung into a large bron- chus. Pulmonary cavities are generally caused by phthisis, but they may THE PLE8SIGRAPH. 31 result from abscess. Amphoric resonance is therefore a sign of .pneumo- thorax, phthisis, and possibly of abscess or gangrene. Bell Sound, — "While listening over a large pulmonary cavity, if percussion be made on the opposite side of the chest, with one large coin striking upon another used as a pleximeter, a ringing bell sound will be heard, which is some- times very loud. Cracked-pot resokajstce {bruit de pot fele) may be imitated by placing the hands loosely together, palm upon palm, and striking upon the knee. It is described as resembling the clinking of coin or the timbre of a cracked metallic kettle. Generally the sign seems to be the result of forcing air suddenly from a pulmonary cavity through a small opening. It has been considered by some as diagnostic of a pulmonary cavity, but this sign may occasionally be obtained when no cavity exists, and sometimes even in healthy individuals. Something closely resem- bling this resonance is apt to be heard during percussion if the plexim- eter is placed lightly against the surface, so that air remains beneath and is suddenly forced out by the blow. It is said that occasionally this sound may be elicited in the bronchitis of children, or just above the level of the fluid in pleurisy with effusion. As a rule, cracked-pot resonance is significant of a cavity, but the ma- jority of cavities do not produce it. When found, it can seldom be heard more than two or three times together, and it requires an interval of rest before it can be reproduced. This is probably due to the small opening into the cavity — the air, having been driven out, returns slowly. THE PLESSIGRAPH. In percussion with the ordinary pleximeter, no matter what its material or its form of construction, all the tissue beneath it is thrown into vibration. This renders it next to impossible to define sharply the outlines of dulness when solid tissue is overlapped by the lung, because the pleximeter covers too much space, and the sounds from the tissues containing air and from those which do not are blended. For instance, in attempting to determine the lower border of the lung, overlapping the liver, we commence above and percuss downward to the point of complete flatness, then upward ag-ain to a point where the vesicular resonance is clear, and thus back and forth, until two adjacent points are reached where we obtain on the one hand quite perfect pulmonary resonance, and on the other flatness. Then we judge that the border of the lung lies midway between the two. To avoid throwing too much tissue into vibration, the size of the pleximeter must be abridged ; but as the size is diminished, unless compensated for in some way, the intensity of the sound is correspondingly lessened. These difficulties seem to have been overcome in the construction of a little instrument known as the plessigraph devised by M. Peter, of Paris. It consists of a small cylinder of wood about four inches in length and five- eighths of an inch in diameter, with a disc at one end upon which percussion is to be made. The other end consists of a truncated cone, the plane surface of which measures nearly an eighth of an inch in diameter. In using the instrument, the 32 PHYSICAL DIAGNOSIS. small end is placed on the surface of the chest, and percussion is made upon the other end with the pulp of a single finger. Care must be taken that the instru- ment is held perpendicular to the surface. On account of the smallness of the surface which rests against the chest, the sound obtained would be very feeble, were it not in a measure intensified by the body of the instrument acting as a sounding-board. Trousse;m claimed that it is not necessary to strike upon the disc, but that we may simply tap upon it with the pulp of the finger, and that by means of this instrument even students may rapidly map out the liver or heart, when with ordinary percussion this might be impossible, even for a skilled diagnostician. The instrument as constructed by Peter had upon the side an arrangement holding a crayon which could be pressed down to mark the skin when the border of the organ had been found, so that a dotted line would be left corresponding to the outlines of the solid viscus or tumor. I have found this in- strument very satisfactory in determining superficial dulness, so long as it is employed only in the intercostal spaces, but not when applied over the ribs. AUSCULTATORY PERCUSSION. Auscultatory percussion was instituted by Camman and Clark in 1840. It consists, as the name implies, of combined auscultation and percussion. In practising it, a stethoscope is needed. For this purpose the originators of the method devised a peculiar instrument, which con- Ftg. 11.— Camjian's Stethoscope for Auscultatory Percussion. sists of a solid cylinder of wood formed at one end into a truncated wedge, and at the other into a disc (Fig. 11). The wedge-shaped ex- tremity is placed in an intercostal space, over the most superficial por- tion of the organ or tumor to be examined, and the examiner's ear is placed upon the disc. An assistant then percusses from the healthy lung tissue toward the instrument. The moment percussion is made over solid tissue, the changed sound reveals the fact to the listener, and thus enables him to determine the deep outlines of the solid mass much more accurately than by simple percussion. The ordinary binaural stethoscope with the smaller chest-piece may be used for the same pur- pose. The advantage claimed for this method is that it enables one to determine the outlines of intra-thoracic tumors or organs much more accurately and rapidly than by other means. Outlines of the liver, the spleen, and the kidney may also be ascertained with considerable accu- racy, even when ascites is present. In the practice of this method, a second person has been necessary to make the percussion, and it is often impossible to get a skilled assistant at the time needed. To overcome this difficulty, I have devised an in- strument known as the emballometer (Fig. 12). It consists of a hoi- AUSCULTATORY PERCUSSION. 33 low cylinder about three inches in length by five-eighths of an inch in diameter, within which plays a metallic plunger. Tc the objective end of the instrument is fitted a soft-rubber chest-piece, against which the plunger strikes. To the other end is attached a rubber tube about eighteen inches in length, connecting it with a rubber bulb. Compres- sion of the rubber bulb drives the plunger against the chest-piece; at the instant the pressure is removed, the bulb expands and the plunger is forced upward by atmospheric pressure. In practising auscultatory percussion by the aid of this instrument, the stethoscope is held with S-HARP a SMITH Fig. 12.— Ingals 1 Emballometer. the left hand; the bulb of the emballometer is held in the palm of the right hand by the last three fingers, and the cylinder by the thumb and forefinger. This enables the physician to move the instrument without restraint, to strike any point as rapidly or as slowly as he chooses and with whatever force may be desirable. By means of this little instru- ment and the binaural stethoscope, auscultatory percussion can be satis- factorily practised without the aid of an assistant. In using the bin- aural stethoscope for this purpose, the small chest-piece should be employed. Probably one still smaller or flattened, so that it might be applied between the ribs, would give even better results. 3 CHAPTEK III. METHODS OF EXAMINATION. —Continued. AUSCULTATION. Auscultatiox, the art of listening to sounds produced within the chest, originated early in the present century. It ranks first among the methods for physical exploration. The sounds to be studied by this method are produced during either insjfiration or expiration, or during both portions of the respiratory act. Auscultation may be mediate or immediate. In the former, the sounds are conducted to the ear through an instrument known as the stethoscope; in the latter, the ear is placed directly on the surface of the chest, or on the chest but slightly covered. In this connection, a brief notice of Laennec, the inventor of mediate auscul- tation, is of peculiar interest. He was born in an obscure province in France, and at the age of nineteen went to Paris to obtain his medical education, where he very soon attracted the attention of the profession by his diligence and atten- tiveness at the hospitals. From the time that he entered Paris until his final departure, about five years before his death, his whole life seems to have been given to careful clinical study and verification of the results by autopsy. The fruit of his labor we find in papers written on inflammation, melanosis, encephaloid cancer, and numerous other topics, but especially in the great work of his life, his treatise on ausculta- tion, published in 1816, when the author was about thirty-five years of age. This was the introduction of auscultation to the profession. So thorough were the author's observations, so accurate his conclusions, that subsequent writers have been able to add but little to the information upon this subject gathered by him. Not long after he published this work, close application began to undermine his health, and in a few years the very method which he had introduced disclosed the signs of phthisis in his own chest. Realizing fully their significance, he re- signed his work in Paris and retired to his native province, where he died at the age of forty-five, leaving a name which will still be remembered when most ot those now prominent have sunk into oblivion. Since Laennec's death, the method known as immediate auscultation, according to him first practised by Boyle, has received great favor with the profession. Many physicians now consider this the only proper method of auscultation, while a few others rely entirely upon the medi- ate method. "Whatever the advantages of either, we must familiarize ourselves with both to become accurate diagnosticians. The stethoscope has some disadvantages. The first and main objec- A USCULTA TION. 35 tion is that it has a peculiar ringing sound always confusing to begin- ners. Until we become sufficiently familiar with the instrument to ig- nore this, we shall be unable to appreciate the pulmonary sounds. Many of these instruments are poorly constructed. The stethoscope is of very little value in examining children, because it is likely to frighten them; besides, the respiratory murmur in them is so loud that it can be easily heard with the unaided ear. In examining the lungs, the ear alone is usually sufficient; but to differentiate between the sounds produced at the various orifices of the heart, we must employ the stethoscope, the small chest-piece of which excludes in a great measure all sounds excepting those produced imme- diately beneath it. Mediate auscultation has, however, the advantage of greatly intensify- ing the intra-thoracic sounds, so that signs which could not be heard by the unaided ear may be readily recognized through the instrument. Some portions of the chest cannot be easily examined by immediate auscultation — for instance, the axillary space and the supra- clavicular region; therefore the instrument becomes necessary; sometimes it may be unpleasant to apply the ear. to the chest, and sometimes for the sake of delicacy it is not advisable. The advantages claimed for immediate auscultation are: It yields no humming sound; it obviates the necessity of carrying an instrument; it does not frighten little children, and the results obtained are usually sufficiently accurate. If the stethoscope moves slightly upon the chest, it produces a grat- ing sound much more intense than the respiratory murmur. The same thing occurs if the finger moves upon the instrument, if the hand is drawn over the surface of the chest, or if the patient's clothes move upon the chest or upon the instrument. In some cases neither mediate nor immediate auscultation alone yields accurate results, while the two combined enable us to make a proper diagnosis. There is now a great variety of stethoscopes. They may be classified, however, as solid and flexible, some of which are binaural and others single. The binaural instrument is provided with two tubes which con- duct the sound simultaneously to both ears. The single stethoscope is designed only for one ear. The solid stethoscope most in use is a tubu- lar instrument about six inches in length, expanded at one end into a bell-shaped chest-piece about an inch and a fourth in diameter. At the other extremity is a disk or ear-piece about two inches in diameter (Fig. 13). Some of these instruments are so made that the ear-piece may be removed for convenience in carrying, and a soft-rubber ring encircles the disk, so that it may be used as a hammer in percussion. I think physicians generally find more difficulty in examining the chest with this instrument than with the binaural stethoscope. A binaural stethoscope devised by Leared, of London, was made of gutta-percha and 36 PH YSICA L DIA GNOSIS. consisted of two tubes, one for each "ear. The auricular extremities of these tubes were disk-shaped, and the other ends were fitted into a hoi. low cylindrical or cup-shaped chest-piece. The elasticity of the tubes kept the disks in firm apposition with the ears. This instrument was exhibited in London in the year 1851, but it attracted little attention. About the same time Camman, of Xew York, introduced the binaural in- strument that bears his name. This consists of two metal tubes so curved Fig. 13.— Solid Wooden Stethoscope. as to fit into both ears, and connected with each other by a hinge-joint. These, when placed in the ears, are held in position by an elastic passing from one to the other just above the joint, or by springs of various con- trivance. The auricular ends of these tubes are tipped with gutta-percha or ivory of sufficient size to close the external meatus and prevent the entrance of external sounds. To the other ends are fitted two flexible tubes which connect them with the body of the instrument to which the chest-piece is attached (Fig. 14). Each instrument has two chest- pieces, one about an inch and a quarter in diameter, for examination SHARP — SMITH Fig. 14.— Knight's Stethoscope, with Extension. This extension tube renders it easy for the student to examine his own chest and is a great convenience in examining patients in bed. of the lungs; the other five-eighths of an inch in diameter, for the ex- amination of the heart. Of the various modifications of C'amman's stethoscope, Knight's is the best. It possesses all of the essential points of a good instrument, viz. : the metallic ear-tubes are curved at the proper angle to conduct A USCULTA TION. 37 the sound directly into the auditory canal; the ear-tips are of proper size to exclude external sounds, and are not so small as to pass into the audi- tory canal and occasion pain; the tubes which connect the ear-pieces with the chest-piece are very pliable and have a calibre equal to that of other portions of the instrument; the chest-pieces are of proper size, and the whole instrument is thoroughly finished. With many instruments a soft-rubber attachment is furnished which may be fitted over the end of the smaller chest-piece, and is designed for the examination of emaciated patients. This chest-piece, however, is practically worthless, on account of the creaking which is produced, dur- ing the respiratory movements, by friction with the wooden chest-piece on which it is adjusted. Charles Dennison, of Denver, has an excellent modification of the binaural instrument; the conducting tubes are of large calibre, com- posed of gutta-percha and unite in a common tube with flaring extremity about an inch across; into this three other chest-pieces may be tightly fitted, two of the same material, one of medium size and one three inches in diameter. The latter is especially valuable when it is desired to hold Fig. 15.— ALlison's Differential Stethoscope. the chest-piece of the stethoscope before the patient's open mouth while percussion is being made on the chest as recommended when the signs of consolidation of the lung are indistinct. The third chest-piece is of soft rubber. The differential stethoscope invented by Allison is essentially the same as Camman's, except that the flexible tubes are each fitted with a distinct chest-piece, so that sound can be conducted to the two ears simultaneously from different portions of the chest (Fig. 15). A stethoscope which will fit one person perfectly and allow the sounds to be conducted without obstruction into the auditory canal, with another may rest against the external ear in such a position as nearly to occlude the orifice of the ear-piece; therefore in purchasing, one should see that the tubes are so bent that the instrument fits the ears accu- rately. The larger chest-piece ought never to exceed one and one-fourth inches in diameter. If larger than this, it cannot be accurately applied to an emaciated patient; consequently air passing beneath it will pro- duce a humming sound, which will drown the pulmonary signs. 38 PHYSICAL DIAGNOSIS. The apparatus on Knight's stethoscope for adjusting- the pressure of the ear- pieces works perfectly, and is often very useful, though a simple rubber hand of proper length would answer the purpose, if only one person were using the in- strument. A rubber band, which could be lengthened or shortened by a buckle, would allow the instrument to be easily adjusted to any head, and would be less expensive than the metal attachment. Considerable practice is required to perform auscultation properly. As guides, a few rules may be laid down : In mediate auscultation, the chest must be bared; in immediate auscultation, the covering must be as soft, thin, and smooth as possible. The position of both patient and examiner should be easy and unre- strained. If the patient is in bed, it is preferable to have him sitting, if health will permit. If the examiner is in an uncomfortable position, he cannot properly concentrate his attention upon the sounds. In examining a child, or a patient in bed, it is a good plan to rest on one knee, so that the head will not be on a plane lower than the body, otherwise gravitation of blood to the brain will cause fulness of the head, dizziness, and impaired sense of hearing. We must early learn to concentrate the whole attention on the sound to which we are listening. It is desirable to have the room quiet, especially in practising imme- diate auscultation, for the ear which is not applied to the chest catches every extraneous sound, unless it is stopped with the finger. The ear or the stethoscope should be applied firmly, but not with great force, to the surface, and in such manner that no air can pass beneath it. Compare corresponding portions of the two sides during both natural and deep respirations. If one side is examined during ordinary or for- cible respiration, the other must be examined under the same condi- tions. The pulmonary sounds are not exactly alike in any two individuals, nor are they the same in different regions of the chest in the same in- dividual; therefore it is necessary to study healthy cases carefully, in order to become familiar with all varieties of healthy sounds. This familiarity must be so perfect that no effort of the mind is required to remember the variations in different localities. This cannot be urged too forcibly, because until we can easily recognize the healthy sounds it is absolutely useless for us to attempt to detect the signs of disease. When the blood leaves the right side of the heart, surcharged with carbonic acid and other debris of tissue metamorphosis, it makes a pecul- iar impression upon the respiratory nerves, which is transmitted to the brain as a call for more oxygen. Instantly a message is flashed back over the nerves, to the inspiratory muscles, causing them to contract. By this action the diaphragm is shortened and its convexity lessened; the ribs are lifted, and by rotation on their articulations with the spinal column, they are at the same time carried forward and outward. Thus AUSCULTATION IN HEALTH. 39 the diameters of the chest are increased in every direction, and air rush- ing in through the open glottis distends the elastic lungs as the chest expands. Immediately the respiratory act ceases, the muscles relax, the elastic tissue of the lung asserts itself, and the air is expelled from the pulmonary vesicles. This latter is a passive movement, in which the expiratory muscles take little part, excepting in forcihle expiration. While inspiration is taking place, we hear a soft, breezy, or rustling sound, known as the inspiratory murmur. As soon as it ceases, a sound soft and breezy, but less intense and much shorter, occurs, which is the expiratory murmur. This is followed by a period of rest, which com- pletes the cycle of respiration. AUSCULTATION IX HEALTH. A variety of signs may be obtained in the normal chest owing to the position of surrounding organs, and the difference in the force and vol- ume of the air current producing the sounds. Auscultatory sounds are possessed of elements similar to those of the percussion sounds, viz., intensity, pitch, quality, duration, and in addi- tion, rhythm. The latter refers to the relation between the different portions of the respiratory act. The intensity of the sound varies in different people. The pitch and the quality are practically the same in all healthy cases. The duration of the sound also varies in different cases, but is about equal to the duration of the respiratory act which produces it. All modifications of the respiratory murmur which may be obtained in (lif- erent regions of the chest are simply alterations in one or more of these elements. Thus in the different parts of the respiratory tract we ob- tain the normal vesicular murmur, bronchial respiration, and tracheal and laryngeal respiration, each of which differs from the others more or less in intensity, pitch, quality, duration, and rhythm. The clearest vesicular murmur is obtained in the infra-clavicular and infra-scapular 'regions. Laryngeal respiration and tracheal respiration are obtained over the larynx and the trachea, and are essentially the same. Bronchial respiration, or more properly broncho-vesicular respiration, may be heard over the bronchial tubes, and for an inch or more about them in every direction upon either the anterior or the posterior surface of the chest. The vesiculae mtjemue, which is the sound obtained over the pulmonary parenchyma, is taken as the standard of comparison for all others. This sound may be best studied in the infra-scapular region, though it is more intense in front, below the clavicle: but in the latter position the heart sounds interfere with its easy recognition. The vesic- ular murmur, like all other respiratory sounds, is possessed of two parts. The first of these, the inspiratory, begins as a soft and distant blowing sound, and gradually increases in intensity and approaches more nearly to the ear toward the end of the act, when it is breezy or rustling in 40 PHYSICAL DIAGNOSIS. character. It varies in intensity in different individuals, but is gener- ally easily heard. Its pitch is low; in duration it corresponds with the inspiratory act. Its quality, called vesicular, cannot be accurately de- scribed, though it may be easily learned by practice upon a healthy chest. This sound is followed immediately by a gentle rustling sound, the ex- piratory murmur, which passes off gradually into a low breath or puff. It is less intense than tbe preceding, being usually so feeble that one must listen for it very attentively ; it is of the same low pitch, and about one-fourth the duration of the inspiratory sound. Though termed vesic- ular, its quality is neither strictly vesicular nor bronchial, but slightly blowing. The normal vesicular murmur is modified in different regions of the chest, by the size of the bronchial tubes, and more or less by the thick- ness of the chest walls and by the position of other organs. It is heard in perfection in the left infra- clavicular region. On the right side the sound is more intense, and the expiratory sound generally slightly pro- longed ; this disparity being due evidently to the direction and size of the right bronchus as compared with the left. There may be a very slight interval between the inspiratory and expiratory murmurs, and the qual- ity of both is usually slightly tubular. Over the upper portion of the sternum and the inner third of the infra-clavicular regions, the proximity of the trachea and of the large bronchial tubes renders the normal murmur somewhat tubular or bron- cho-vesicular in quality. In the inter-scapular space, owing to the thickness of the chest walls, the vesicular sounds are less distinct; owing to the presence of the main bronchi, they are more tubular in character, so that in this position also we find a sound which might properly be termed the broncho-vesicular murmur, but which is usually called normal bronchial breathing. In the scapular regions, the thickness of the chest wall renders the vesicular sound indistinct. In children, the vesicular murmur is much more intense than in adults. Over the upper portion of the chest it is usually much more intense in women than in men. In the aged, it frequently loses some- thing of its soft quality, and becomes slightly more tubular, and is altered in its rhythm, the expiratory sound being occasionally preceded by a short period of silence, and having a duration nearly or quite equal to the inspiratory murmur. This change seems due to partial atrophy of lung tissue and to changes in the elasticity of the chest walls. In extreme anaemia, the vesicular murmur is intensified over the en- tire chest. In listening to the respiration of muscular subjects, a continuous, low- pitched, superficial, rumbling murmur is heard where the muscles are thickest, which is due to the contraction of muscular fibres. In rare cases this is so marked as closely to resemble the vesicular murmur. AUSCULTATION IN DISEASE. 41 Laryngeal asd Tracheal Kespiration. — The respiratory murmur over the larynx and the trachea differs from vesicular respiration in its intensity, pitch, quality, duration, and rhythm. The inspiratory sound is much more intense than in the vesicular murmur, its pitch is higher, its quality tubular, and there is a marked interval between it and the expiratory sound. The expiratory sound is generally more intense than the inspiratory, and even higher in pitch. It has the same tubular quality and about the same duration. To sum up these points of distinction, laryngeal and tracheal respiration differs from the vesicular in being more intense, higher pitched, and tubular in quality- in having an interval between the two portions of the act, and the expiratory sound is as long as the inspiratory, or even of greater duration. Bronchial respiration, or, perhaps more properly, broncho- vesicular respiration, is next in importance to the vesicular. It may always be found in the healthy chest, but is only heard in a limited area, immediately over and surrounding the large bronchial tubes. The latter term seems more appropriate, as this combines both the bronchial and the vesicular varieties. True bronchial breathing is the same as tracheal, excepting that it is usually less intense* It is the sound ob- tained in pulmonary diseases where the air vesicles are completely filled by inflammatory lymph or other products. Broncho-vesicular respira- tion holds a place midway between bronchial and vesicular, and is the sound obtained when only a portion of the air vesicles are occluded. The sound heard over the main bronchial tubes in the healthy chest is more intense than the vesicular murmur, and its pitch is higher; its quality is a combination of the vesicular and tubular, and a slight inter- val may be noticed between inspiration and expiration. The expiratory sound is of nearly equal duration with the inspiratory. "We shall at once perceive the necessity of being able to recognize these normal sounds and of knowing the localities in which they occur; for some of these, when heard in abnormal positions, are the signs of grave diseases. auscultation in disease. The auscultatory sounds are altered by disease, principally iu their intensity, rhythm, and quality. The intensity may be increased, giving rise to exaggerated, compen- satory, or supplementary respiration. It may be diminished, and is then called feeble respiration; or the sounds may be entirely suppressed. The rhythm of the murmur may be interrupted. It is then termed jerking, wavy, or cog-wheel respiration ; and the interval between the two portions of the act may be lengthened, or the expiratory sound may be prolonged. The quality of the sound may be rude, termed broncho-vesicular, or bronchial, cavernous, or amphoric. 42 PHYSICAL DIAGNOSIS. Exaggerated respiration differs from the normal murmur in in- tensity and duration, both the inspiratory and the expiratory sounds being intensified and somewhat prolonged. It is produced in lung tissue which is performing more than its ordinary function. When obtained over the chest of an adult it closely resembles the natural sound in a child, and hence has been termed puerile respiration. It is also termed supplementary or compensatory respiration. Like exaggerated percus- sion resonance, it may be said to indicate the highest degree of health in the organs where it is produced; but it also points to disease of some other portion of the respiratory tract, and is therefore a valuable nega- tive sign. It results from any condition which, by interfering with the entrance of air into one portion of the respiratory organs, may cause more activity in the remainder. Thus, partial consolidation, collapse, or compression of the lung gives exaggerated respiration well marked in the sound portion of the affected organ, and more or less also on the sound side. So also obstruction of a bronchial tube by secretion or diminution in its calibre, by compression from tumors or thickening or contraction of its wall, may give rise to this sign in the portions of the lung not thus obstructed. (Edema of the lungs may also cause exaggerated respiration over their apices ; and in hemiplegia, more or less paralysis of the respiratory mus- cles on one side causes exaggerated respiration on the other. Feeble respiration differs from the normal vesicular murmur in being less intense and shorter in duration. The inspiratory part of the sound is most affected. The sign may be occasioned by anything which interferes with the perfect transmission of sounds to the surface, as thick chest walls whether due to muscular or to adipose tissue; it is also caused by small quantities of air, fluid, or inflammatory lymph in the pleural sac. It may result from loss of elasticity of the lung tissue in consequence of dilatation of the air vesicles, as in pulmonary emphysema, or from tubercular or inflammatory consolidation of the lung; also from defi- cient action of the respiratory muscles, occurring in paralysis; or it may exist in diseases of the abdominal or thoracic organs which give rise to pain and cause the patient to restrain muscular movement. Collections of fluid or gas in the pleural cavit}', tumors in the chest or abdomen or a pregnant uterus may interfere with the function of the lung, and prevent the descent of the diaphragm by mechanical pres- sure, thus causing feeble respiration. Obstructions of the larynx, trachea, or bronchi also cause feeble respi- ration resulting from collection of fluids, the presence of foreign bodies, thickening of the walls by inflammation, diphtheritic or croupous de- posits, oedema, and neoplasms; from contraction of the walls, as in asthma, spasm of the glottis, or paralysis of its dilators; or through com- pression from without by inflammatory growths, tumors, and the like. AUSCULTATION IN DISEASE. 43 When this diminished murmur is found in the upper part of one lung, it often indicates phthisis; if found in the lower part of the lung, it is very often an indication of pneumonia; found over the lower por- tion of both lungs, it is suggestive of oedema. Suppressed respiration is due to the same causes which, occurring in a less degree, give rise to feeble respiration. It is often observed over the diseased portion of a lung, the remainder of which yields the exaggerated respiratory murmur. IN INTERRUPTED RESPIRATION, also known as COG-WHEEL RESPIRA- TION, either inspiration, expiration, or both may be broken into two or more parts, the sound being suddenly interrupted, to return again, and perhaps again and again, before a single respiration is complete. The interruption takes place most frequently with inspiration. The sign is found under a variety of circumstances, not only in disease, but also in health, so that it is not of much importance, though sometimes helpful in confirming a diagnosis based on other evidence. It is sometimes present over the whole chest, at other times confined to a limited space. When occurring in health, it is often heard over the whole chest; but when resulting from pulmonary disease, it is more apt to be localized. In the incipiency of phthisis this sign is frequently obtained directly over the diseased lung, especially when the lesions are in the left apex. It may be produced by any disease which renders respiration painful, as intercostal neuralgia, pleurisy, and pleurodynia. It also occurs in nervous persons when agitated by the examination, and is very apt to be found in hysterical patients. When due to nervousness or pain, the sign will be found over the whole of one or both lungs. As an indication of disease, interrupted respiration is a sign of very little value, excepting in the early stage of phthisis. In incipient phthisis the immediate cause of this sign seems to be forcible contraction of the heart, whereby an abnormal amount of blood is forced into the pulmonary circuit, thereby causing some narrowing of the calibre of the bronchial tubes. A prolonged interval between inspiration and expiration may be caused by shortening of the inspiratory murmur, or by a delay in the com- mencement of the expiratory murmur. Shortened Inspiration. — The inspiratory sound in this condition ceases before the act is complete and is consequently shortened, in partial consolidation of the lung due to inflammatory or tubercular deposits. It is deferred in its commencement after the inspiratory act begins, and thus is shortened where the air vesicles are dilated. Deferred Expiration. — The expiratory sound is delayed when the air vesicles are distended, as in pulmonary emphysema. 44 PHYSICAL DIAGNOSIS. Prolonged expiration results from a loss of elasticity of the lungs, either by consolidation or by distention. When due to consolidation, a prolonged expiratory murmur is usually more intense than normal. It is high pitched and more or less tubular in quality, and usually possesses so much of the bronchial element as to be termed broncho-vesicular. The prolonged expiratory murmur which is sometimes found in healthy chests possesses the same pitch and quality as the normal vesicular sound, which enables us to distinguish it from the prolonged expiration of consolidation, in which the pitch is always high and the quality somewhat tubular. We must not forget that in health the vesicular murmur over the right apex is sometimes more or less tubular and high in pitch, and that the expiratory sound is pro- longed, as compared with the left side. Therefore, in this position the sign can- not always be considered as indicative of disease, unless it be taken in connection with other signs. When obtained on the left side, prolonged expiration is nearly always due to phthisis or to emphysema. The difference in the two is that in consumption the expiratory sound is high pitched and more or less tubular in quality; while in emphysema it is usually even more pro- longed — it may be two or three times as long as the inspiratory murmur — and it has a low pitch, it is not tubular but rather vesicular in quality, and is apt to be considerably less intense than the inspiratory sound. Occasionally prolonged expiration may be caused by interference with the free exit of air from the lungs, as by obstruction in the larynx or bronchial tubes. In these cases it is usually associated with a deferred inspiratory murmur, in which the sound does not begin with the inspiratory act. Exceptional. — Prolonged expiration having the pitch and quality of the healthy murmur is obtained with cavernous respiration in rare cases. In such instances its significance is ascertained by the character of the inspiratory sound and by other signs. Rude respiration (broncho-vesicular or harsh respiration) closely resembles the sound which can be obtained directly over the bronchial tubes in a healthy chest. The respiratory sound is raised in pitch in proportion as the tubular supplants its vesicular quality. The expiratory sound is always higher in pitch than the inspiratory, its quality is more or less tubular, and it is prolonged. The alteration in pitch and duration is in proportion to the preponderance of the tubular over the vesicular quality. Disease may furnish all degrees of broncho-vesicular respiration from the normal vesicular murmur to perfect bronchial breathing, according to the amount of consolidation. This sign is due to the better transmission of the vibrations from the larynx, trachea, and bronchial tubes to the surface of the chest, in con- sequence of the consolidation of the air vesicles, making the parenchyma a better conductor of sound-waves and rendering the bronchial tubes AUSCULTATION IN DISEASE. 45 more rigid, so that they transmit these waves from the upper air passages with less resistance. The sign is obtained in incipient phthisis over the upper part of the lung, and in pneumonia, usually over the lower lobe. It is also heard in some cases of pulmonary apoplexy, and over a lung partially collapsed from any cause or which has been compressed for a considerable time by fluid or air in the pleural sac. It is most valuable as a sign of incip- ient phthisis. Exceptional. — Occasionally in cases where broncho-vesicular respiration oc- curs, either the inspiratory or expiratory murmur may be absent ; then, as in similar instances of bronchial respiration, its detection will depend on the pitch and quality of the sounds which are present, and upon concomitant signs. Beoxchial eespieatiox is one of the most important varieties of the healthy sounds, which may sometimes be indicative of disease. Its quality and its other elements excepting its intensity are much the same as those of normal tracheal respiration. The intensity of this sound is usually greater by far than that of the vesicular murmur, but sometimes very feeble; the pitch is high, the quality tubular, and the duration of both inspiration and expiration is prolonged, the two being of about equal length. There is an appreciable interval between the inspiratory and expiratory sounds. Exceptional. — In bronchial respiration, either portion of the respiratory murmur may sometimes be absent. Laennec taught that the bronchial sound was always produced in a healthy chest, but that it was not usually heard because of the interven- tion of air vesicles between the tubes and the chest walls. When ob- tained in disease, he considered the sign due simjjly to the better trans- mission of the sounds to the surface. Skoda believed that consolidation of the air vesicles surrounding the bronchus was necessary for the pro- duction of the perfect sign. Whichever of these views is correct, or whether both are in part true, matters little to us, so long as we know that the sign always indicates consolidation of lung tissue (Fig. 27). The tubular sounds in this variety of the respiratory murmur 'are transmitted for a considerable distance beyond the consolidated lung, which accounts for the fact that the bronchial and the vesicular elements are frequently combined in the regions immediately surrounding that which yields simply bronchial respiration. The greater intensity of the expiratory sound in bronchial respiration ac- counts for the fact that occasionally we obtain a vesicular inspiratory and a bronchial expiratory sound, as the intensity of the bronchial sound drowns the vesicular in expiration. Bronchial respiration is found in greatest perfection, in pneumonia, over the consolidated lung. It is obtained also in some cases of phthisis, but in this affection we are more apt to hear broncho-vesicular respiration. 46 PHYSICAL DIAGNOSIS. Exceptional. — In rare cases cancer of the lung yields bronchial breathing. Pulmonary apoplexj' sometimes causes the sign ; it is heard over the entire chest, though more distant than in consolidation, in a few cases of pleurisy with extensive effusion. Cavernous respiration has been likened to both bronchial and vesicular. We are told by one author that it closely resembles the former, and by another that great care is necessary to distinguish it from the latter. This discrepancy is probably due to confusion in the application of the term to different signs. Flint made the distinction clear by in- troducing the term broncho-cavernous to designate those hollow, high- pitched sounds which, although conveying the idea of a cavity, do not correspond with true cavernous respiration. The intensity of cavernous respiration is usually feeble, so that, unless searched for carefully, it will be overlooked. The pitch is low, and the quality, instead of being vesic- ular or tubular, is soft and blowing or puffing. The expiratory portion of the sound is prolonged to about the same length as the inspiratory, and is even lower in pitch than the latter. The failure of some diagnos- ticians to appreciate the quality of this sound has caused them to deny its existence. I have occasionally heard the true cavernous murmur as just described, but I think it a very rare sign. It is produced in empty pulmonary cavities, the walls of which are so flaccid that they expand readily in inspiration and collapse in expiration (Fig. 16). It is a sign, therefore, of any of those diseases which might cause such a cavity, viz. y consumption, pulmonary abscess, or gangrene of the lung. Broncho-cavernous respiration is made up of both the bronchial and the cavernous sounds. It is usually described as cavernous, but it is higher in pitch and more tubular in quality than the latter. Its quality is not sufficiently tubular to be called bronchial, nor yet sufficiently soft and puffing to be termed cavernous. It is produced in pulmonary cav- ities, surrounded by lung tissue more or less consolidated; the tubular element being dependent upon the amount of consolidation. Sometimes the first part of the inspiratory murmur may be tubular in quality and the last part cavernous; again, we may obtain cavernous inspiration with bronchial expiration, due to the presence of consolidated lung tissue near the cavity. In the latter case the intense expiratory bronchial murmur probably drowns the cavernous sound which was heard with the feebler inspiratory murmur. Broncho-cavernous respiration is the characteristic sign of the later stages of consumption, but it may also be produced in the cavities due to abscess or to gangrene. Amphoric respiration resembles the sound produced by blowing into the mouth of an empty bottle, hence the name. It is of a metallic musical quality, and may be heard during either inspiration or expira- tion, or during both portions of the respiratory act, but is generally most marked in expiration. The expiratory sound is lower in pitch than that AUSCULTATION IN DISEASE. 47 in bronchial respiration. In this connection it is well to emphasize the necessity of studying the pitch of the respiratory sounds, for in some instances there is absolutely no other means of distinguishing between the sounds transmitted from the bronchial tubes in consolidated lungs and those heard over pulmonary cavities. The distinction in these cases is clear if we remember that the expiratory sound in the former instance is always high in pitch, in the latter always low. Amphoric respiration occurs under the same conditions as amphoric resonance, and is frequently found in connection with cracked-pot reso- nance. It is due to the passage of air in and out through an opening Gurgles Gvmi WITHOUT So Fig. 16.— Phthisis. from a bronchus into a large pulmonary cavity or into the pleural sac (Fig. 26). Tbe sign is obtained most perfectly in pneumothorax or in pneumo-hydrothorax. In the latter it disappears and returns again, as the quantity of fluid rises so as to cover the oj)ening or falls below it. This sign is also heard in phthisis when the pulmonary cavity is large- and its walls are firm, so that they will not collapse in expiration. Cavities may exist within the lungs without yielding either of the varieties of respiration which may be caused by a vomica; for example, if a cavity be filled with fluid, or if the fluid in the cavity rise above the orifice of the bronchial tube, none of these sounds will be heard (Fig. 16); but if the patient's position be chauged or the amount of fluid de- creased by coughing, the signs return. CHAPTEE IV. METHODS OF EXAMINATION— Continued. ADVENTITIOUS SOUNDS. The auscultatory sounds -which we have thus far been studying are 6uch as may be obtained, in more or less perfection, over the healthy chest. Certain accidental or adventitious sounds occur only in disease. These may accompany normal sounds or take their place, and will vary according to their origin. Those produced -within the lungs are called rales or ronchi; those upon the pleural surfaces are termed friction sounds. Eale>. — Bales are as numerous and as different in variety as the shades of color, but they may be grouped into a few distinct classes, •which are generally capable of some peculiar interpretation. All of them are either dry or moist; hence we may group the different sounds under one of these heads, according to peculiarities in their pitch and quality, as shown below: Rales, or rhonchi, Dry. Moist. j Sonorous rales. ( Sibilant rales. Mucous rales (large and small). Subcrepitant rales. Crepitant rales. Gurgles (large and small). Mucous click. Rales may originate in the larynx, trachea, bronchial tubes, air vesi- cles, or in any cavity connected with the bronchial tubes. They are pro- duced by various conditions which interfere with the passage of air through the tubes and into the air vesicles, and may be heard in inspi- ration or expiration, or during both portions of the respiratory act. Dry rales are distinguished as sonorous or sibilant according to their pitch, which depends on the size of the bronchial tube in which they are produced. Sonorous rales are usually musical, or snoring in quality, resembling the sound produced by blowing through a tube; they are sometimes cooing, sighing, or moaning in character. Their intensity varies from a sound which can be scarcely recognized to one which may be heard at ADVENTITIOUS SOUNDS. 49 a distance from the chest, and their pitch is always low. They may be heard during both inspiration and expiration, but are most frequent in expiration. They are produced in bronchial tubes exceeding one-eighth of an inch in diameter. They are caused by the vibrations of viscid mucus or by a fold of mucous membrane, or by anything which con- stricts the calibre of the tube, as pressure upon its external surface by tumors, bands of cicatricial tissue resulting from former diseases, or contraction of the circular muscular fibres causing a uniform narrowing of the tube (Fig. 1?). These sounds are not removed by coughing, un- less caused by tenacious mucus adhering to the side of the bronchial tube. Though in the great majority of instances after coughing or after deep inspiration an individual rale may disappear, other rales will remain in some portion of the chest. This sign is obtained in greatest Subcrepitant rales Mucous rales. 7 Sonorous rales K Sibilant rales. Crepitant rales. Fig. 17.— Bronchial Rales, Dry and Moist, and Subcrepitant Rales. perfection in the early stages of acute bronchitis and in asthma. It is also heard in some cases of chronic bronchitis, occasionally in phthisis, and rarely in jmeumonia, being in these latter instances associated with other adventitious sounds. When obtained in phthisis, the dry rales are few in number and are associated with moist rales. In the early stage of asthma, sonorous rales may be heard in great numbers over the entire chest. Sibilant rales occur both in inspiration and in expiration, but are heard mostly in inspiration. They are not so intense as the sonorous sounds. Their pitch is high, and in quality they vary almost as much as sonorous rales, being sometimes whistling, sometimes hissing, and sometimes almost creaking. They are caused in the smaller bronchial tubes by the same conditions which give rise to rales in the larger bron- chi (Fig. 17). They are heard most frequently and abundantly in asthma and in 4 50 PHYSICAL DIAGNOSIS. capillary bronchitis. In ordinary acute bronchitis they may be heard, though in limited numbers. Sibilant rales are heard occasionally in phthisis, due then to localized bron- chitis or to tubercular deposits. They are sometimes, though not often, heard in pneumonia. Occasionally, even in healthy or apparently healthy chests, we may hear two or three of these fine sounds near tbe borders of the lungs. Sibilant rales may be altered, but they are seldom removed*by cough- ing or by forced inspiration. Moist rales are grouped as mucous, large and small, subcrepitant and crepitant, according to their characteristics. Mucous rales, also produced in the bronchial tubes, are large or small according to the size of the tubes, and are caused by air bubbling through fluid — mucus, pus, serum, or blood (Fig. 17). If the bubbling happen to be in a large bronchus, we get a large, coarse, mucous rale; if in a smaller bronchus, the rale is much finer. These rales are heard during both inspiration and expiration, and vary greatly in intensity. Sometimes, like sonorous rales, they may be heard at a distance from the chest ; they are at other times hardly audi- ble. Their pitch depends upon the condition of the surrounding lung tissue. In simple inflammation of the mucous membrane, the rales are low pitched; but when consolidation surrounds the bronchial tubes, as in pneumonia and in phthisis, the pitch is high. These sounds are ob- tained in greatest perfection in chronic brunch if is, but may be heard in acute bronchitis after the dry stage has passed. They are present in greater or less degree in nearly all cases of consumption, in the third stage of pneumonia, and in pulmonary oedema, and are numerous when hemorrhage has taken place into the bronchial tubes until coagulation occurs. In phthisis they are found over a limited space, due some- times to associated bronchitis, at other times to the escape of fluid from a cavity into the bronchial tubes. These, unlike dry rales, are usually much affected by deep inspiration and coughing, by which they may be considerably altered or entirely removed. Subcrepitant rales are moist sounds, which are produced in the very fine bronchial tubes, probably in the ultimate bronchi and those a size larger (Fig. IT). They are caused by air bubbling through fluid, and may be heard during either or both portions of the respiratory act, but are most frequently heard with inspiration. They are of comparatively feeble intensity, vary in pitch according to the condition of the surround- ing tissue, and are distinctly moist and crepitating or crackling in quality. These rales may be heard most perfectly in capillary bronchitis and the third stage of pneumonia. They are often found in asthma shortly after the paroxysm. They are present in congestion of the lung, puru- lent bronchitis, and pulmonary oedema, and are found over a limited por- ADVENTITIOUS SOUNDS. 51 tion of the lung in many cases of phthisis. They occur in brown indu- ration of the lungs, and are heard after hemorrhage into the smaller bronchial tubes, limited to the position of the hemorrhage. The subcrepitant rale, due to circumscribed capillary bronchitis, is a sign of great value in the early diagnosis of phthisis, in which it may often be found at the apex of the lung before any other signs can be detected. The crepitant rale is largely like the subcrepitant, but differs from the latter in two respects : it is not so moist or liquid in character, so that it is sometimes classed as a dry rale; and it is never obtained in expiration. Crepitant rales are very well imitated by rubbing together a lock of hair close to the ear. They were compared by Laennec to the sound produced by throwing salt upon a fire. These rales are produced in the vesicles, intercellular spaces, and ultimate bronchi (Fig. 17). There are two hypotheses as to their mode of production: one is that they are caused by air bubbling through fluid within the air vesicle, just as mucous rales are produced in the bronchial tubes; the other, that they are due to the separation of the agglutinated surfaces of the capillary tubes or of the air vesicles. Which of these is true, or whether both are in part correct, has not been decided. To me they seem to be produced by separation of the sticky surfaces of the air vesicles, and the capillary bronchi. In some cases of pneumonia, for instance when associated with inflammatory rheumatism, no crepitant rale can be obtained which may be accounted for by slight viscidity of the inflammatory lymph; for if the sounds were produced by air bubbling through fluid, they would occur regardless of the nature of that fluid. Crepitant rales are much more numerous than the subcrepitant. In listen- ing to subcrepitant rales, we seldom seem to hear more than ten or fifteen at once ; whereas with the crepitant rale we seem to hear a hundred or more with each inspiration. Crepitant rales are obtained in perfection in the early stage of pneu- monia, of which they are considered diagnostic. This stage lasts but a few hours; consequently in many cases of inflammation of the lung the rales have disappeared before we see the patient. A few crepitant rales are sometimes heard in congestion of the lung and in pulmonary oedema, and they are frequently found in phthisis, in a small zone around the consolidation. In this latter case they seem to result from gradual extension of the pneumonitis, which often pre- cedes tubercular deposit. Crepitant rales, subcrepitant rales, and friction sounds are sometimes so much alike that it is difficult to distinguish between them. If dry crepitating sounds are numerous and heard only on inspiration, they are crepitant rales; but if dry crepitating sounds are few in number and 52 PHYSICAL DIAGNOSIS. are heard in expiration or iu both inspiration and expiration, they are likely to be friction sounds. Subcrepitant rales are more moist and not nearly so numerous as crepitant rales, and they are usually heard in both inspiration and expiration. The moist character, the number, and the time of occurrence of subcrepitant rales will enable us to distinguish them from the crepitant; and their deeper seat and their constancy will usu- ally enable us to distinguish them from fine friction sounds — which are still fewer in number — even when the latter are moist in character. Crepitant rales are not much affected by cough or forced respiration when due to pneumonia, but in other instances two or three full inspi- rations will frequently dispel them. Exceptional. — Either crepitant or subcrepitant rales may be sometimes brought out directly after coughing where they were absent a moment pre- viously. A sound closely i*esembling the subcrepitant or the crepitant rale may frequently be obtained over the thin border of the healthy lung ; in these in- stances, only a few of the rales are heard, and they disappear after three or four forced inspirations. Gurgles resemble large mucous rales, but are generally higher in pitch and possess a hollow metallic quality; though occurring during both portions of the respiratory act, they are most frequent in inspira- tion. They are produced by air bubbling through fluid in cavities which communicate with the bronchial tubes (Fig. 16). If cavities are com- pletely filled with fluid or entirely empty, or if the level of the fluid does not reach above the opening of the bronchial tube, no gurgles will be produced. These sounds are large or small, according to the size of the cavity in which they are produced. This sign is usually indicative of phthisis, but may occur in any pul- monary disease which causes excavations. The mucous click resembles an isolated subcrepitant rale, and is heard during inspiration only. The sign generally consists of a single click, or, at most, of two or three clicks. It is a sharp crackling or clicking sound, supposed to be produced in the smaller bronchial tubes by sudden separation of their agglutinated surfaces during inspiration; it is not usually affected by cough. When heard over the apex of one lung, it is a sign of considerable value in the early diagnosis of phthisis. Such sounds are sometimes heard over a considerable portion of the lung in acute tuberculosis, in extensive chronic pneumonia, or in the later stages of interstitial or catarrhal pneumonia. Friction Sounds. — Friction sounds are produced by rubbing to- gether of the two pleural surfaces, which are either dry from diminu- tion of their natural secretions or roughened by exudation of inflamma- tory lymph (Fig. 18). These sounds are grazing, rubbing, grating, rasp- ing, or creaking in character; sometimes dry, sometimes moist. They may be simulated by rubbing the back of the hand, while listening with the stethoscope on its palm, or by rubbing the fingers on the integument ADVENTITIOUS SOUNDS. 53 when auscultating the chest. They are usually few in number and transitory, being heard for a few respirations, and then disappearing to return again in a few minutes; they may be heard just at the end of inspiration or at the beginning of expiration. This is the characteristic sign of pleurisy. The grazing friction sound is only heard in the be- ginning of the inflammation, and can be detected most frequently in the circumscribed pleurisy accompanying phthisis. Some one of the other varieties, of which the quality is of no importance, may be heard in the first and third stages of pleurisy. Care must always be taken not to mis- take for this sign the sounds produced by crackling of the hairs beneath the instrument, or by the rubbing of the stethoscope, the fingers, or the Friction.— — Deficient respiratory | murmur and dulness. ) Flatness ; loss of ) respiratory sounds, j" Fig. 18.— Acute Pleurisy. The upper part of the lung is in a normal condition, or the air cells are slightly distended. The lower part of the lung is partially collapsed. The upper surface of the fluid is not horizontal, but it conforms more or less perfectly to the natural outline of the lung. clothing on the surface, or of the clothing or fingers on the instrument. Sounds closely resembling the friction murmur are often heard over the false ribs in a healthy chest. They seem to be produced by slight movements of the skin beneath the rim of the stethoscope. Creaking or crumpling sounds are sometimes obtained over the chest, the signification of which is not fully understood. The creaking sounds are most frequently heard at the lower part of the thorax, and are sup- posed to be due to old pleuritic adhesions. Both creaking or crackling and crumpling sounds are sometimes obtained over the upper portion of the chest. The crumpling sounds which are heard in inspiration re- semble those which may be produced by inflating a dried bladder, and are supposed to be produced from similar causes; that is, the inflation 54 PHYSICAL DIAGNOSIS. of dry emphysematous air cells. Thompson considers these sounds in- dicative of syphilitic disease of the lungs. "When confined to the apex, they are nearly always associated with phthisis. Metallic tinkling is a clear, silvery, tinkling sound, like that pro- duced by dropping a pin into a glass. It seems to be caused by the falling of a drop of fluid from the upper part of a large cavity on the surface of fluid below. It can sometimes be heard over one entire side, but it is usually most distinct on a level with the nipple. "When the proper conditions are present within the chest — that is, a large cavity containing air and fluid — it may be produced by any agitation, such, for example, as speaking, coughing, deep inspiration, or occasionally by the act of swallowing. The sign occurs most frequently in the pleural cav- itv in pneumo-hydrothorax; but in exceptional instances it is produced in very large pulmonary cavities. A sound very similar to this may sometimes be heard over the stomach when distended with gas. VOCAL SOUNDS. Considerable information regarding the condition of the lungs can be obtained by studying the sounds of the voice as transmitted through the chest walls. If we listen over the healthy chest while the person is sjieaking, an indistinct, distant, and muffled sound will be heard, termed normal vocal resonance. It is due to the fact that sounds produced in the larynx are transmitted not only outward through the mouth, but also downward through every branch of the bronchial tree. Vocal resonance, like most of the other pulmonary sounds, varies greatly in different healthy indi- viduals and fti different portions of the same chest. If a person has a low-pitched intense voice, the vocal resonance will be more forcible than in those who have high-pitched or feeble voices. In studying the voice-sounds by immediate auscultation, it is desira- ble to close the ear which is not applied to the chest, in order to exclude sounds coming from the mouth, and it is better to have the patient count one, two, three, than to ask him questions and listen for the an- swers. By the latter course the examiner's attention is distracted from the sounds within the chest in the attempt to catch the patient's reply. The varieties of vocal resonance which may be heard over different re- gions of the normal chest are named from the parts in which they are produced; over the larynx and trachea we have laryngeal and tracheal resonance; over the bronchial tubes, bronchial resonance; and over air vesicles, the normal vesicular or, as it is usually termed, normal vocal resonance. Laryngophony is the vocal resonance obtained over the larynx, and tracheophony that obtained over the trachea. In these varieties the words are imperfectly articulated, but the voice is transmitted to the ear " with a force and intensity almost painful." The sounds are con- VOCAL SOUNDS. 55 centrated or, in other words, seem to be produced within a small area immediately beneath the stethoscope, and necessarily vary in pitch with the pitch of the individual's voice. Normal bronchophony is obtained while the person is speaking, by listening over the bronchial tubes, near the border of the sternum from the first to the third rib, or more especially directly over the main bronchi on a level with the second costal cartilages in front, or on a level with the fourth dorsal vertebra in the inter-scapular region. This occupies a position midway between normal vocal resonance and laryn- gophony. The sounds thus obtained are transmitted to the ear with considerable intensity, though with much less force than over the larynx; they appear to be produced immediately beneath the stethoscope, but the words seem very imperfectly articulated. Whenever this sign is ob- tained over any other portion of the chest, it indicates consolidation of the pulmonary parenchyma. Normal vocal resonance is obtained by listening to the voice over the vesicular portions of the lung. This sound, having no approach to articulation, is distant and diffused, seeming to come from the deeper portions of the lung two or three inches beneath the surface. As a rule, vocal resonance is always more intense upon the right side than upon the left, especially in the infra-clavicular regions. Exceptional. — In a few instances over the right apex, even in health, the resonance very nearly approaches bronchophony. If the sounds have this character upon both sides, as they have in rare instances, they will be found most intense upon the right side, but higher in pitch on the left — a disparity due to the difference in calibre of the bronchial tubes ; those upon the right side being" the larger must necessarily give the more intense and lower-pitched sound. The normal vocal resonance is generally obtained over the entire chest in men, but only over the upper part in women and children, in whom it is a sign of little value. This sign is modified by disease, principally in its intensity, which *riay be either diminished or increased. Diminished. ■{ Vocal sounds feeble or suppressed. CO J a r Vocal sounds exaggerated. Resonance which is termed bronchophony. Increased. < " ■ " " asgophony. " " " pectoriloquy. [ " " " amphoric voice. Diminished Kesonance. — Diminished resonance is usually due to much the same causes as the diminished respiratory murmur;, that is,, separation of the pulmonary from the costal pleura by air or fluid, as in pneumothorax or pleurisy. It also occurs in cases of extreme emphysema, in pulmonary oedema, in bronchitis with free secretion, and occasionally where there is extreme pulmonary consolidation. 56 PHYSICAL DIAGNOSIS. The vocal sounds are mostly suppressed over fluid in the pleural sac; but just above the level of the fluid the air cells are partially collapsed, so that vocal resonance is increased. For an inch or an inch and a half below the level of the fluid the resonance is diminished in intensity, and a little lower it is nearly suppressed. Thus we are able to ascertain the height of the fluid by means of the vocal resonance as well as by percussion. This sign is principally of value in the diagnosis of pleuritic effusion, by enabling us to distinguish between it and consolidation of the lower part of the lung. Exceptional — In some cases the vocai resonance may be heard distinctly all over the pleuritic effusion, though the sounds are distant and more or less muffled. Increased Vocal Kesonance. — Exaggerated vocal resonance differs from the normal voice-sounds simrdy in its intensity. This sign de- notes more or less consolidation of the lung tissue or collapse of the air vesicles, and is usually associated with broncho-vesicular respiration. It is a sign of considerable importance in the diagnosis of the early stage of phthisis and in discriminating between pneumonia and pleurisy. Exceptional. — In very rare cases the vocal resonance is exaggerated in pneu- mothorax and in emphysema. Bronchophony, as already noted, consists of more or less intense vocal sounds, usually imperfectly articulated, which have a peculiar degree of concentration, or, in other words, seem to be produced immediately be- neath the stethoscope, instead of coming from the deeper portions of the lung. The intensity of this sign, which may be greater or less than that of normal resonance, is an unimportant element; so also is the dis- tinctness of articulation. Its recognition depends chiefly on the charac- teristic concentration. The significance of bronchophony depends upon its location. If heard over the main bronchial tubes, it may be simply a healthy sound; but if heard over vesicular portions of the lungs, it is indicative of consolidation. It is usually associated with a tubular respiratory mur- mur; but as it occurs with a less amount of consolidation than is neces- sary for true bronchial breathing, it may frequently be obtained with broncho-vesicular respiration. Exceptional. — Bronchophony usually possesses the characteristic concentra- tion ; but when the consolidated lung is separated from the chest wall by fluid, ft may sound distant. This sign is of special value in the diagnosis of the second stage of pneumonia (Fig. 27). It is seldom obtained perfectly in phthisis, because in this disease consolidation is not usually complete. Exceptional. — Bronchophony is occasionally obtained in carcinoma of the lung, though usually tins disease involves the whole tissue, air vesicles and bron- VOCAL SOUJJ-DS. 57 chial tubes alike, or it crowds the pulmonary tissue before it, thus hindering the transmission of the voice. But when the air vesicles alone are filled and the bronchial tubes remain patent, as occurs in rare cases, br-onchophony may be ob- tained. It is also present in hemorrhagic infarctions which fill the air vesicles but leave the bronchial tubes open, and may therefore be a sign in pulmonary apoplexy. ^Egophony is a variety of bronchophony. It is a tremulous sound which has been compared to the bleating of a goat; hence the name. Like bronchophony, it conveys to the listening ear the impression of having been produced within a very limited portion of the lung; unlike the latter, it seems to come up from a considerable depth, and to trem- ble about the end of the stethoscope. When present, it may be most readily obtained in the inter-scapular or axillary regions. This sound is generally produced in consolidated lung tissue which is separated from the chest wall by a thin layer of fluid. It is a sign of pleuro-yneu- monia — that is, pneumonia and pleurisy with effusion ; but even in this disease it is present only a short time, and is a sign of little value. zEgophony is most frequently produced when the pleural cavity is about half filled with fluid. In ordinary pleuritic effusions, the lung just above the surface of the fluid is more or less solidified by collapse of a portion of the air vesicles; under such circumstances segophony may be produced providing the pleura-pulmonalis and the pleura-costalis are agglutinated just above the collapsed lung. Pectoriloquy differs from bronchophony in that the articulated speech is more completely transmitted. In bronchophony the voice is heard, but the words are not distinct. In pectoriloquy articulation is nearly perfect. There are two varieties of pectoriloquy : one in which the sounds are concentrated and near the ear like bronchophony, but are heard over a considerable portion of the lung; and another in which the ^ign is confined to a limited space and has not the degree of concen- tration found in bronchophony. The first of these, which is high in pitch and clanging or metallic in quality, is frequently produced by sim- ple consolidation of lung tissue. The second, which is low in pitch and softer in quality, is always a trustworthy sign of a pulmonary cavity with smooth walls and a large opening into a bronchial tube. Well- defined pectoriloquy is not a frequent sign, but when heard the first variety is a sign of phthisis or pneumonia, and the second of any of those diseases which cause vomica?, viz., phthisis, pulmonary abscess or gan- grene, and bronchiectasis. Amphoric voice is hollow and more or less musical in character. The musical quality follows the voice and is termed the amphoric echo. The words are not articulated, as in pectoriloquy. This sign occurs under the same conditions as amphoric respiration and amphoric per- cussion resonance; that is, over the pleural sac when containing air and 58 PHYSICAL DIAGNOSIS. communicating freely with a bronchial tube, and over very large cavities in the lungs. Exceptional. — There are good reasons for believing that, in rare cases, am- phoric voice, as well as amphoric respiration, may be heard over a layer of air in the pleural cavity which does not communicate with the bronchial tubes. Amphoric voice is a sign of pneumo-hydrothorax, in which disease it is associated with tympanitic resonance over the upper part of the chest, and ordinarily with the succussion sound. If the latter signs are absent, the amphoric voice is probably produced in a phthisical cavity. "Whispering Vocal Resonance. — Flint described the whisper reso- nance with considerable minuteness. He considered the signs which it furnishes of equal value Avith those from a loud voice; I find them of even greater importance. The normal bronchial whisper is a term applied to sounds of a blowing or tubular character, very closely resembling the sound of forced respiration, heard in listening over the upper portion of the chest when a person is speaking in a sharp whisper. Its modifications by disease are classified as exaggerated bronchial whisper, whispering bron- chophony, cavernous whisper, whispering pectoriloquy, and amphoric whisper. Exaggerated bronchial whisper is more intense and higher in pitch than the normal sound. It is produced in lungs which are slightly solidified. Whispering bronchophony is higher in pitch and more intense and blowing than the preceding. It has the same characteristic concen- tration and nearness to the ear as bronchophony with the loud voice. It may be obtained over lungs so slightly solidified as to yield only ex- aggerated vocal resonance when the patient is speaking aloud; therefore it can be appreciated sooner than bronchophony with the loud voice. This fact renders whispering bronchophony a most important sign in the early stage of jmthisis. The cavernous whisper is a low-pitched, blowing sound, confined to a limited portion of the chest. It is produced within pulmonary cavities under the same conditions as cavernous respiration. This sign is principally of value in the diagnosis of phthisis. Whispering pectoriloquy differs from whispering bronchophony only in its more perfect articulation. When obtained over a small space only, this is a sign of a cavity. It is most frequently found in phthisis. Amphoric whisper occurs under the same conditions as the am- phoric voice or amphoric resonance on percussion; that is, over the pleural sac filled with air, or over very large cavities in the lung tissue. Aphonic pectoriloquy is a term which has been applied to the voice sounds when the patient is speaking in a low tone. It has been stated that these sounds can be distinctly heard not only over consolidated or collapsed lung, TUSSIVE SIGNS. 59 but also even when the organ in this condition is separated from the thoracic ■wall by a collection of air or serum- ; however, these vibrations are not conducted through %)us. By studying this variety of vocal resonance, it is claimed that we may determine whether pleural effusions are of a serous or of a purulent character. I have been able to verify this statement in a few cases, but not in all. Tussive Sigxs. — The resonance of cough may sometimes be studied with advantage, especially in children. The act of coughing is often of special value in dislodging obstructions in the bronchial tubes or pul- monary cavities, and also in causing a subsequent deep inspiration which will freely inflate the air cells, thus bringing out signs which might otherwise be overlooked. The different varieties of cough are classified as laryngeal, bronchial, cavernous, and amphoric. Laryngeal cough is usually more or less hacking in charac- ter, and often spasmodic. It is indicative of laryngitis. Beoxchial cough is quick, harsh, and brassy. It is accompanied by a thrill or fremitus, and if severe is nearly always attended with pain beneath the sternum or along the inferior ribs, corresponding to the attachment of the diaphragm. It is generally indicative of bronchitis. Caveexous cough is produced under the same circumstances as cavernous respiration, and is generally associated with gurgles. It has a hollow quality and is usually very intense. Amphoric cough is more musical and hollow in quality, is generally lower in pitch, and seems to penetrate the ear with less force than the cavernous. It is heard over very large pulmonary cavities or over the pleura when filled with air. Sometimes large pulmonary cavities are traversed by trabecule which yield a peculiar twang when the patient coughs. This is of special value, as these strings prevent cavernous or amphoric voice-sounds. Tussive signs are usually, though not always, transmitted through consolidated lung, but seldom through collections of fluid. TTe may obtain considerable information about the condition of the lungs in children who cannot be induced to speak by studying the cry, which is subject to the same variations as vocal resonance in adults. CHAPTER V. PULMONARY DISEASES. PLEURISY OR PLEURITIS. Pleurisy consists of an inflammation, more or less extensive, of the serous membrane covering the lungs and lining the thoracic walls. There are three recognized varieties of this disease: the acute, subacute, and chronic or suppurative, also called empyema. Anatomical and Pathological Characteristics. — There is first hyperemia and reddening of the pleura with dryness from checking of its normal secretion, there is swelling from transudation of serum into the perivascular spaces, and multiplication of connective-tissue cells with loss of the normal glistening of the pleural surface due to degeneration and exfoliation of superficial endothelial cells. Then follow exudation of inflammatory lymph and effusion of serum to a greater or less extent; the former clinging to the pleural surface presents a rough, shaggy appearance ; the latter gravitating to the lowest part of the pleural sac, usually holds in suspension shreds of fibrin, leucocytes, and endothelial cells. Thickening of the serous membrane results from multiplication, in it and in the fibrous exudate, of new connective-tissue cells; these mature, new blood-vessels form, making connection with the original vessels of the pleura, and organization of the exudate is the result. Adhesions more or less extensive may form between opposing pleural surfaces, which become bound together closely by the plastic organiza- tion, or more loosely by fibrous bands and false membranes. The pleural surface early in the inflammation may present irregular spots of ecchymosis surrounded by the more diffused redness; later, whitish spots of fibrous organization appear on the free surface. The effused serum is generally of a light yellow or greenish color, has a specific gravity of from 1,010 to 1,024, contains four to six per cent of albumen, and coagulates readily upon exposure. In these respects it differs from the fluid of hydrothorax, which contains but one per cent of albumen, its specific gravity being below 1,015. The amount of fluid varies; in acute pleurisy, it is not usually great, seldom occupying more than one-third or at most one-half of the pleural sac, and is very rarely sufficient to fill the cavity. In subacute pleurisy the quantity is often sufficient to fill the cavity and cause great distention of the side. In empyema the amount is seldom greater than in acute pleurisy. ACUTE PLEURISY. 61 The processes of pleuritic inflammation vary with the causes and severity of the affection. The effusion takes its character from the pres- ence of serum, fibrin, endothelial cells, blood, and pus in varying quantity and variously combined. The products of inflammation in mild cases- may be chiefly fibrinous with little or no serous effusion; hence the so- called plastic or dry pleurisy. If fibrinous exudate and pleural thick- ening are marked and serous effusion is copious, we have the sero-fibrin- ous form. If infective inflammation occur pus results, and we call it empyema. The purulent accumulation in these cases swarms with the characteristic streptococci and staphylococci of suppuration, and in some instances the so-called diplococci of pneumonia and bacilli of tuberculosis may be found, though they are difficult of demonstration. Hemorrhagic pleurisy occasionally complicates purpura hemorrhagica, cancer, scorbutus, and tuberculosis, or may result from the lighting up of a new inflammation in an old pleuritis. Serous pleuritic effusions after remaining for a time are usually gradually absorbed, but purulent accumulations never to any great ex- tent. In the latter the fluid tends to perforate the surrounding wall either to appear externally or to empty itself into an adjacent cavity or organ. The solid portion of an effusion may be absorbed after under- going fatty metamorphosis, but not infrequently, sooner or later it be- comes the seat of tubercular degeneration ; or it may become incapsulated and remain so for years; or it may be the seat of calcareous deposition. Cases are reported in which the fibrous exudate covering an entire lung had been the site of such deposit. Aside from these characteristics of an inflamed pleura, certain pathological conditions result from the effect of the process upon adjacent structures. Inflammation usually extends to the lung tissue immediately beneath the pleura, giving rise to exudation which occludes some of the alveoli. It may also by ex- tension cause pericarditis. The pleuritic effusion may be sufficient to cause complete collapse of the corresponding lung. The compressed lung, upon disappearance of the fluid, tends slowly to re-expand unless pressure has been too long continued, in which case car- nification of the organ results, and it remains as a small, compact, leathery mass, a suitable nidus for subsequent disease. Its complete expansion in any case is apt to be limited by the formation of cicatricial bands, and the great vessels may suffer serious compression. ACUTE PLEURISY. For convenience of description, acute pleurisy has been divided into four stages by some authors: First, a dry stage; second, a plastic stage; third, a stage of effusion; and fourth, a stage of absorption. I prefer the division into three stages analogous to the three stages of pneumo- nia, calling the first the dry stage ; the second, the stage of effusion ; the third, the stage of absorption. G2 PULMONARY DISEASES. Etiology. — Acute pleurisy ma}' be primary, or secondary to some other disease. Predisposing Causes. — It occurs most frequently in winter and spring, in adults rather than children, and attacks preferably the male sex. Malnutrition and poor hygienic conditions favor its occurrence. Exciting Causes. — The most common causes are exposure and rheu- matism. In a weak person mental depression may be an exciting cause. It may result from traumatism, even of slight character. It arises not infrequently from pneumonia, phthisis, pulmonary infarction, ab- scess, gangrene, or tumors; other causes are found in hemorrhage into the pleural cavity, pericarditis, costal or vertebral caries, abscess of the mediastinum, peritonitis, and hydatids of the liver; also in infective dis- eases, Bright's disease, pysemia and septicaemia. Symptomatology. — The usual symptoms of this disease are: A sharp, cutting pain in the side, aggravated by general and respiratory move- ments; rapid and incomplete inspiration; a short, dry cough and a hard, rapid pulse, with more or less disturbance of the digestive organs. Pain is especially severe on inspiration and apt to be located just be- neath the nipple, though in children frequently it is less circumscribed. It is a more constant symptom in adults, but variable in duration; it usually diminishes as the general pyrexia appears, or with the occurrence of effusion. The temperature is usually but slightly elevated the first day, 99° or 100° F. in adults, but in children 102° or 103° F. In pleuritic effusion of children, surface thermometry may reveal on the affected side higher temperature by one or two degrees, rising and falling with the increase and decrease of the effusion. While in very mild cases the subjective symptoms may be so slight as to attract little or no attention, in rare cases they may be so severe as to suggest pneumonia. Pleuritic symp- toms are apt to be less marked in the feeble and cachectic. "When a large effusion occurs, nausea and vomiting are frequently present and dyspnoea becomes a prominent symptom. The most important signs of pleurisy are : short and catching respi- ration, friction fremitus on palpation, and friction sounds heard on auscultation. Over the collection of fluid after effusion has taken place, there is flatness and loss of vocal fremitus and respiratory murmur. The upper line of flatness changes with the position of the patient (Fig. 18). In the first stage we have in the beginning simply dryness of the pleura, and shortly afterward an exudation of inflammatory lymph. By inspection we observe jerking or interrupted and incomplete res- piration, with diminution of the expansive movements of the affected side. This catching respiration results from the patient's efforts to limit inspiratory movement, in order to prevent pain. This sign, though nearly always present, is not diagnostic of pleurisy; for in inter- costal neuralgia and in pleurodynia may be found similar movements. If the patient is sitting or in a semi-recumbent position, his body ACUTE PLEURISY. 63 will be inclined toward the affected side. If recumbent, he is likely to be lying on the unaffected side. Occasionally, especially in children, the patient's efforts to restrain the move- ments of the affected side result in temporary spinal curvature toward that side. On palpation, no signs will be obtained in the early part of this stage; but a little later friction fremitus may frequently be detected, and the vocal fremitus may be found diminished. Pressure usually elicits deep-seated tenderness. Mensuration yields no additional signs. Percussion yields no signs at first; but when plastic exudation has taken place, dulness, in proportion to the amount of exudation, will be elicited. The dulness is always less marked at the end of forced expiration than during normal respiration. Auscultation early in this stage discovers a feeble respiratory mur- mur with jerking or cog-wheel respiration, and in some instances, just at the end of inspiration, a feeble, grazing friction sound. When plastic exudation has taken place the respiratory sounds are still more feeble, and the friction sound becomes distinct, on both inspiration and expiration, but usually most intense with the latter. This may have any of the characteristics of friction sounds, as rubbing, grazing, creak- ing, or crackling. It may not be obtainable except on cough or deep ■inspiration, and will not be heard if the inflammation is confined to the mediastinal or diaphragmatic pleura. At this stage the vocal resonance is somewhat diminished. In the second stage of pleurisy by inspection we still observe dimin- ished respiratory movements, but not the interrupted respiration noticed in the first stage, perhaps also an apparent increase in size of the affected side ; but sufficient fluid to dilate the side of the chest is excep- tional in acute pleurisy. In palpation the vocal fremitus is absent over the effusion. Earely, distinct fluctuation can be obtained. The apex beat of the heart will be found crowded to the right or left, according to the seat and amount of the effusion. If the pleurisy is upon the left side, the heart is crowded to the right; if upon the right side, it is displaced in the oppo- site direction. Exceptional. — In very rare instances of serous effusion, the vocal fremitus is not lost. Percussion over the lower part of the chest yields flatness, extend- ing upward to the surface of the fluid. The height of this surface is not altered by deep inspirations or forced expirations, but its relations are changed by alterations in the patient's position, unless the effusion entirely fills the pleural sac or there are complete adhesions above its surface. Above the fluid the resonance is exaggerated, and in exceptional cases it may have a vesiculo-tympanitic or amphoric quality. 64 PULMONARY DISEASES. Investigations by Damoiseau, of Paris, and more recently by the late Dr. Ellis, of Boston, show that usually, when the pleural sac is no more than one-fourth or one-third filled, the upper surface of the fluid corre- sponds to a curved line known as the letter S curve, termed by Ellis the curved line of flatness (Fig. 19). G. M. Garland, in his monograph on Pneumo-dynamics, describes this curved line as follows : " Its lowest point is found behind, near the spinal column. From this point it curves upward and outward across the lateral region, where it is highest ; and from this point it proceeds almost horizontally forward to the sternum." The experiments of Garland demonstrate that, instead of a gradual rising of the fluid in c pears that numerous cases have been benefited by it. I have found it of much value in stimulating the heart and relieving the painful parox- ysm, but I have not witnessed curative results. It is administered either in pill, tablet triturate, or solution. The dose administered to relieve the paroxysm is ordinarily gr. jfa, which may be repeated once in twenty minutes until three or four doses have been taken or relief is obtained, unless its physiological effects are too strongly developed. AXixIXA PECTORIS. 253 AYhen the susceptibility of the patient to the remedy has been ascer- tained, doses two or three times larger may sometimes be given. To prevent recurrence of the attack, it may be given three times daily, at first in doses of gr. j-^-, but these may be increased to five, ten, or even fifteen times as much, providing that it does not cause severe headache, giddiness, or overpowering somnolence. During the intervals between the attacks of angina, the same hygienic rules should be observed as in valvular disease. Arsenious acid should be given in moderate doses, with or without iron, strychnine, and digitalis, acccrding to special indications. Huchard claims that large doses of potassium iodide (grs. xl. to 1. daily) continued several years with intervals of eight or ten days each month during which it is suspended, will cure angina pectoris and arterio- sclerosis of the heart (Gazette des Eopitauz, 1890). The remedy is cer- tainly very efficient in relieving the pains of aneurism and sometimes in relieving cardiac pain. In pseudo-angina, the cause must be ascertained and removed if possible. Remedies usually should be directed to the relief of rheumatism, anaemia, or debility, or, most important, to the correction of indigestion. CHAPTER XV. CAEDIAC AND ARTERIAL DISEASES.— OntitM*a AORTITIS. The symptoms ascribed to acute exudative inflammation of the aorta have been described by Frank, Bizot, and others; but as stated by R. Douglass Powell, the disease as a primary affection is of very doubtful, if not impossible, occurrence. We need not attempt to describe any of the signs or symptoms it might possibly occasion. ATHEROMA OF THE AORTA. Synonyms. — Aortic endarteritis ; atheromatous degeneration of the aorta. Atheroma of the aorta may be defined as a degeneration of the coats of the aorta, consisting of an irregular thickening and softening of its walls, especially of its inner coat. It seldom occurs before the forty-fifth year of age. Anatomical and Pathological Characteristics. — The disease consists of thickening and fatty degeneration, usually followed by cal- careous infiltration and occasionally by ulceration. It is primarily con- fined to the intima, but not infrequently involves the muscular coat. It begins with inflammation, occurring in scattered patches, which have the milky opacity characteristic of the first stage of acute endocarditis ; later these become yellow from loXtj change. These areas may coalesce to some extent, and deposits of lime salts commonly take place, giving the surface a scaly or nodular appearance and chalky hardness. Ulcera- tion occasionally results from rapid central softening of the patch and discharge of the debris. Microscopically, the thickened intima early shows round and spindle cell infiltration and more or less increase of fibrous elements, but no blood-vessels. Later the spots of softening are found to contain oil globules, crystals of cholesterin, and a granular debris. These processes result at first in thickening of the arterial wall, finally weakening, loss of elasticity, dilatation, and in some cases aneu- rism. The affection is usually limited to the initial portion of the blood- vessel ; indeed clinical evidence of its existence beyond the transverse portion of the arch is very rare. Etiology. — The chief causes are: gout, rheumatism, syphilis, chronic ATHEROMA OF THE AORTA. 255 nephritis, high living with insufficient exercise, and the excessive rise of alcoholics. It sometimes results from undue strain of the artery, as in excessive muscular efforts. Symptomatology. — The symptoms of atheroma of the aorta are always obscure, and its physical signs, in many cases, are far from posi- tive. Among the most prominent symptoms and signs, we observe at- tacks of palpitation or anginal pain and dyspnoea, which are usually brought on by exercise, but may occur independent of exertion. Dur- ing these attacks the pulse is commonly very weak. Signs of gen- eral atheroma may often be detected in the abnormal rigidity of the temporal, radial, and brachial arteries. By inspection and palpation, when dilatation has taken place, feeble pulsation may be seen or felt in the second intercostal space close to the sternum, on the right side. Upon percussion, there is found a somewhat increased area of dulness over the ascending or transverse portion of the aorta. On auscultation early in the disease, there may be some evidence of hypertrophy of the left ventricle, as indicated by an increased impulse and muffling of the first sound of the heart. These signs, however, are not characteristic, as they might arise from emphysema or other cause of obstructed circulation. "With the advent of dilatation, the first sound of the heart becomes more indistinct, while there is accentuation of the second sound over the aortic valves, thought by some to be diagnostic of dilatation of the aorta. A short murmur is usually heard over the aorta, immediately after the systole of the ventricles, especially when the action of the heart is rapid. As dilatation progresses, the bruit becomes more distinct. It is some- times rough in character, and may be associated with a purring tremor. The second sound may be partially supplanted by a faint diastolic murmur, due to dilatation at the origin of the artery, which renders the semilunar valves incompetent to close the orifice, and allows regurgi- tation into the ventricles. When the heart is beating slowly and regularly, both the first and second sounds may be accentuated over the upper part of the sternum, and the systole of the heart may be attended by a slight impulse in the aortic area; but this latter sign, to be of value, must be obtained when the patient is perfectly quiet. Later in the disease, dyspnoea becomes marked, the attacks of angina are more frequent and persistent, and the symptoms of embolism, such as hemiplegia, rigors, hematuria, superficial hemorrhages, or gangrene, may make their appearance; or the formation of a sacculated aneurism from the affected portion of the artery may be indicated by the sudden occurrence of pain, dyspnoea, and faintness. Finally, sudden death may result from heart failure or from rupture of the aorta. Diagnosis. — The principal symptoms and signs of atheroma of the 25G CARDIAC AND ARTE RIAL DISEASES. aorta are: palpitation, pain, and dyspnoea, with rigidity of the superficial arteries, muffling of the first sound of the heart, and accentuation of the second, over the aortic valves. The first heart sound is usually followed by a more or less distinct systolic murmur. Sometimes there is a dias- tolic murmur in the region of the ascending or transverse portion of the arch of the aorta, with slight increase in the area of dulness during the later stages. The affection might be mistaken for simple disease of the aortic valves, or inorganic disease of the heart, with ana?mic murmurs. Though it may cause many of the symptoms and signs of atheroma, disease of tin 1 aortic valves is not attended by a rigid condition of the superficial arteries, or the peculiar neuralgic pains which usually attend atheroma, and it does not cause accentuation of the second sound at the aortic valves or an increased area of dulness at the base. When anaemic murmurs are associated with functional disease of the heart, they are not attended by rigidity of the superficial arteries, by the peculiarly distinct accentuation of the second sound, by the systolic shock, by the diastolic bruit, or by increased area of dulness. Treatment. — Morphine, nitroglycerin, or other anti-spasmodic rem- edies are indicated during the attacks of dyspnoea. Potassium iodide continued for months, with short intermissions, is sometimes useful. Excessive exertion must be avoided. AORTIC OR THORACIC ANEURISM. An aneurism is a sac the cavity of which communicates with the lumen of the artery. Anatomical and Pathological Characteristics. — Aneurism may exist as a fusiform dilatation of the artery, but usually, when well marked, it is saccular, forming a pouch-like projection from the vessel. The wall of the aneurism may be composed of all the coats of the vessel, though commonly the muscular tunic is wanting. Earely, the walls are formed by a condensation of the surrounding tissues into which the artery has ruptured, called diffuse aneurism. If the blood effects sepa- ration of the arterial coats, a dissecting aneurism is formed. The cavity is generally lined with concentrically stratified blood clots of varying age, thickness, and consistence, which are occasionally calcified. As the aneurism enlarges, pressure upon adjacent respiratory, circula- tory, nervous, or bony structures produces characteristic symptoms and may eventually effect their destruction. The walls of the sac gen- erally undergo atheromatous degeneration, and may rupture into the pleural cavity, lungs, bronchi, trachea, pericardium, oesophagus, or through the chest wall. Etiology. — Aneurism occurs generally in adults, oftenest between the ages of forty and fifty. Occupations which subject the individual to exposure and severe bodily strain favor its development. Atheroma ANEURISM OF THE DESCENDING AORTA. 257 of the walls of the artery is the chief predisposing cause, whether due to syphilis, chronic nephritis, gout, rheumatism, chronic alcoholism, lead or mercurial poisoning, or to several of these combined. The immediate cause may be sudden strain, a blow, fall or wound, or continued excesses. ANEURISM OF THE SINUSES OF VALSALVA. Aneurism of the sinuses of Valsalva is usually so small as to give rise to no peculiar symptoms or signs, but the indications of athe- romatous degeneration, with a pulmonary systolic or diastolic mur- mur due to pressure of the aneurism on the origin of the pulmonary artery, might lead us to susjDect the true nature of the lesion. The diag- nosis can rarely, if ever, be made with certainty, as the tumor lies en- veloped in the pericardium, so close to the heart that it is almost impos- sible to distinguish between the murmurs which it produces and those of valvular origin. ANEURISM OF THE ARCH OF THE AORTA. Aneurism of the arch of the aorta consists of preternatural dilatation of the artery, Avhich may be general involving the whole circumference in a fusiform, cylindrical or globular swelling; or sacculated, forming a pouch-like projection from one side of the artery. Sacculated aneurisms are usually globular at first, but may subse- quently acquire different forms, especially the conical. Aneurisms may occur in the ascending, transverse, or descending portion of the arch of the aorta. About one-half have their origin in the ascending portion; a few involve both the ascending and the trans- verse, or simply the transverse portion of the arch. Nearly one-fourth arise from the descending arch, and about the same number from that portion of the aorta between the arch and the diaphragm. ANEURISM OF THE DESCENDING AORTA. Aneurism of the descending aorta ultimately causes a pulsating tumor behind, at the left of the spinal column, between the third dorsal verte- bra and the point at which the aorta perforates the diaphragm. Erosion of the vertebras, with consequent curvature of the spine, is usually pro- duced by pressure. Subsequent compression of the spinal cord may cause paraplegia. The tumor, if large, usually displaces the heart for- ward and to the right. In exceptional instances, aneurisms of this por- tion of the aorta may be detected upon the right side of the spinal column. The bruit, in an aneurism of the descending aorta, may be distinguished from a mitral regurgitant murmur, frequently heard in a similar position, by the fact that the aneurismal murmur is heard not only between the fifth and the eighth dorsal vertebras, but also above and below this position. The mitral regurgitant murmur is not heard i7 258 CARDIAC AND ARTERIAL DISEASES. distinctly above the lower border of the fifth or below the upper border of the eighth vertebra. Symptomatology.— Tumors of this character may sometimes be diagnosticated from the symptoms, when they cannot be located by the physical signs. The more prominent symptoms, though not indi- vidually characteristic, may be sufficient for the purpose of diagnosis when grouped together, and are of great value when taken in connection with the physical signs. Enumerated nearly in the order of their im- portance, they are: pain, dyspnoea, palpitation, dysphagia, headache, and disordered vision. The pain in aortic aneurism is persistent, of a peculiar wearing, ach- ing, or burning character, and is referred to the region of the tumor. Frequently there are neuralgic exacerbations, with pain radiating in the course of contiguous nerves. Dyspnoea of varying degree is generally present, and is usually ag- gravated by much slighter causes than those which would occasion the same symptom in other varieties of intrathoracic tumors. It fre- quently occurs in severe paroxysms, which may be due to one or more causes. Ordinarily, such attacks are ascribed to spasm of the glottis, resulting from irritation of one or both of the recurrent laryngeal nerves. More probably they are due to paralysis of the abductor muscles of the glottis which are supplied by these nerves, with consequent falling to- gether of the vocal cords, and obstruction of the glottis during inspira- tion. The exacerbations of this symptom are due in some instances to a collection of mucus at the glottis; in others to the varying pressure of the aneurism upon the nerve which, at one time, completely suspends its function, at another interferes with it but slightly. The voice is also modified more or less by the same cause, and may be entirely lost. Dyspnoea is sometimes dependent upon narrowing of the trachea or of the bronchi from pressure of the aneurism. In such instances, the paroxysms are probably due to a collection of mucus which the patient may be unable to expectorate at the point of stricture. Palpitation of the heart is generally produced by slight exertion; it may be due to irritation of the sympathetic nerve or paralysis of the vagus from pressure. Dysphagia, due to pressure upon the oesophagus, is often present, though it is a less frequent symptom with aneurismal than with other tumors. Headache, due to interference with the return of blood to the heart, is not uncommon. Disordered vision is due to pressure upon the sympathetic nerve, and consequent interference with the action of the iris. Ordinarily the pupil upon the affected side is strongly contracted, but in rare instances, from complete paralysis of its sympathetic nerve, it may be dilated. ANEURISM OF THE DESCENDING AORTA. 259 Haemoptysis, to a slight degree, is an occasional symptom due to con- gestion of the mucous membrane. Copious haemoptysis frequently oc- curs at the close of the disease, when the aneurism ruptures into the air passages. The essential signs are : a pulsating tumor in the region of the aorta, with systolic and diastolic shock and sometimes bruits. Upon inspection, we often observe marked lividity of the face, neck, and upper extremities; with turgescence and a varicose condition of the veins, and perhaps oedema, due to obstruction in the return of blood to the heart from pressure of the aneurism upon one of the venae innom- inatae or the descending vena cava. Occasionally a thick fleshy collar is found about the base of the neck, due to capillary turgescence. (Edema and turgescence are ordinarily limited to one side, and are caused by pressure on one of the venae innominatae. If the pressure is upon the descending vena cava, which is most likely to occur with an aneurism of the ascending arch, these signs will be found upon both sides. The surface of the chest is seen to have a marbled appearance, caused by the prominence and blueness of the veins. A tumor may usually be observed in the course of the aorta, the position of which will indicate the part of the blood-vessel affected. When an aneurism originates in the sinuses of Valsalva it causes no external tumor. When in the ascending portion of the aorta, if bulging occurs, it will be seen in the second intercostal space at the right side of the sternum; but if large, it may extend far into the infraclavicular region, and even to the mammary. Aneurism of the transverse portion of the arch causes a tumor at the upper part of the sternum. When the descending arch is involved the tumor generally presents posteriorly at the left of the spinal column. Exceptional. — In exceptional cases, an aneurism of the descending arch of the aorta may be seen in front, and in very rare instances it may be found at the right of the spinal column. Aneurisms of the descending aorta present posteriorly below the fourth dorsal vertebra at the left of the spine. Very rarely they are seen at the right of the spinal column. These tumors vary in size from a slight prominence to one as large as a child's head. The absence of a tumor does not necessarily prove that no aneurism exists ; for, while the aneurism is small, it may not press upon the chest walls, and even when of considerable size the posi- tion may be such that no bulging is occasioned. The larger of these tumors are generally conical in form, and present very much the appear- ance of an immense boil, covered by thin glazed integument. 260 CARDIAC AND ARTERIAL DISEASES. If pulsation of the tumor be observed, it will occur rhythmically with the apex beat of the heart. Pulsation, which cannot otherwise be seen, may sometimes be detected by bringing the eye to the level of the sur- face of the chest, as in standing behind the patient and looking down over his shoulders. "No pulsation will be visible if the aneurismal sac is occupied by fibrin or coagulated blood. If the tumor press on one of the main bronchi the respiratory move- ments on the corresponding side will be diminished or absent. By palpation we may frequently detect a tumor, the impulse of which cannot be seen; we can ascertain the condition of the chest walls, whether there be perforation of the costal cartilages, sternum, or ribs, and may usually determine whether the contents of the tumor are fluid or solid. The character of the pulsation is expansile, that is, alike in every direction, and not simply lifting as is the case when a solid tumor rests upon an artery. The most valuable sign obtained by this method is the detection of two pulsating points, as though there were two hearts, one beating in the normal position in the fifth interspace, and the other above the third rib. If the aneurism is so small as to escape observation by ordinary palpation it may sometimes be detected by pressing- firmly with one hand over the aorta in front, and with the other posteriorly. The impulse obtained over an aneurism may be systolic, occurring with the contraction of the ventricles; or it may be both systolic and diastolic. The latter, produced by contraction of the artery, is usually slight, but occasionally quite forcible. When found, it is a valuable sign. Frequently these tumors give rise to a peculiar thrill, similar to the purring tremor; sometimes very early in the course of an aneurism of the transverse arch, an impulse or a thrill may be felt by pressing the finger downward behind the suprasternal notch. Valuable information may be obtained in some cases from the pulse, or from sphygmographic tracings (Fig. 42). If the aneurism press upon the arteria innominata, or upon either of the subclavian arteries, or if either of these vessels is obstructed by a coagulum, the radial pulse will be feebler upon the corresponding side. The carotids are sometimes similarly affected. If atheromatous degeneration of the arteries be general, the superficial arteries, especially the radial and tem- poral, will be found rigid and non-elastic. Alterations in the movements of the chest walls and in the vocal fremitus are also to be sought by palpation. Pressure on the air pas- sages will diminish the respiratory movements, and cause local or gen- eral diminution or absence of the vocal fremitus, according as a bronchus or the trachea is obstructed or the lung itself compressed. Percussion must be performed gently, especially over large aneurisms, as a forcible stroke might possibly rupture the weakened blood-vessel. ANEURISM OF THE DESCENDING AORTA. 261 Upon gentle percussion, the extent of dulness will not correspond to the size of the tumor, because of the overlapping borders of the lungs; but by a more forcible stroke, or by auscultatory percussion, we may deter- mine the limits accurately. The area of abnormal dulness is usually much smaller than in other tumors, causing symptoms of equal gravity. The sense of resistance felt upon percussion is a valuable sign in dis- tinguishing between aneurisms and other intrathoracic tumors. Over a tumor filled with fluid, the resistance is much less than over a solid growth or over an aneurism filled with fibrinous deposits. If the aneurism present posteriorly, dulness will be obtained in the interscapular region. If it press upon a main bronchus, or upon one lung, causing collapse or congestion of this organ, dulness will be found over the corresponding side. In auscultation, upon listening over an aneurism, we first notice an impulse or shock with each contraction of the heart. This is frequently followed immediately by a second or diastolic shock, due to contraction of the arteries. The impulse is usually attended by one or two sounds which consist mainly of the transmitted heart sounds, but are in part produced by dilatation and contraction of the artery. These sounds may be associated with or supplanted by murmurs somewhat similar in character to endocardial murmurs. However, they are ordinarily less intense, though they may be even louder than the loudest heart murmurs. They are usually harsh in quality, and are not transmitted into the same regions as endocardial murmurs. Sometimes neither sounds nor murmurs can be detected over the aneurism. If the tumor press upon a main bronchus, the respiratory murmur will be diminished or absent upon the corresponding side, while on the other it will be exaggerated. In these instances a forced inspiration will sometimes distend the lung, and bring out the respiratory murmur where it could not be heard during ordinary breathing. Vocal resonance will be diminished or absent over the obstructed lung, and absent over the aneurism. If the lung be condensed by pressure, broncho- vesicular respiration may be heard. If the tumor press upon the recurrent laryngeal nerve, so as to cause paralysis or spasm of the vocal cords, there will be stridulous respiration, with dysphonia or aphonia, and inspection of the larynx will usually reveal the existence of paralysis of the cord on the corresponding side, with possible paresis of the other. Occasionally the pressure is upon both nerves, with consequent paralysis of both vocal cords. Ferdinand Schnell (Milnchener medicinische Wochenschrift, April, 1890) claims a new means for diagnosis of deep-seated thoracic aneu- risms in the aneurismatoscope. This consists of a soft rubber tube closed at the lower end and filled with colored fluid, a piece of glass tubing being inserted into the upper end. When this apparatus is 262 CARDIAC AND ARTERIAL DISEASES. partly inserted into the oesophagus, it is said that the pulsations of an aneurism of the descending arch are communicated to the tube and are indicated in the rise and fall of the fluid. Diagnosis. — Aneurism of the thoracic aorta may be confounded with solid tumors; with aortic pulsation, due to regurgitation through the semilunar valves ; with pulsating empyema; with dilatation of the auricle; and with consolidation of the anterior border of the lung, with aneurism of the pulmonary artery, and with aneurism of the arteria in- nominata. Venous turgescence, displacement of the heart, dulness on percus- sion, and modifications of the respiratory sounds, due to pressure, are signs common to these and to other varieties of intrathoracic tumors. Variation in the force and volume of the pulse on the two sides, expan- sile pulsation of the tumor, with a shock and bruit, are usually charac- teristic of aneurisms, but occasionally even these signs may be caused by solid growths. A diastolic bruit and shock over an intrathoracic tumor, accompanied by a clear second sound at the base of the heart, is diagnos- tic of aneurism, especially if following a distinct S} T stolic bruit and shock. A murmur at the base of the heart, taking the place of the second sound, when associated w T ith the signs of a tumor in the course of the aorta, is valuable evidence of probable atheromatous degeneration of the aorta, and the formation of an aneurism. The differential features between aortic and pulmonary aneurisms and other diseases are pointed out below. Aneurisms may be distinguished from other intrathoracic tumors by attention to the history and symptoms as well as to the physical signs. The distinctive features between aneurism of the aorta and solid tumors are as follows ; Aneurism of the aorta. Solid tumors. History. Seldom or never occurring before the Usually malignant. They may oc- twenty -fifth year of age, and usually cur in early life, and not infrequently not until after the forty-fifth year. before the twenty-fifth year. Grave Slight, if any, constitutional disturb- constitutional disturbance, ance. Symptoms. Pain constant, and of a burning, wear- Pain not so deep-seated as in aneu- ing, or aching character and usually rism; may be sharp and lancinating aggravated by exercise; frequentlj 7 sub- in character; not affected by exercise; ject to neuralgic exacerbations. The not subject to neuralgic exacerbations, symptoms and signs of pressure vary The symptoms and signs of pressure from time to time, owing to changes in are constant, and steadily increase the direction of the pressure. from day to day. ANEURISM OF THE AORTA. 263 Aneurism of the aorta. Signs. Expansile pulsation. Often dispar- ity between the radial pulses of the two sides. The area of dulness small in proportion to the size of the tumor and the length of its history. Sense of re- sistance slight. Solid tuhors. No pulsation, or if any, simply a slight lifting impulse, caused by the tumor resting upon a large artery. Usually no disparity in the pulse of the two sides. Area of dulness large, and rapidly increases. Sense of resistance well marked. Aortic aneurism is distinguished from aortic pulsation by the fol- lowing symptoms and signs: Aneurism of the aorta. Aortic pulsation. Symptoms. Symptoms of pressure upon the trachea, oesophagus, or recurrent la- ryngeal nerve. Signs Pulsation in a limited space over the arch of the aorta. No symptoms of pressure. Radial pulse not exaggerated on either side by elevation of arm; usually feeble on one side. Increased area of aortic dulness. Arterial bruits, systolic or diastolic, generally distinct from endocardial murmurs. Pulsation not only over the aorta, but in the carotids, subclavians, and brachials. Pulse sharp and apparently forcible; hammer pulse exaggerated by eleva- tion of the arm, and alike on both sides. No increase in the area of dulness. Aortic regurgitant murmur, but no special bruit over the pulsating vessel. Aneurism may be simulated by pulsating empyema, but ordinarily" it can be easily distinguished by its position. If, however, perforation of the chest walls should take place in the course of the aorta, as in a case recorded by Flint, the diagnosis would be much more difficult. Aneurism of the aorta. Symptoms Symptoms and signs of pressure up- on adjacent organs. Dulness confined to the region of the aorta. Arterial bruits. No pulmonary signs, unless there be pressure upon the trachea, bronchus, or lung itseif. Expansile pulsation of the tumor. Pulsating empyema, and Signs. Usually no symptoms of pressure upon the trachea, oesophagus, and other adjacent organs. Dulness or flatness over the pulsat- ing tumor, and also over the lower part of one siae. No bruit. Signs due to compression of tne lung by nuid in the pleural sac. Pulsation somewnat similar to that of" aneurisms, buc usually less expansile. 264 CARDIAC AND ARTERIAL DISEASES. An aneurism of the aorta is distinguished from a dilated auricle as follows : Aneurism of the aorta. Dilated auricle. Symptoms and Signs. Signs and symptoms due to pressure Few, if any, signs and symptoms upon adjacent organs. Pulsation fol- of pressure. Pulsation preceding the lowing the systole of the ventricles and apex beat, the apex beat. Dulness in the region of the aorta. Dulness extending far beyond the Arterial bruits common, but propa- region of the aorta, and usually at a gated mostly over the arteries. lower level ; usually endocardial mur- murs propagated in directions different from those of the aneurismal bruit. Aneurism of the aorta is differentiated from consolidation of the hot 'j by the position of the dulness and by the signs upon ausculta- tion. If the consolidation is due to an aneurism, care must be taken not to overlook the signs of the latter. Aneurism of the aorta. Consolidation of the lung. Signs. Durness limited to the course of the Dulness not limited to the aortic aor ta. region, but extending externally, and usually involving the whole apex of the lung. A normal respiratory murmur may Rales and other signs of consolida- often be heard over the greater portion tion. No bruits excepting possibly a of the aneurism. Arterial bruits. systolic subclavian murmur. Aneurism of the Pulmonary Artery. — Aneurism of the pulmonary artery is one of the rarest affections of the circulatory system. From the few cases which have keen described, we are unable to obtain any characteristic symptoms or signs. The principal indications which have been noticed are: extreme cyanosis, with dropsy and great dyspnoea, associated with a strongly pulsating tumor, located in the second inter- costal space of the left side, and limited to this region. This tumor is likely to yield a thrill upon palpation. Upon auscultation, systolic or diastolic murmurs, or both, may be detected, but they are not propagated above the clavicles. It is hardly possible to distinguish aneurism of the pulmonary artery from one of the aorta, which happens to present to the left of the sternum. The position of a pulmonary aneurism is different from that of most aneurisms of the aorta. An aneurism of the ascending portion of the aorta might possibly present to the left of the sternum, though in this locality we are more likely to observe aneurism of the descending aorta. The distinctive features between aortic aneurisms and those of the pul- ANEURISM OF THE AORTA. 205 monary artery may be stated, from the symptoms and signs which have been observed up to the present time, as follows: ANEURISM OF THE AORTA. ANEURISM OF THE PULMONARY ARTERY. Aneurism of the ascending arch pre- The tumor is confined to the second sents to the right of the sternum, and intercostal space of the left side, those of the descending arch usually present behind at the left of the third dorsal vertebra, and very rarely in front. Signs and symptoms due to pressure The signs of pressure are compara- upon the trachea, bronchial tubes, tively slight, but usually there is con- cesophagus, blood-vessels, or recurrent gestion of the face, anasarca, and great laryngeal nerve, common. dyspnoea. Bruits, which may be propagated in- Bruits, not propagated above the to the carotids and subclavians. clavicles. Aneurism of the Arteria Innominata. — Aneurisms of the arteria innominata cause pulsating tumors similar to those of the aorta. An aneurism of the arteria innominata may be distinguished from an aneurism of the arch of the aorta — first, by its position ; second, by the comparative absence of signs due to pressure; and third, by the effect on the pulsation of compression of the subclavian and carotid arte- ries. Such an aneurism is located entirely upon the right side of the sternum, and causes a prominence in the region of the inner end of the clavicle. It is not likely to cause much pressure upon the recurrent laryngeal nerve with consequent obstruction of the larynx; or on the oesophagus, so as to interfere with deglutition ; or upon the trachea so as to cause dyspnoea. Compression of the carotid or subclavian artery on the affected side greatly diminishes the pulsation in an aneurism of the innominate artery, but does not affect the pulsation of an aneurism involving the arch of the aorta alone. Prognosis. — The average duration of thoracic aneurism is two years and a half (Loomis, Practical Medicine). Eecovery rarely occurs. In some cases the affection seems to remain stationary for many months. Death may occur suddenly at anytime; the prognosis as to duration is therefore extremely uncertain. It depends somewhat upon the posi- tion of the aneurism, the structures pressed upon, and the occupation, temperament, habits and general health of the individual. Death usually occurs from rupture of the sac, but may be due to asphyxia, pneumonia, gangrene, or cerebral embolism. Treatment. — A mixture composed of equal parts of tincture of belladonna and chloroform liniment has been recommended for relief of pain, but when this is acute opiates will generally be required for temporary relief. The persistent boring pain will usually be greatly or completely relieved after a day or two by potassium iodide given in doses of gr. x. to xx., three or four times a day. These methods of 266 CARDIAC AND ARTERIAL DISEASES. treatment have been successfully employed in a few cases for the relief or the cure of aneurisms. Tufnell's method, which in several cases has succeeded in at least greatly relieving the patient, is a modification of Valsalva's starvation plan. It consists of perfect rest in the recumbent position with mod- erate diet. Ciniselli's method of galvano puncture first proposed in 1846 has been successfully employed in a few cases and may be tried if the fore- going methods fail. It is especially applicable in sacculated aneurisms near to the surface. Before making the puncture the patient may be given a full dose of morphine, or a small amount of cocaine may be in- jected at the joints when the needles are to be inserted. From fifteen to thirty small cells should be used, and insulated needles connected with both poles should be thrust vertically into the aneurism an inch or two apart. Electrolysis should be continued fifteen or twenty minutes and may be repeated after a week if necessary. Great care should be used in withdrawing the needles to avoid loosening the clot. During and after the operation, the patient should be kept quiet in the recumbent position. Another method consists of the use of large doses of potassium iodide. This treatment usually soon relieves the severe neuralgic pains, and possesses the advantage of allowing the patient to move about, though it is more effective if the patient can be kept continuously in a recum- bent position. The remedy should be given in doses of ten to thirty grains three times a day. The larger dose is much the best. Coryza may be relieved by moderate doses of nux vomica. If the stomach be- comes irritable, the medicine should be suspended for a few days. Sometimes patients will bear large doses who cannot tolerate small ones. "When an aneurism causes dyspnoea through spasm or paralysis of the vocal cords, tracheotomy may be necessary; but this operation can do no good when the difficulty of breathing results from pressure on the trachea. COARCTATION OF THE AORTA. Synonym. — Stenosis of the aorta. Coarctation of the aorta is one of the very rare affections of the cir- culatory system. The constriction may be ring-like, as though a cord had been tied about the artery; it may consist of a cicatricial band, par- tially obstructing the calibre of the blood-vessel; or it may be due to irreg- ular contraction of the artery, the result of inflammation. The nar- rowing of the vessel may be slight, or the aorta may have dwindled to an impervious cord. In a few instances the constriction has been found to be general, involving both the arch and the descending aorta. In such cases usually no symptoms have been observed until about the age SOLID MEDIASTINAL TUMORS. 267 of puberty, when deficient development of the lower extremities, and es- pecially of the sexual organs, has been the first indication of the condi- tion. Inspection reveals signs of hypertrophy and more or less dilatation of the heart; usually, dilatation of the arch of the aorta, of the subclavian arteries, and of the carotids; a dilated and tortuous condition of the superficial arteries, which in the normal state are not visible. This con- dition of the superficial arteries is attended by marked pulsation, and sometimes by small aneurismal enlargements of the intercostal arteries which may be sufficient to cause erosion of the ribs. A thrill can generally be detected by palpation over the large arteries. The obstruction of the vessel renders the pulsation feeble in the branches of the abdominal aorta, and causes feebleness or absence of the pulse in the tibial and popliteal arteries. Percussion gives no signs. On auscul- tation, a harsh, high-pitched, and usually intense systolic or postsystolic murmur will be heard over the aorta and larger blood-vessels. This is usually most intense close to the edge of the sternum in the second in- tercostal space upon the right side. This murmur is propagated through the carotids and subclavians toward the shoulder, and may also be heard posteriorly over the course of the aorta. The occurrence of such a murmur will lead us to suspect the exist- ence of an aneurism; but the latter may be excluded by absence of the symptoms and signs clue to pressure, and by the want of an increased area of dulness on percussion. Diagxosis. — The diagnosis of coarctation of the aorta rests mainly upon the enlarged and tortuous condition of the superficial arteries in the upper portion of the body, and the feeble pulsation in the lower ex- tremities, associated with an aortic systolic murmur. Tebatmeut. — ISTo treatment can be recommended. SOLID MEDIASTINAL TUMORS. Excluding aneurisms, tumors within the chest are nearly always ma- lignant in character, and are therefore attended with grave constitutional symptoms; some are of syphilitic and others of tubercular origin. Symptomatology. — A growth usually causes pain of a persistent character, sometimes lancinating, but not subject to the neuralgic par- oxysms which attend an aneurism. The principal signs are: tnrgescence of the veins, oedema, dyspnoea, dysphagia, and other evidences of pressure on surrounding organs, with dulness and loss of respiratory murmurs over the growth. By inspection we commonly find persistent turgescence of the veins, and oedema of the neck and upper extremities in a more marked de- gree than from an aneurism. A tumor is nearly always accompanied by enlargement of the lymphatic glands in the neck and axillary re- 268 CARDIAC AND ARTERIAL DISEASES. gions. The condition of these glands is an important point in the differential diagnosis; for, if it is due to malignant disease, they will be adherent to the surrounding tissues, but, if the conditions are not of malignant origin, they may usually be moved freely beneath the in- tegument. The symptoms and signs caused by pressure on the sur- rounding organs are persistent, and they gradually increase in severity. A malignant tumor is not usually confined to the course of the aorta, but is apt to extend a considerable distance beyond the borders of the sternum. A solid tumor does not ordinarily pulsate, and, when it does, the pulsation is not expansile, but is simply lifting. This impulse is caused by the pulsation of a large artery upon which the tumor rests. On percussion, the sense of resistance is marked, and the area of dul- ness is usually much larger than over an aneurism, because the malig- nant disease gradually involves the adjacent lungs, instead of crowding them before it. By auscultation, no bruit can be heard over a tumor, unless it presses upon an artery, and then the murmur is distant and comparatively feeble. Exceptional. — In those unique cases where a tumor coexists with a quies- cent aneurism, some peculiar phenomena have been observed. The sense of re- sistance to the percussion stroke over an aneurism may be great ; whereas over a solid tumor there may be only slight resistance, and in the same position we may detect an expansile pulsation, which should naturally be found over an aneurism. Diagnosis. — The essential features which enable us to distinguish between a solid tumor within the chest and an aneurism were referred to in the consideration of aneurisms. Pkognosis. — Sarcomata and carcinomata of the mediastinum are commonly fatal within a twelvemonth. Syphilistic growths will often subside under proper remedies. Enlargement of the bronchial glands is not infrequently followed by suppuration, and often eventually termi- nates fatally. Tkeatjient. — No special treatment can be recommended excepting that indicated by the constitutional dyscrasia. Diseases of the Throat. CHAPTER XVI. THE THEOAT. EXAMINATION OF THE FAUCES. A consideration of the diseases of the chest is very properly associ- ated with a study of the upper air passages, since diseases of the nose, fauces, pharynx, or larynx often cause symptoms which simulate those of pulmonary affections. In some instances so slight a difficulty as elonga- tion of the uvula will cause the symptoms of laryngitis, or even the per- sistent cough, emaciation, and other symptoms of the later stages of phthisis. For the examination of the fauces it is generally necessary to depress the tongue. For this purpose a great variety of tongue depressors have Fig. 50.— Turck's Tongue Depressor (J4 size). Fig. 51.— Pocket Tongue Depressor (2-5 size). Fig. 52.— Bosworth's Tongue Depressor (2-5 size). been devised which will be found useful, but, if not at hand, a spoon- handle, lead-pencil or the forefinger will answer the purpose. For ordinary use, a spoon-handle is perhaps the best, as many pa- tients object to an instrument which is used promiscuously. Of the different varieties of tongue depressors, for carrying in the pocket those which are jointed are most convenient (Fig. 51). In office practice, some of the larger, stronger varieties are preferable (Figs. 50 and 52). Some patients can so control the base of the tongue as to allow a view of the throat without the aid of a depressor, but this is not the rule. A fair view may often be obtained in children while they are crying or cough- ing. If the child resists, a spoon-handle or other depressor may be 272 THE THROAT. passed well back upon the base of the tongue, so as to induce retching, which will afford a good view of the pharynx. We should embrace every opportunity for inspecting the healthy throat, in order to become familiar with its normal conditions, other- wise we are unable to recognize quickly the signs of disease. Upon inspection of the healthy fauces, we first notice the soft palate with the pendent uvula, which forms the back part of the roof of the mouth. Running downward from either side of the soft palate will be seen two folds of mucous membrane, known as the anterior and poste- rior pillars of the fauces, between which may be seen a glandular mass, termed the tonsil. Posteriorly we observe the posterior pharyngeal wall, which closely covers the bodies of the cervical vertebrae. Superiorly, our field of vision is obstructed by the palate; inferiorly, by the base of the tongue. LARYNGOSCOPY. In order to look beyond the lines of direct vision, we must use mir- rors. Inspection of the larynx with these is called laryngoscopy, and the same method applied to the nasal passages and nasopharynx is called rhinoscopy. The essentials for laryngoscopy are, a throat mirror and a good light. The combination of a throat mirror and a reflector for directing the light is called a laryngoscope. A reflector and smaller mirror used in examining the nasopharynx is called a rhinoscope. History.— The credit of having- discovered the art of laryngoscopy is usually given to Czermak, of Pesth, but many before his time had experimented more or less successfully in illuminating the larynx. Bozzini in the beginning of the present century, Bennatti in 1832, and Avery, of London, in 1844 attempted to illuminate the larynx by means of artificial light conducted through tubes ; but, as shown by Trousseau and Bellocq, these instruments crowded the tongue and epiglottis before them, so as nearly or quite to close the orifice of the larynx. At most, they could expose only a small portion of its posterior wall. About a hundred years previous, to these efforts, Levret, of Paris, probably the first experimenter in this direction, attempted to see the larynx by means of a small throat mirror, similar to that now in use. Senn, of Geneva, in 1827; Babbington, of London, in 1829 ; Baumes, of Lyons, in 1838 ; and Liston, of Lon- don, in 1840, employed similar instruments with equally unsatisfactory results. Warden, in 1844, made experiments with a couple of prisms. All of these in- vestigators failed more or less completely, for the reason that they could not se- cure suitable illumination. The first to demonstrate the larynx in the living subject was Signor Manuel Garcia, a teacher of vocal music in London. He became quite expert in auto- laryngoscopy, and also succeeded in demonstrating the larynx in others. Garcia's observations were communicated to the Royal Society of London in 1855. They attracted little attention at first, for the art was thought to be of no practical value in the diagnosis of disease, because a thorough inspection was supposed to depend upon a peculiar education of the muscles which would enable the patient to control the position and movements of his throat. However, Garcia's writings induced Tiirck, of Vienna, to experiment with similar mirrors LARYNGOSCOPY. 273 in the hospital during the summer of 1857. Although Tiirck was fairly successful in these experiments, he finally threw aside his mirrors as the autumn came on, because of the difficulty in obtaining sunlight. His experiments were not lost, for Czermak, of Pesth, who had been visiting in Vienna during the summer, bor- rowed the mirrors and continued the investigations. He overcame the difficulties which had previously prevented a clear view of the larynx, by employing the reflector and causing the patient to protrude the tongue, instead of depressing it, and by substituting artificial light for the direct rays of the sun. Soon a rivalry sprang up between Czermak and Tiirck as to the priority of their claims. Their letters, which were published in the various medical journals, spread a knowledge of the new art throughout the medical world. Theoat mirrors have been made in various forms. Some are round, others oval or lozenge-shaped, and still others quadrilateral. For gen- Fig. 53.— Throat Mirrors for Laryngoscopy. 1. a, Handle; b, stem; c, mirror. sizes of round mirrors. 3. a, b, c, Different forms of throat mirrors. 2. Different eral use the round mirrors, varying in diameter from three-eighths of an inch to an inch and a quarter are preferable. Mirrors should be made of clear and perfectly white glass. The quality of the glass may be tested by placing a white card before the mirror. If the glass is per- fectly white, the reflection will also be white; if the glass is tinged with color, it will give a corresponding shade to the reflected image of the card, and would necessarily similarly affect the laryngeal image. The glass and its setting should be thin, in order to economize space in the throat. The glass should be set firmly in a metallic frame, which must en- croach as little as possible upon the anterior surface of the glass, so that the largest possible reflecting surface may be secured. Some of these mirrors are backed with amalgam, and others with silver-leaf. Silver- ;2T4 THE THROAT. leaf renders a mirror more durable, as it is less affected by beat and moisture. I bave used mirrors backed with amalgam many times daily for several months without injuring them, though one may be ruined in a week if heated too much or left in the water. The mirror should be firmly attached to a wire stem about four inches in length, at an angle of not less than one hundred and twenty degrees. This stem may be fixed in a small handle about three inches long, or the handle may be removable, the stem when inserted being held by a set-screw. Some laryngologists recommend a flexible stem, so that the angle of the mirror can be easily altered; but it is likely to become bent by contraction of the palatine muscles, when the mirror is in position, in such a manner that the larynx cannot be seen. An inflexible stem is always preferable, for the obliquity of the mir- ror can be easily altered b}* elevating or lowering the handle. If the beginner attempts to alter the obliquity of the mirror by bending the stem, he is likely to break the instrument in his frequent attempts to secure an angle which will give a different view of the larynx; and it is better for him to attribute want of success to lack of skill rather than to a defect in the mirror. Illumination. — To obtain a perfect illumination of the larynx, three things are necessary : first, the eye should be brought as nearly as pos- sible into the centre of the beam of light used in the illumination; second, the light should be bright, especially if a small throat mirror is used, for the smaller the mirror the fewer the rays which can be reflected from it, and we must make up in intensity what is lost in volume; third, the focal point, when convergent rays are used, should fall upon the part to be inspected. All forms of illumination which cast convergent rays into tbe larynx cause above and below the focal point what are known as circles of dis- persion, in which the illumination for a short distance is nearly as bright as at the focal point. In examining the larynx, an effort should be made to concentrate the rays of light on the vocal cords; the circles of dispersion will then give a good illumination for half an inch above or below the plane of the glottis. In men, the glottis is about three inches below the mirror when it is held in the posterior part of the mouth, and in this position the mirror is about three inches from the lips; therefore in men the glottis is about six inches within the lips, but in women about five inches. As the eye cannot be brought nearer to the mouth than five inches, without interfering with the manipulation of the instrument, the radiant or focal point must fall eleven inches from the reflector, which is worn on the forehead. Being myself hypermetropic, I find it most convenient to have the eye at least eight inches from the patient's mouth; and therefore must use a reflector which will concentrate the rays of light at a point four- teen inches from itself. LARYNGOSCOPY. 275 Persons with presbyopic eyes may obtain a good, view in the same manner; deficient accommodation in the eye maybe corrected by glasses. Myopic eyes of less than one-tenth will necessitate the use of concave glasses; but for eyes, myopic from one-tenth to one-seventeenth, glasses will not be needed, excejDting to view the bifurcation of the trachea. To examine the bifurcation of the trachea, wbich is five or six inches below the plane of the vocal cords, we must remember that the focal point should be at least sixteen or seventeen inches distant from the reflector. The larynx may be illuminated by a simple flame, or a plane or con- cave reflector with or without condensing lenses may be employed to reflect the rays of light into the throat. In illuminating the larynx by the direct rays of the sun, lenses are not used, and reflectors are not absolutely necessary. When diffused daylight is employed, reflectors are required to concentrate the rays. Though direct sunlight, or sometimes diffused daylight, gives a beautiful illumination, artificial light will be found indispensable for general use. Natural light cannot usually be secured in the proper position at the time we wish to use it. Illumination with Direct Artificial Light. — When using a simple flame without a reflector, the lamp must be placed directly in front of the patient's mouth, and shaded toward the eye of the observer. This will give a good illumination if the light is very bright, but with the ordi- nary lamp or gas-jet it is not satisfactory, This method may be im- proved by using a condensing lens with a focal distance of six or seven inches. The lens should be held between the light and the patient's mouth, and about five inches from the latter. The flame should be placed at a point which will cause its rays to be brought to a focus eleven inches beyond the lens at the plane of the glottis. The obser- ver's eye must then be brought near the edge of the lens. Illumination with Reflected Artificial Light. — The above-named ap- paratus may be supplemented by a plane perforated reflector, which,placed in front of the observer's eye, reflects into the mouth the rays from the condensing lens; or this reflector may be used with the simple flame without a condenser. In order to fulfil the three essential conditions — that is, to have the eye in the centre of the cone of light, to obtain a bright illumination, and to have the focal point fall upon the part to be examined — laryngol- ogists generally resort to a perforated concave reflector. Such a mirror, by collecting many rays otherwise lost, and concentrating them on the point to be examined, intensifies the illumination, and the perforation in its centre brings the observer's eye into line with the centre of the cone of light. Many laryngologists prefer to place the reflector above the eye, but unless a very bright light is employed this position will not give a good illumination of the larynx, and if a brilliant light is used it is very trying to the eyes. 270 THE THROAT. The reflectors vary in size, in focal distance, and in the maierial of which they are constructed. Those used in laryngoscopy are usually from three to four inches in diameter, with a focal distance ranging from five or six to fourteen or sixteen inches. They are made of either glass or metal; the former are best, as they do not become dim by tar- nishing. For ordinary use, a reflector with a focal distance of seven or eight inches will give better satisfaction than one with a longer focus, except when parallel rays of light, as those of the sun or of diffused day- light are to be reflected. The rays coming from any artificial light are necessarily divergent, and consequently cannot be brought to a focus in the larynx by a reflector with a focal distance of eleven inches, which would concentrate only parallel rays at the proper point. With the ordinary position of the flame, and of the observer's eye, a reflector of seven inches focal distance will throw the radiant point upon the glottis. The radiant point may readily be moved toward and from the eye by increasing or lessening the distance of the flame from the reflector, so that reflectors of varying focal distances may be employed, providing the light is sufficiently intense. On account of its simplicity, the formula -p- = -£ + ~^r has been generally adopted in determining the focal distance of the reflector, or the proper position of a flame, which, with a reflector of known focal distance, will cause the image of the flame to fall upon the glottis. The image of the flame and the radiant point are in this connection used as synonymous terms. The focal point is the same as the radiant point when parallel rays of light are employed. In this formula, F represents the focal distance of the reflector; A, the distance of the reflector from the flame; A' the distance of the reflected image of the flame (focal or radiant point) from the reflector. Knowing the focal distance of the reflector, seven inches, and the proper distance of the image of the flame, which, as already explained, should fall upon the glottis, and will therefore be eleven inches from the reflector — five inches from the observer's eye to the patient's mouth, and six inches from the patient's lips to his vocal cords — we can readily ascertain the proper position of the flame by substitut- ing the known quantities in the formula thus: \ = — ■ -\- 1 1 r . This, re- duced, will give a fraction over nineteen inches as the value of A, which will represent the proper distance of the flame from the reflector. To find the focal distance of the reflector by artificial light, we pro- ceed in a similar manner with the same formula. Placing the light at a fixed point and the reflector in front of it, we find the distances from the flame to the reflector, and from the reflector to the image of the flame, by direct measurement with an ordinary tape. These two known quantities being then inserted in the formula in the place of A and A', the value of F can readily be obtained. The focal distance of a reflector LARYNGOSCOPY. 277 may be easily ascertained with solar light by placing it in the sunlight, throwing the radiant point on some object, and measuring its distance from the centre of the reflector. The focal distance may be measured with diffused light by reflecting the image of some distant object, as a window, on some plane surface, and measuring the distance from this image to the reflector. In using reflectors, it is essential that the light be so managed that the radiant point will fall on the part to be illuminated. Students of laryngoscopy usually have great difficulty in obtaining a uniform illumination. Sometimes the parts will be brilliantly illumi- nated; at other times with the same light and the same laryngoscope the larynx is only seen in a deep shadow. This is generally due to the im- proper position of the light. "We must not forget that the larynx is necessarily from eleven to fourteen inches from the eye, and that, with a* reflector of seven or eight inches focal distance, if the flame be placed too near the eye, the radiant point will fall a considerable distance be- yond the glottis ; or if too far from the eye, the radiant point will not reach the glottis. We should always know the focal distance of our re- flector, and ascertain by the formula just explained the proper distance at which to place the flame, remembering that the distance of the radiant point from the reflector will vary inversely as the latter is carried toward or from the flame. Practically, if we have a proper reflector of seven to eight inches focal distance, it will not be necessary to measure accurately the dis*- tance of the flame. Placing the light beside the patient, we may sit in front with the reflector, ten or eleven inches from the patient's mouth; carry the light forward or backward until its perfect inverted image falls on the patient's lips, this will be the proper position for the light. By bringing the reflector about four inches nearer the mouth, the radi- ant point falls upon the glottis. Various contrivances are employed for holding the reflector. Czermak at first had it fastened to a mouthpiece of orris root, which he held be- tween his teeth. Semeleder and others are in favor of a spectacle frame, to which the reflector is so fastened that it may rotate in any direction. If the physician happen to be myopic or hypermetropic, lenses may be fitted in this frame to correct the error in accommodation. Jointed arms for holding the reflector accompany many forms of illuminating appa- ratus. These are inconvenient for, if the patient moves after the arm has been adjusted, each movement may require a change in the position of the reflector. Kramer's head band, or some modification of it, is the most common, and, I think, the best device for holding the reflector. It consists of a head band with a metallic or vulcanite plate in front to which the reflector is attached by a ball-and-socket joint, which enables one to fix it in any position. Most of the head bands are open to two objections; first, they cannot be made tight enough to hold the reflector 278 THE THROAT. firmly without causing headache; and second, the ball-and-socket joint is so constructed that, after it becomes a little worn, it is impossible to fix the reflector firmly. Schrotter's head band made of firm non-elastic webbing, with nasal rest, obviates these difficulties. Fig. 54. — Schrotter*s Head Band with Nasal Rest. Whatever the means employed for holding the reflector, it must be borne in mind that the flame must have a certain definite relation to the reflector, depending on the focal distance of the latter and its distance from the glottis, so that the image of the flame will fall upon the vocal cords. W i dtp! Fig. 55.— Krishaber's Illuminator. a, Lens ; b, reflector. Fig. 56.— Modified Mackenzie's Rack-movement Bull's-eye Condenser. For gas or incandescent electric light. In place of throwing the radiant point on the glottis, some physi- cians prefer to illuminate the parts to be examined with the bright disc of light which may be obtained in the circle of dispersion above or below the radiant point. Several instruments have been devised for the purpose of rendering the light in this disc more intense. LARYNGOSCOPY. 279 One of the simplest of these is Krishaber's illuminator (Fig. 55). It consists of a reflector and a convex lens, which may be fastened by the clamp to an ordinary lamp. This apparatus will often give very satisfactory results. Mackenzie's bull's-eye condenser is used for the same purpose. It consists of a rack-movement gas fixture with a metallic chimney, which can be adjusted to the ordinary gas-burner (Fig. 56). The chimney has an orifice on one side for the condensing lens, and the latter is placed at a fixed point in front of the flame, so that the rays of light on leaving Fig. 57.- -Modification of Mackenzie's Illuminator, which may be Used either with a Student's Lamp or an Argand Gas-burner. it will be nearly parallel. This illuminator may be brought directly in front of the patient's mouth for direct illumination, but it is generally used with a reflector of from eleven to fourteen inches focal distance. Fraenkel's illuminator is somewhat similar in construction as regards the condensing lens, but is so arranged that the rays of light on leaving the lens may be made either divergent, parallel, or convergent, according to the size and focal distance of the reflector which is employed. In accordance with my suggestions a similar condenser has been con- structed, which may be used with the ordinary Argand gas-burner or Ger- man student's lamp (Fig. 57). In this condenser the lens, which has a focal distance of three and one-half inches, is set about two inches from the name, so that the rays of light are divergent on leaving it, and are thus adapted 280 THE THROAT. for a reflector with a focal distance of seven or eight inches. If it is desired to obtain a bright circle of dispersion for illumination, or to use a reflector with a longer focal distance, the cap in which the lens is set can be drawn out so that the rays will be less divergent. This condenser is comparatively inexpensive, and possesses all the advantages of the last two described, as well as those of Tobold's illuminator, without the imperfections of the latter. With this condenser and Fraenkel's, either the radiant point or the circle of dispersion may be used for illuminating the glottis. Tobold's illuminator, a combination of lenses devised by Tobold, is in common use. Weil has shown that the apparatus is improved by re- moving one or two of its lenses. These lenses merely cause a large circle of dispersion, which, though brilliant when thrown on an external object, is, in point of fact, less intense than the image of the flame. Tobold's apparatus has a combination of three lenses, two of which, each having a focal distance of about three inches, are placed closely together, and so near the flame that they collect divergent rays as they leave the lamp, and con- centrate them to a focus about six inches in front of the second lens. The third lens, farthest from the flame, has a focal distance of about five inches. It is placed four inches in front of the second lens, about two inches within the point at which the rays of light are concentrated by the latter, so that the rays of light falling on it are convergent. The convergent rays, bypassing through the third lens, are rendered still more convergent, and are brought to a focus about three inches in front of the apparatus, where the image of the flame is perfect. The reflector is fixed about four inches in front of the apparatus, or one inch beyond the radiant point of the last lens. Here the rays, having crossed, are so widely divergent, that a reflector of one and a half inches focal distance would be re- quired to concentrate them upon the glottis. The reflector used has a focal dis- tance varying, in different instruments examined, from five to nine inches. There- fore the rays must also leave the reflector widely divergent, so that most of them will be lost. Hence, we see that the large bundle of rays collected by the first lens, which might then have been entirely utilized, is first subjected to the loss incident to refraction, and then largely thrown away. We must admit that a sufficient number of rays are still retained to give a good illumination, though less intense than when only one lens is employed. Xo advantage can be derived from such a combination, except where cheap lenses of a moderate convexity are placed together to secure a short focal distance. A single lens of sufficiently high power to ac- complish the same result would be comparatively expensive. Tobold has also devised a smaller instrument known as the pocket illuminator, the construction of which is similar to that of the one just described. The image of the flame may be so magnified by a single lens, as found in the condensers already mentioned, that it is as large as can possibly be reflected from any throat mirror. In using condensing lenses, any one of three methods may be adopted : the flame may be placed at the focal point of the lens; it may be placed beyond the focal point ; it may be placed nearer to the lens than its focal point. With the flame at the focal point, the rays which always leave the LARYNGOSCOPY. 281 light in a divergent direction are refracted, so as to leave the lens in a parallel direction, and they must then be managed in the same manner as the parallel rays of sunlight or diffused daylight. In this instance, a reflector of a diameter the same as that of the lens should be em- ployed, having a focal distance of from eleven to fourteen inches. This will bring the image of the flame upon the glottis, providing the eye is from five to eight inches from the mouth. When the flame is placed beyond the focal distance of the lens, its divergent rays, after passing through the lens, become convergent. Here the reflector may be smaller than the lens, but it must have a focal dis- tance of more than eleven inches; otherwise the rays will be brought to a focus too soon. When the flame is placed nearer the lens than its focal distance, the rays, after passing through, are still divergent, and, in order that none be lost, they must be received on a reflector larger than the lens, which must have a focal distance of not more than eight inches, the same focal distance as that required when a flame is used without a condensing lens. This is by far the best method for practical purposes, as it gives an illumination equally as good as the other methods, and does not ne- cessitate the possession of a number of reflectors. Some form of condenser is desirable for office use, but I have always found a simple concave reflector of large size and short focal distance sufficient for purposes of diagnosis, and ordinarily for operations within the larynx. Such a reflector may be used with an ordinary gas-jet or with any lamp, and may be sufficient, even if one is obliged to rely on candles. For general use it will certainly be found more satisfactory than a cumbersome illuminating apparatus. When performing operations in the larynx, it is desirable to have as large a field illuminated as possible. This may be attained by means of the bull's-eye condenser with the ordinary flame, or with a brighter light and a reflector with a long- focal distance, so that the circle of dispersion can be utilized in place of the radiant point. Several laryngoscopes, illuminated by electric light, have been in- vented, but they are not usually so satisfactory as the simple reflector and Argand burner or German student's lamp. A bright electric light, if properly arranged, would perhaps be the best for laryngoscopy, and, next to it, the oxyhydrogen light. The former, however, cannot always be obtained, and the latter, besides being difficult to manage, requires a great deal of apparatus, and is consequently expensive. A good Argand gas-burner or a German stu- dent's lamp with a bull's-eye condenser is all that is necessary for illumination, even during operations. I have sometimes obtained brill- iant illumination even with a common kerosene lamp, having a circular wick like that shown in Fig. 55. For purposes of diagnosis, any ordi- nary lamp, freshly trimmed, and Avith a clean chimney, wiK generally be 282 THE THROAT. sufficient. As suggested by J. Solis Cohen, two or three candles tied together, and placed in front of the bowl of a spoon used as a reflec- tor, may be made to answer the purpose if a lamp cannot be obtained. Diffused daylight,' when properly managed, gives a beautiful illumi- nation of the larynx. Artificial light more or less discolors the image, causing the normal larynx to appear yellowish or red, whereas diffused daylight shows the parts in their natural colors. Unfortunately the latter is seldom sufficiently bright. On a bright day, if light can be admitted through a small opening into a darkened room, so as to fall upon the reflector, it will give a good illumination. If it is impossible to admit the light through a small aperture, a good view may sometimes be obtained by placing the patient at the farther side of the room, op- posite a single window left uncovered, with his back to the light. This position will give a much better view than when the patient is placed near the window. Direct sunlight may be employed, with the patient facing the win- dow, in such a position that the rays fall upon the throat mirror held in the pharynx. A serious hindrance to this method is that the light can- not often be obtained in a suitable position. Reflected sunlight may more frequently be employed with the aid of a plane reflector, or of one with a long focal distance, but it is only in comparatively rare instances that we have a proper exposure and find the sun at the desired altitude. Heliostats have been constructed for reflecting the sunlight in a given direction. They may be arranged by a system of clockwork to maintain the beam of light at a given point throughout the day. This apparatus is very expensive, and not to be recommended. An ordinary toilet mirror may be so placed as to receive a beam of sunlight, and direct it horizontally in any desired direction; but this is not often satisfactory for consecutive work. For the reasons named, we are usually compelled to use artificial light. Laryngoscopy should be practised with both natural and artificial light, to give familiarity with the appearance of the parts under both forms of illumination. The same larynx will have different shades when viewed by different lights; what appears congested when viewed by artificial light, may seem of normal color by daylight. For the purpose of magnifying the image of the larynx, Wertheim recom- mended concave throat mirrors, and Turck suggested a small telescope, some improvements in which were made by Voltolini ; but these have all been found practically useless. The laryngoscope which I prefer consists of a perforated reflector four inches in diameter (Fig. 58), with a focal distance of eight inches, attached to Schrotter's head band, with nasal rest, by means of a ball- and-socket joint; with three round throat mirrors, three-eighths, seven- eighths, and nine-eighths of an inch in diameter respectively, the small- LARYNGOSCOPY. 283 est for children, and one oval mirror three-fourths of an inch in diame- ter, for use in cases of enlarged tonsils. As before stated, these throat mirrors should be backed with silver-leaf and firmly fastened to an in- flexible stem, which may be permanently fastened to the handle or not, as is most convenient. The reflector need not be more than three and one-half inches in diameter, but the larger instrument will reflect a greater number of rays, and thus give a somewhat brighter illumination. The four-inch reflector possesses the additional advantage, when worn before one eye, of shading the other from the light. The only objection I have found to it is that the attachment for the ball-and-socket joint is in some instruments placed too far from the perforation, causing diffi- Fig. 58.— Laryngoscopy Reflector, with attachment for holding lens co correct defective ac- commodation. The ball for ball-and-socket joint should be placed accurately \% inches from centre of reflector. culty in bringing the perforation squarely before the eye. This objec- tion should always be remedied by the manufacturer. For an illuminating apparatus, we may use an Argand gas-burner at- tached to a rack-movement fixture, similar to the one shown (Fig. 56), or a German student's lamp, which may be supplemented by a condenser (Fig. 57). Manipulation of the Laryngoscope. — After familiarizing ourselves with the laryngoscope and the rules for its use, before attempting laryn- goscopy on a living subject, it is well to practise for some time on a dummy, or on a larynx which has been removed from the body and attached to a standard. If one of these cannot be obtained, we may easily make a model by boring a couple of holes in a block of wood — one about two inches in diameter to represent the mouth, and the other about an inch in diameter, intersecting the first at an angle of eighty degrees, to represent the larynx. By practising on it we may 284 THE THROAT. familiarize ourselves with the management of the light, reflector, and throat mirror, and may educate our hands to steadiness. Having learned to control the hands so that the mirror will not tremble, and to reflect the rays of light accurately to the objective point, we may begin to practise upon the living subject. A novice at first will find it of great advantage to practise upon a patient who has been trained and can undergo the manipulations of an unskilled hand with- out retching ; subsequently he should practise upon healthy individ- uals for some time, in order to become so familiar with the normal appearance of the larynx that any deviations from it will be at once recognized. For the most favorable laryngoscopic examination the patient should be seated in an erect position with the head thrown slightly Fig. 59.— Position of Head giving the Best View of Larynx, as shown in small err at thb LEFT (ALTERED FROM BROWNE). back. The physician should be seated in front on the same or on a slightly higher level, and as close as possible, with one knee on either side of the patient's knees, which are brought together. It is often necessary to make the examination with the patient slightly propped up in bed, and the physician sitting as best he may beside him ; or with the patient standing, as when a library drop-light is used, which cannot be brought low enough to illuminate the throat when the patient is sitting. The most suitable seat for the patient is a narrow chair, with a straight back, sufficiently high to support the head, and a seat not more than a foot in depth, which will compel the patient to sit erect. For the physician a small stool, which can be raised or lowered to any de- sired level, is most convenient. LARYNGOSCOPY. 285 The patient should be seated beside or just in front of the table which holds the instruments, with a cuspidor beside him, and a glass of water close at hand. If direct sunlight is employed, the patient should be placed near the window, facing the light, which, coming in over the physician's shoulders, falls directly upon the pharyngeal mirror. With reflected sunlight, the positions of patient and examiner as regards the window are reversed. When artificial light is employed, the examining- room should be shaded. The light should be placed on a level with the eyes of the patient, and slightly behind him, so that it will not shine on his face, and about six inches distant at one side, so that the rays may fall without obstruction on the reflector. If the flame is much above or below the level of the eyes of the patient, or far from his head, at one side, the angle at which the rays fall upon the reflector will be so great that a good illumination will be impossible. The patient's Fig. 60. — Position of Head giving a Pooh. Vifw of Larynx, as shown in the small cut AT THE LEFT (BROWXE). head should be inclined backward (Fig. 59), so that the edge of the upper incisor teeth will be nearly on a horizontal plane with the poste- rior margin of the soft palate. The reflector may be worn on the forehead, or preferably before one eye. If the lamp is on the patient's right, the reflector should be placed in front of the examiner's left eye, or vice versa. The throat mirror may be held in either hand, the j)atient's tongue being held by the other or by the patient himself. Eight-handed persons should educate the left hand to the task as soon as possible; for when other instruments are to be used, the right hand will be required for them. Even in diagnostic manipulations ambidexterity is very desirable, for by hold- ing the mirror first with one hand and then with the other, any false impressions of asymmetry may be corrected. 286 THE THROAT. In making a laryngoscopic examination, everything being in readi- ness, the physician takes his position in front of the patient, and fixes the reflector in its place; his eve is now brought within about ten inches of the patient's lips, upon which the light is directed. If the lamp has been placed at the proper distance, a perfect inverted image of the flame will be seen on the patient's lips: otherwise the light should be moved backward or forward until this result is obtained. The patient Fig. 61.— The Laryngoscopic Mirror in Position. Stem td One Side (Cohen). is then directed to protrude his tongue, which the physician grasps and holds between his thumb and fore-finger, which have been previously enveloped in a soft napkin. The eye of the examiner is then brought about four inches nearer, and the light from the reflector is so directed that the brightest point falls on the base of the uvula, where it must be retained. The throat mirror, having been warmed for a moment over the lamp and its temperature tested on the cheek or back of the hand, is carried into position in the throat, and, by a slight, steady movement of the mirror, the image of the larynx is brought into view (Fig. 61). LARYNGOSCOPY. 287 The first difficulty which the beginner experiences is to direct the light into the month, and the second is to keep it there. These difficul- ties may be readily overcome by practice, and should always be mastered on a dummy or some other object before an attempt is made to examine a patient. The patient should protrude the tongue as far as possible by the muscles of the tongue itself, and it must be held gently by the physician without an attempt to draw it farther out, for such an attempt would cause pain and contraction of its muscles. A soft cloth is necessary in holding the tongue, not only for neatness, but because if it be grasped simply with the fingers it will slip away. In holding the tongue, the finger which is beneath it should be held slightly higher than the edge of the lower teeth, or the teeth may be covered by a napkin to avoid injury to the frsenum. Whenever both of the physician's hands are to be occupied with in- struments, the tongue may be held by the patient; sometimes this is a useful aid in overcoming the individual's nervousness. The throat mirror employed must correspond to the size of the fauces. The one most generally useful for adults is seven-eighths of an inch in diameter; but mirrors one and one-fourth inches in diameter, or even somewhat larger, may often be employed. The larger the mirror, the better the illumination. The mirror should be warmed so that the moisture of the breath may not condense upon it. When first placed over the flame, a thin film will be seen to spread over its surface, which disappears as soon as the glass becomes warm. It is then of a proper temperature for use, but should always be tested on the cheek or back of the hand. Instead of warming the mirror, its surface may be covered with a solution of glycerine and water to prevent condensation of moisture ; this does not leave so good a reflecting surface, and, as a result, the image will be less distinct. Other devices have been suggested for preventing condensation of the breath on the mirror, but they are of no practical value. The mirror is less irritating to the fauces when warm, and it will re- tain the heat as long as it ought to be kept in the throat. It should be held like a penholder between the thumb and fingers, with the hand bent slightly backward upon the wrist. It should be passed horizontally into the mouth, with the reflecting surface downward, and carried promptly midway between the tongue and the roof of the mouth, back to the uvula, which is caught upon it and carried upward and backward, until the rim of the mirror almost touches the posterior wall of the pharynx. If the uvula hangs too low to be easily caught on the back of the mirror, it may be elevated by causing the patient to take a deep inspiration or to phonate the syllable ah or eh. If the throat will tolerate it, the mirror may be rested against the posterior wall of the pharynx. x!S8 THE THROAT. The stem of the instrument may be held either above or at one side, and its handle should be carried outward toward the angle of the mouth, so that the hand will not obstruct the light. The angle of the mirror should be about forty-five degrees to the plane of the horizon, though, in practice, it will be found that good views can be obtained from dif- ferent points with the mirror in various positions, by altering the rela- tive positions of the physician and patient, or by inclining the patient's head more or less. If the light has been properly directed, it will now fall on the mir- ror, whence it will be more or less perfectly reflected into the larynx, an inverted image of which will be seen in the mirror (Fig. 61). If the view be not perfect, the mirror may be slightly rotated or its obliquity altered by moving the handle ; but these movements must be few and precise, for if many or executed by an uncertain, tremulous hand, retch- ing is apt to occur. Beginners generally have considerable difficulty in this manipulation either by losing the light or by being unable to obtain a view of the larynx, on account of an improper position of the throat mirror. In either case, the mirror should be promptly withdrawn and reintroduced, for if held in position while the light is being rearranged, or if moved about in the throat to secure another view, it is likely to irritate the fauces. With the throat mirror in position, one will obtain a more or less perfect view of the base of the tongue and of the larynx. If only the base of the tongue or the upper part of the epiglottis is brought into view, depressing the handle slightly will expose the parts below; if these are first brought into view, the superior structures may be ex- posed by elevating the handle. By rotating the mirror slowly, the lateral walls of the pharynx or larynx may be exposed. To expose the anterior or larygneal surface of the arytenoids, the head should be thrown slightly backward during a deep inspiration, and the light should be directed more posteriorly than in illuminating the cords, by holding the throat mirror more nearly horizontal. To expose their posterior or pharyngeal surface, the head should be nearly erect, and the mirror should be held as just directed while the voice is sounded. To examine either side, the mirror should be placed partly upon the opposite side of the fauces, with its obliquity changed so as to illuminate the parts to be inspected. In order to obtain a good view of the laryngeal surface of the epi- glottis, the patient should be directed to sound a high note quickly and with considerable force. This throws the cartilage upward with a sud- den jerk. An inspiration accompanied with sound or an ironical laugh will answer the same purpose. The hand which holds the mirror may be steadied by resting the ring and little fingers on the patient's cheek. OBSTACLES TO LARYNGOSCOPY. 289 The mirror should not be kept in the throat more than twenty or thirty seconds, but the examination may be continued by reintroducing it several times. Whenever the slightest indication of retching occurs, the mirror must be instantly withdrawn, but, after a few moments, another trial may be made, which the patient will usually tolerate as well as the first. When inserting the mirror, its reflecting surface should not touch the tongue, nor its back rub against the palate. The former accident clouds the reflecting surface, and either is likely to cause retching or an attempt to swallow, which will prevent the examination. OBSTACLES TO LARYNGOSCOPY. The obstacles frequently encountered in laryngoscopy can usually be overcome by a little tact and patience, at least at a second sitting. We should not expect a thorough view of the larynx without introducing the mirror two or three times; though, if the patient's throat is not sensitive, by rotating the mirror slightly the entire larynx may some- times be inspected with a single introduction of the mirror. The principal obstacles to be overcome are : an elongated uvula, en- larged tonsils, irritable fauces, a short frasnum, arching upward of the back of the tongue, and a pendent epiglottis. In two cases, one an actor, and the other an elocutionist, I have found difficulty in inspecting the larynx apparently on account of hypertrojdiy of the lingual muscles, which greatly restricted the space between the tongue and the posterior wall of the pharynx. An elongated uvula, hanging below the mirror, appears as though curled over the lower edge and resting upon the reflecting surface. This is very confusing and prevents a view of the parts below. To obviate this difficulty in ordinary cases, it is only necessary to use a large mirror and to be careful in placing it against the uvula. Mir- rors have been devised with a little pocket in the back for catching the uvula, but they are now rarely if ever used. If the uvula is so long that it cannot be managed with a large mirror, it may be contracted by as- tringents; if these are inadequate, it should be amputated and the ex- amination made at a subsequent sitting. On account of irritable fauces some patients cannot bear simple Inspection of the mouth without gagging or retching; others are so af- fected when the tongue is protruded ; still others as soon as the throat mirror touches the fauces. To overcome these difficulties, the patient should be fully impressed with the necessity of the examination, and urged to restrain himself from retching; the mirror should then be introduced during a deep inspiration or as the patient says eh or ah, which elevates the uvula, and, by thus preventing the necessity for pressure against the palate, secures nauch greater tolerance of the instrument. T 9 200 THE THROAT. "With nervous patients it is often best, for the sake of first gaining their confidence, to introduce the mirror once or twice so as just to touch the palate, and then withdraw it at once without attempting to see the larynx. Ice may be sucked for fifteen or twenty minutes, to produce some degree of temporary local anaesthesia. If these devices fail, the most feasible method for overcoming the disposition to retching is an application a few times of a small amount of a ten-per-cent solu- tion of cocaine, by spray. Many persons, in whom the pharynx is sensitive, will tolerate an examination at a second or third sitting, in whom hardly a glimpse could be obtained at the first. In such cases it is a good plan to have the patient educate the throat to bear instruments, by introducing a spoon- handle against the uvula before a mirror several times daily during the interim. In cases of irritability of the fauces, some laryngologists recommend titilla- tion of the palate with a probe or a penholder before attempting to introduce the mirror, in order that the parts may become accustomed to manipulation. Various other devices have been recommended for overcoming the sensitiveness such as painting the fauces with chloroform and morphine, inhalation of a few whiffs of chloroform, and the internal use of large doses of potassium bromide ; but none of these measures are very satisfactory. Ordinarily we will succeed best simply by patience and care in introducing and holding the mirror, supple- mented, when necessary, by the use of ice or cocaine. The fauces are more irritable when the stomach is disordered and during digestion than at other times; therefore it is best, whenever the throat is sensitive, to make the exami- nation before eating or not until three or four hours afterward. A short fr.esum is one of the minor obstacles. If it proves very troublesome, it may be cut witli a pair of blunt-pointed scissors. Archixg of the toxgue occurs in some patients just as the mir- ror is being carried between the teeth, the posterior part of the tongue arching upward, so as to touch the soft palate, and thus preventing the passage of the mirror into the fauces; or remaining here to intercept the rays of light after the mirror is in position. This difficulty is best overcome by cautioning the patient not to strain and by care not to draw the tongue far out of the mouth or downward toward the chin. Sometimes a good view of the larynx can be obtained in these in- stances by holding the throat mirror nearly horizontally against the palate, and reflecting the light upon it from below upward. In some cases, the patient, by watching the movements of his tongue in a hand mirror, may be able to keep its base depressed. Other patients will need to practise before a mirror at home for several days before control of the organ can be obtained. Tongue depressors seem indicated in these cases, but are of little value. Greatly enlarged toxsils may prevent the introduction of any mirror into the throat; in such cases the only remedy is excision. When OBSTACLES TO LARYNGOSCOPY. 291 they are only moderately enlarged, it will sometimes be impossible to introduce the ordinary mirror without touching them both, and perhaps causing retching; but in many cases, if the mirror is carried promptly between and behind the tonsils, the throat will remain quiet, even though both sides have been touched. In other cases it is best to use an oval mirror, which may be passed into the fauces without touching the tonsils. A laege or pendent epiglottis is sometimes an insurmountable obstacle to laryngoscopy. When the glosso-epiglottidean ligaments are relaxed, or when the epiglottis is swollen, it falls downward, so that its Fig. 62. — Bkuns' Pincette free edge may rest against the pharyngeal wall, leaving little if any space for the passage of light. In some of these cases we can obtain a view of the larynx by causing the patient to sound the letter e in a high key or to utter a high falsetto note. A vocal sound, as ah or eh made during inspiration, will have a similar effect. By a laugh or a cough the epiglottis may be thrown upward with a sudden jerk. In other instances it is only necessary for the patient to drawn a deep breath in order to raise the epiglottis sufficiently to give a view beneath it. Frequently by passing the mirror lower into the pharynx, and more perpendicularly than usual, the inferior surface of the epiglottis and other portions of the larynx may be seen. Various instruments have been devised for lifting the epiglottis. The best of these is known as Voltolini's staff, a stout whale- bone or metallic rod, bent nearly to a right angle about an inch from the end, with its terminal extremity turned slightly backward. It may be passed behind the lip of the epi- glottis, so as to lift and draw it forward. Occasionally when operations are to be performed, or for simple inspection, some special instrument may be necessary to hold the lip of the epiglottis forward. For this purpose Bruns' pincette has been recom- mended. Instruments of this kind, how- ever, usually cause too much irritation to be tolerated, and a simple bent staff or strong probe will be found preferable. It occasionally happens that only the posterior part of the larynx can be seen, and the vocal cords cannot be brought into view. In such in- Fig. 63.— Infra-glottic Laryn- goscopy Small metallic mirror in position in the fenestra of the tracheal canula. 292 THE THROAT. stances the movements of the arytenoid cartilages may be seen suffi- ciently to enable us to judge of the mobility of the cords; but the ap- pearance of the tissue covering them is not an accurate indication of the condition of the mucous membrane in other portions of the larynx. INFKA-G LOTTIC LARYNGOSCOPY. It is sometimes desirable to inspect the larynx from below, which may be done, after tracheotomy, through a fenestra in the canula, by the aid of a small metallic mirror (Fig. 63). CHAPTER XVII. DISEASES OF THE THEOAT.— Continued. THE LARYNX AND RHINOSCOPY. The image of the larynx, as seen in the throat mirror, is reversed, so that the anterior portion, nearest the observer, appears in the glass above and farthest from its surface, the portion normally posterior appearing Fig. 64. Fis. 65. Fig. 64. — Relative Positions of Larynx and its Image in the Laryngoscopy Mirror (Cohen). Fig. 65.— Normal Larynx in Respiration, enlarged. Parts exaggerated to render them more conspicuous. 1,1, Lingual surface of epiglottis ; 2, 2, laryngeal surface of epiglottis ; 3, indented crest of epiglottis ; 4. 4, pharyngo-epiglottic folds ; 5, 5. ary-epiglottic folds ; 6, cushion of epiglottis ; 7. glosso-epiglottic ligament ; 8, 8, valeeulas ; 9, 9, pyriform sinuses ; 10, 10, posterior pharyngeal wall and entrance into oesophagus ; 11, inter-arytenoid incisure ; 12, 12, cartilages of Santorini ; 13, inter- arytenoid fold ; 14, 14, cartilages of Wrisberg ; 15. 15. ventricular bands ; 16, 16, vocal cords ; 17, 17, ventricles : 18, 18, posterior vocal processes ; 19, thyroid cartilage ; 20. crico-thyroid membrane ; 21, cricoid cartilage ; 22, 22. 22, rings of trachea ; 23, 23, 23, 23, interspaces between rings of trachea (Cohen). below close to the lower edge of the mirror. The sides of the larynx are not reversed in the image. An image of the whole larynx can seldom be obtained at a single glance; but by slight rotation of the mirror, with elevation and depres- sion of the handle, so as to alter the plane of the reflecting surface, the different parts may be brought into view. The vocal cords, because of THE THROAT. their white appearance and frequent respiratory movements, naturally attract the most attention, and when once seen can hardly be forgotten; but the epiglottis comes first into view. The normal larynx is shown in a somewhat exaggerated form (Fig. 65) in order that the parts may be more clearly identified. The epiglottis is a leaf-like valve, which covers the upper opening of the larynx and closes it during deglutition. The base of the epiglottis — in reality the apex of the cartilage — is connected with the thyroid cartilage at its receding angle by a long narrow band, known as the thyro-epiglottic ligament; a small band, the hyo-epiglottic ligament, connects it with the posterior surface of the hyoid bone. The free extremity is broad and rounded. The lingual or upper surface of this oartilage usually curves forward, its concavity toward the base of the tongue. Its covering of mucous membrane forms a median and two lateral folds, known as the glosso-epiglottic folds. The central one of these is also called the frsenum of the epiglottis, or the glosso-epiglottic ligament as it contains a ligamentous band. The lateral folds contain no fibrous tissue and are frequently absent. The laryngeal or inferior surface curves in a reverse direction. It is convex from above downward, and concave from side to side. To its sides are attached the pharyngo-epiglottic and the ary-epiglottic folds. It varies greatly in size and form in different individuals (Figs. 66 to 71). It may be long and thin, or short and thick; it may be broad, or narrow and pointed ; its free edge may be curved like a bow, it may be folded in upon itself like a scroll in what is known as the jews-harp form (Fig. TO), or it may be asymmetrical. It may cover the whole larynx, or it may be nearly invisible. Sometimes only the upper or an- terior surface of the epiglottis can be seen, at other times its lower por- tion or laryngeal surface is most visible; again, only its tip is brought into view; and still again considerable portions of both the anterior and the posterior surfaces may be seen at the same time. With respiration, the lip of the epiglottis rises and falls slightly. With phonation it is generally thrown upward, and in deglutition it is carried downward to the posterior border of the larynx. The whole epiglottis is seldom visible even to a skilful laryngologist. Usually a portion of its upper surface is visible on each side. In the middle, its laryngeal surface is turned upward like a lip, and below this a small prominence may frequently be seen near the base of the epiglot- tis, known as its cushion, pad, or protuberance (Fig. 68). The color of this organ varies in different parts. The upper surface is of a pinkish hue, and frequently blood-vessels may be seen crossing it. The lip looks like a yellow cartilage, as it really is, covered with mucous membrane. The cushion generally appears of a much brighter red color than other portions of the e])iglottis. When the whole of the laryngeal surface can be seen, it often has a uniform bright-red color, THE LARYNX. 295 which might be easily mistaken for congestion. When only the edge of the epiglottis is visible, it appears like a pale whitish line just beneath the base of the tongue. The vallecula, upon either side of the fraenum of the epiglottis, are two sinuses known also as the lingual sinuses, closely resembling de- pressions, such as might be made by pressing the tips of two fingers into Fig. 60. Fig. 68. Fig. 70. Fig. 71. Figs. 66 to 71.— Normal Larynx, showing Various Forms of Epiglottis and Supra-aryte- noid Cartilages. Fig. 66. — Pitcher-shaped Inter- arytenoid Fold, Phonation. Fig. 67. — Lapping of Arytenoid Cartilages in Phonation, with Gaping of Vocal Cords. Fig. 68. — Cushion of Epiglottis Visible ; no Gaping of Vocal Cords in Phonation (Ziemssen). Fig. 69. — Pointed Epiglottis; Ventricles Distinct; Inspiration. Fig. 70.— "'Jews-harp 1 ' or Omega-like Epiglottis. Fig. 71.— Female Larynx in Respiration (Cohen). The female larynx may have the form shown in any of the preceding figures. some plastic substance (Fig. 65). They vary greatly in depth and in width in different individuals, and in various positions of the epiglottis in the same individual. These sinuses should always be examined as they frequently give lodgement to portions of food which are a source of irri- tation, and they are sometimes the seat of ulcers. 19 " 296 THE THROAT. The akytenoid cartilages — so named on account of their appar- ent resemblance during phonation to the nose of a jjitcher — appeal be- neath the free edge of the epiglottis. They are two in number, one upon each side. They are located at the back of the larynx, resting upon the upper border of the cricoid cartilage. Each of these cartilages is somewhat pyramidal. The apex, which is slightly pointed and curved upward and inward, is surmounted by a small conical nodule, which has been named the corniculum laryngis or cartilage of Santorini. The cartilages of Santorini, which are usually about the size of a millet seed, are most prominent when the glottis is closed, as in phonation. The mucous membrane immediately covering their apices is of a lighter hue than that in other parts of the larynx, but the light color is usually surrounded by a zone of deeper red. The cartilages of Wrisberg are just external to the cartilages of Santorini, in the fold of mucous membrane which extends on either side to the edge of the epiglottis, prominences known also as the cuneiform cartilages. These cartilages vary considerably in form in different individuals. They are usually round, but are occasionally triangular, the apices being directed downward. Sometimes they are hardly visible, but they are gen- erally quite distinct and fully as large as the cartilages of Santorini. These, like the cornicula, are of a lighter color than the folds which contain them, but they are usually surrounded by a zone of mucous membrane redder than the general surface. In a few instances a small nodule, due to a third cartilage, is seen between the cartilages of Wrisberg and the cartilages of Santorini on each side. The cartilages of "Wrisberg and those of Santorini are some- times termed the supra-arytenoid cartilages. The arytexo-epiglottidean folds or the ary-epiulottic folds constitute the lateral and part of the posterior border of the superior opening of the larynx. They consist of folds of mucous membrane, one on each side, which extend like bows from the arytenoid cartilages up- ward and forward to the sides of the epiglottis. They are usually from one-twelfth to one-eighth of an inch in thickness, but are occasionally thin and sharp. In color they closely resemble the gums, and are somewhat lighter than the zones about the bases of the supra-arytenoid cartilages. The pyramidal, pyriforii, or laryngopharyngeal sinuses are found external to the folds just named, and between them and the wings of the thyroid cartilage. The broad end of each sinus is directed for- ward, and its apex backward. It is bounded internally by the quad- rangular membrane, the upper border of which is formed by the ary- epiglottic fold, anteriorly by the wing of the thyroid cartilage, and laterally by the wall of the pharynx. Like the valecula?, these sinuses often give lodgement to foreign bodies, and are frequently the seat of ulcerations. THE LARYNX. 297 The ventricular bands, known also as the superior or false vocal cords, the regulators of the glottis, or the superior ligaments of the larynx, are thick folds of mucous membrane which stretch across the larynx in an antero-posterior direction, about half an inch below its superior opening and a short distance above the true vocal cords. They are frequently very prominent, standing out in thick welts from the sides of the larynx. In other instances, they can hardly be distin- guished from the surrounding tissues. They are of a deeper red color than the tissues above them, but their inferior or inner borders gen- erally appear pale in the laryngoscopic image, on account of being illu- minated more perfectly than the surrounding parts. Just beneath the anterior ends of the false vocal cords and above the true cords may fre- quently be seen a fossa, about the size of a pin's head which has been Fig. 72.— View of Left Side of Larynx (Turck). a, Left vocal cord ; b, posterior portion of ventricle ; c, left ventricular band ; d, posterior surface of epigloteis ; e, border of ary-epiglottic fold ; /, left cartilage of Wrisberg ; g, right cartilage of Wrisberg ; h, right vocal cord. named by Mackenzie the fossa innominata. This communicates with the laryngeal sinuses upon either side. The ventricles of the larynx are found immediately beneath the ventricular bands. These consist on either side of an oblong fossa, which is the opening to a cul de sac of mucous membrane, known as the sacculus laryngis. They are bounded above by the false vocal cords; below, by the true vocal cords; and externally, by the thyro-arytenoid muscles. The ventricles are seldom seen, and, when visible, usually appear merely as dark lines ; but occasionally they are patulous, with a width of nearly one-eighth of an inch. The sacculus laryngis extends upward and outward in a conical form beneath the ventricular band. The mucous membrane lining it is studded with the openings of sixty or seventy follicular glands, the secre- tion from which is apparently intended for lubricating the vocal cords. This pouch is covered by a fibrous membrane, and this membrane by muscular tissue, which, according to Hilton, compresses the sacculus and discharges its secretion upon the vocal cords. The vocal cords, known also as the inferior or true vocal cords, are the most important objects to be seen on inspection of the larynx. 298 THE THROAT. They appear as two pearly white bands stretched, one along each side of the larynx from its anterior to its posterior part. In the adult they vary from five-eighths of an inch to one inch in length, and are usually about one-eighth of an inch in breadth; they are sometimes perfectly white in women, but in men they are usually of a yellowish white hue. They consist of fibrous bands covered by a thin layer of closely adherent mucous membrane, being attached anteriorly to a depression between the alae of the thyroid cartilage, posteriorly to the anterior angles at the base of the arytenoid cartilages. During respiration the cords alternately approach each other and recede, leaving between them a triangular opening for the passage of air. The cords and the space between them form what is known as the glot- tis. The free edges constitute the lips oi the glottis, and the chink or Fig. 73.— Normal Larynx of Woman in Formation of Head Tones (Cohen). fissure between them is called the rima glottidis. The front of the rima is formed by the anterior commissure of the vocal cords, its sides by the cords themselves, and its base by the arytenoid cartilages and the inter-arytenoid fold. In the adult, this fissure varies in length from seven to ten lines in women, and from ten to thirteen in men. At its widest part it ordinarily measures from three to six lines, but on deep inspiration it may measure as much as eight or ten lines. In children, it is of course much smaller. On inspiration, the cords separate widely at their posterior extremi- ties; but their anterior extremities remain close together, thus forming a triangular opening. On expiration they approach more nearly together, and in phonation their two borders are more or less closely approximated, but there is usually a narrow fissure between them throughout their en- tire length. In women, and occasionally in men, during the production of head tones, the vocal processes are pressed firmly together, so that the fissure is left only between the anterior parts of the cords. From a careful photographic study of the larynx during the produc- tion of the singing voice, Thomas R. French (Transactions of American Laryngological Association, 1888) concludes that the female voice has three and the male voice two registers; the transition from one to the next higher being usually marked by backward movement of the epi- THE LARYNX. 299 glottis, change in the shape of the glottis, shortening of the cords, and an apparent increase in their tension. Protrusion of the tongue does not materially affect the laryngoscopic appearance. The cords are sometimes lengthened in men on changing to a higher register. The processus yocales or vocal processes are sometimes seen as four yellowish spots, two anteriorly and two posteriorly, where the vocal cords are attached to the cartilages, but the anterior processes are not often visible. Usually, when we speak of the vocal processes, simply the anterior angles of the arytenoid cartilages are referred to. Carl Seiler has described narrow fusiform cartilages, found along the edge of the vocal cords in women. These are only rudimentary in men. The lnter-arytexoid fold or posterior commissure is a band of mucous membrane which extends between the arytenoid cartilages. The prominence of this fold depends upon the position of the cartilages. When the glottis is open, it may measure six or eight millimetres in length; but when the cords are approximated, it is folded upon itself so that it can hardly be seen. The cricoid cartilage may usually be seen a short distance below the vocal cords, separated from their anterior extremities by the lower portion of the thyroid cartilage and by the crico-thyroid membrane. This cartilage is of a lighter hue than the membranous tissue above or below it, and is similar in color to the rings of the trachea. The tracheal cartilages or rings of the trachea are usually visible, arching across this tube from side to side with their concavities directed inward and downward. The upper of these rings are very distinct and of a yellowish or a light pinkish hue. They are separated from each other by the intervening membranous tissue, which is of a darker color. As we carry the inspection farther down the trachea, the cartilages appear narrower and narrower until their outlines are finally lost. The mucous membrane lining the trachea is generally paler than that covering the surface of the larynx. Considerable variety in the shape and movements of different parts of the larynx may occur within the limits of health. This is especially the case with the epiglottis; and variations in the appearance of the ary- tenoid cartilages and of the commissures, and slight alterations in other parts of the larynx may occasionally be found, as illustrated in Figs. 66 to 71. The epiglottis may possess any of the various forms already spoken of. The supra-arytenoid cartilages vary considerably in their size and form, as already mentioned. The position of the arytenoids varies constantly with respiration and phonation, and may be quite dif- ferent in healthy individuals (Figs. 66 to 71). In disease of the larynx, changes in its form and movements consti- tute the principal signs. There may be hypertrophy or swelling of its various parts, with more or less loss of movement, or ulceration may THE THROAT. have destroyed more or less of the tissues. Sometimes the epiglottis is eo swollen and wrinkled as to be hardly recognizable; its free edge may be ulcerated, or the cartilage may be partly or entirely destroyed by the same process. Swelling of the inner extremity of the ary-epiglottic folds and of the tissues surrounding the arytenoid cartilages is fre- quently found upon one or both sides. Loss of movement occurs from cicatricial adhesions or paralysis. Morbid growths are of comparatively frequent occurrence. EXAMINATION OB THE TRACHEA. In order to obtain a good view of the trachea, it is usually necessary to hold the mirror more nearly horizontal than in the examination of the larynx, so as to reflect the light somewhat more posteriorly. The glottis must be widely opened, and the focal point of the light must fall Fig. 74.— View of Posterior Wall of Tra- chea and Bronchi, bs. Bifurcation of trachea ; sg, subglottic region ; p, posterior wall of tra- chea (Mackenzie). Fig. To.— View of Anterior Wall of Tra- chea and Bronchi, at. Anterior wall of tra- chea : /'■'■. tec, vocal cords ; rb, right bronchus ; lb. left bronchus : bs, bifurcation or bronchial spur i Mackenzie upon the parts to be examined; that is, at a distance of from seven to eleven inches within the lips, or from twelve to seventeen inches from the reflector, according to the portion of the tube to be examined. Sometimes we can obtain a good view by elevating the patient to a plane above that of the observer, and holding the throat mirror almost hori- Lontal so that the light may be thrown upon it from below upward. To expose the posterior wall of the larynx and the trachea, the patient's head should be kept erect, and the mirror held in a nearly hor- izontal position. With a good light and a favorable condition of the larynx and trachea, the openings of the main bronchi can frequently be seen, and in some instances a few of their cartilaginous rings may be counted. To illu- minate the bifurcation of the trachea, a good plan is first to obtain a view of the laryngeal surface of the epiglottis, and then, by gradually changing the obliquity of the mirror, direct the rays farther and farther downward along the anterior surface of the trachea until the deeper parts are brought into view, ANTERIOR RHINOSCOPY. 301 RHINOSCOPY. Khinoscopy or examination of the nasal cavities is termed anterior or posterior according to the position of the parts inspected. ANTERIOR RHINOSCOPY. Anterior rhinoscopy or the inspection of the anterior nares is per- formed with the aid of the laryngoscopic reflector and a nasal speculum. Various instruments have been made for the purpose. A simple bivalve Fig. 76.— Ingals' Nasal Speculum (3-5 size). speculum, such as shown in Fig. 76, is most satisfactory for purposes of diagnosis; but when operations are to be performed, instruments that will retain their position when placed in the nostrils are preferred by some laryngologists (Figs. 77 and 78). No special directions are needed for anterior rhinoscopy, excepting that, in order to view the back part of the nasal cavities from the front, a condenser, and a reflector as de- scribed with the laryngoscope, are very desirable, and it is absolutely (0> Fig. 77. — Jarvis 1 Small Nasal Speculum Q£ size). Fig. 78.— Sajous 1 Self-retaining Nasal Speculum (3-5 size). necessary that the light be properly focussed according to the principles laid down in speaking of condensing lenses. No obstacles will be found to the examination, excepting in unruly children, unless there be some deformity or swelling of the turbinated bodies. The latter is common, but may usually be quickly reduced by a small amount of a spray of cocaine. The nares are usually about one-eighth of an inch in width and from an inch to two inches in height. The inferior turbinated body is seen occupying about two-thirds of the outer wall; and the middle tur- binated, much smaller, is seen at the upper part of the cavity occupying about one-quarter of the outer wall, and usually approaching to within from one-twelfth to one-sixteenth of an inch of the septum. The superior turbinated body cannot be seen. The whole cavity is 302 THE THUn AT. covered with smooth mucous membrane, normally of about the same color as that covering the gums, but often, under less perfect illu- mination, 'appearing slightly congested. The normal relations of the parts, about an inch back of the nostrils, are shown in the accompany- ing cut from the photograph of a frozen section prepared for me by C. H. Stowell, of Washington, D. C. The soft tissues are somewhat shrunk- en, as always found in the cadaver. In about fcwo-thirda of all cases there is some disparity in size in the two cavities, due to deflection or to outgrowths from the bony or carti- Fig. 79.— Cross-section of Head, looking from before backward (4-5 natural size). Show- ing: a, a, middle turbinated bodies: b. b, inferior turbinated bodies: c. c.c. ethmoid cells: d. d, antra of Hifrhmore ; e, e. orbits : /. septum : y, hard palate laginous septum. Usually the turbinated bodies of one side are some- what swollen, so that it is exceptional to find the nasal cavities exactly alike. POSTERIOR RHINOSCOPY. Posterior rhinoscopy, or inspection of the vault of the pharynx and posterior nares, is practised with instruments similar to those used in the inspection of the larynx, and in much the same manner, excepting that a smaller mirror is necessary, and its reflecting surface is turned upward instead of downward. A mirror from half to five-eighths of an inch in diameter is usually employed, and it is generally best to have a flexible stem, which may be readily bent to conform to the floor of the mouth (Fig. 81). The mirror may be set at right angles to the stem, or at the same angle as the laryngeal mirrors, or at an angle between these two; but this is a matter of little importance, as the obliquity of the mirror may be easily changed by raising or lowering the handle. Special throat mirrors have POSTERIOR RHINOSCOPY. 303 been constructed for rhinoscopy (Fig. 80), but they are not superior to those already described. A tongue depressor will commonly be needed in rhinoscopy, and various forms of blunt hooks and other instruments may be used for holding the uvula; these latter are rarely employed and are seldom if ever of use except during operations. In rhinoscopy, the patient should sit erect, and the head must not be thrown backward, but may be slightly inclined forward. The physician should take a position as for laryngoscopy, or on a slightly higher level, and the light should be placed as for inspection of the larynx, except Fig. 80.— Fraenkel's Rhixoscope. The angle of the mirror (a) can be changed at will by moving the sliding rod at b that it should be on a level with the patient's mouth instead of his eyes. The patient's tongue should not be protruded, but must be left in the floor of the mouth, where it will generally need to be held by a tongue depressor, though some patients can control it better without an instru- ment. The rhinoscope in general use is a number one or number two laryngeal mirror, the stem of which is bent to conform it to the floor of the mouth (Fig. 81). It is to be warmed and introduced with the same care as in laryngoscopy, with the reflecting surface upward. It should be carried back to the posterior pharyngeal wall, though it is better to avoid touching it. The surface of the mirror will then be at an angle of about thirty degrees to a horizontal plane. The stem may be rested on the dorsum of the tongue, but care must be taken not to touch the base of this organ. The handle should be depressed nearly to the lower incisor teeth. A common cause of failure in this examination is holding the mirror handle too high. The mirror should be introduced first on one side of the uvula and 3< »4 77/F THROAT. then on the other, to give a view of different parts. In some cases a larger mirror ma}' be used if it is held completely below the uvula. When the mirror is in position, if only the posterior wall of the pharynx is seen, in order to expose the posterior Dares, the handle must be still farther depressed, or the mirror must be withdrawn and bent more nearly to a right angle with the stem. If at first only the uvula and posterior surface of the palate are exposed, the handle must be ele- vated to obtain a view of the posterior nares or vault of the pharynx. Fro. Si.— Position for Rhinoscopy, showing also Curve in Stem of Mirror. (Slightlj* altered from Browne.) The mirror may be rotated slightly to obtain an image of the lateral walls of the pharynx or of the orifices of the Eustachian tubes. OBSTACLES TO POSTERIOR RHINOSCOPY. Some of the obstacles to rhinoscopy are the same as those to laryn- goscopy, and demand similar treatment. Thus, the uvula may be elon- gated and the fauces may lie irritable. The principal difficulties met in the examination of the posterior nares are: irritability of the tongue causing the patient to retch when- ever an attempt is made to depress it with the spatula; an elongated or sensitive uvula; irritability of the fauces; too close approximation of the uvula and palate to the posterior pharyngeal wall. Irritability of the tongue will sometimes prevent the use of a tongue depressor, but it may generally be employed if the physician is careful not to allow it to slip too far back on the base of the organ. In many cases it is not necessary to depress the tongue with any instru- ment, if patients are instructed to allow it to remain passive in the floor OBSTACLES TO POSTERIOR RHINOSCOPY. 305 of the mouth. A hand mirror, in which the patient can see his tongue, will sometimes aid him materially in controlling it. In other cases the tongue may be held as in laryngoscopy. Some one of these methods will nearly always overcome this diffi- culty; but if they should all fail, the patient must practise at home be- fore a mirror until a spatula can be tolerated, or until the tongue can be held without one. Instruments have been constructed which combine a tongue depressor and the throat mirror; but they are not necessary, for, whenever the physician desires to use both hands, the care of the spatula may be in- trusted to the patient. Instruments of this kind are objectionable, as the depressor necessarily greatly restricts the movements of the mirror. An elongated uvula, so relaxed as to become an obstacle to the use of the rhinoscopic mirror, may be contracted by astringents. If the uvula is too long to be managed in this manner, it should be excised. Various instruments have been devised for raising the uvula and drawing it forward, but they are of very little service, as they usually cause so much irritation that they cannot be borne. Irritability of the fauces can be overcome in many instances by allowing the patient to suck bits of ice for ten or fifteen minutes. In other cases there must be prolonged practice by the patient at home in holding the tongue, and in touching the palate and pharyngeal wall with a spoon-handle. In obstinate cases a solution of cocaine may be used as in laryngos- copy. Closure of the post-palatine space, by contraction of the pala- tine muscles, often occurs the moment a patient opens his mouth, and it sometimes continues in spite of our best directed efforts to overcome it. This is the most common difficulty with which we have to contend in illuminating the vault of the pharynx and the posterior nares. Sometimes this difficulty may be overcome by cautioning the patient to allow the fauces to remain passive when the mouth is opened, or by directing him to simply open the mouth wide without attempting to show the throat. Then, by introducing the mirror carefully so as not to touch any part of the fauces, and removing and reintroducing it several times if necessary without attempting to obtain a view behind the palate, the patient's confidence may be secured and the examination completed. If the patient can be taught to breathe quietly through the nose during the examination, the palate will hang loosely so as to cause no trouble. Sometimes a view may be secured by directing the patient to sound n or ng. Frequently a glimpse may be had if the patient will attempt to expire through the nose. Various palate or uvula hooks have been constructed for the purpose of overcoming the difficulty; but, as has been well stated, the time spent 20 306 THE THROAT. in teaching the patient to tolerate them is usually more than is neces- sary to educate the throat to maintain a position which will require no instrument. Time, patience, and frequent practice by the patient at Fig. 82.— Rubber Palate Retractor tJ- 3 Mz»-i home must be the main dependence for successful examination in these cases. When operations are to be performed, the palate may be drawn for- Fig. 83.— Porchbr's Self-retaining Uvula and Palate Retractor (J^size.) ward by the palate retractor (Fig. S2), or by tapes passed through the nares by means of a Bellocq's canula or a catheter, and brought out of the mouth and tied. Soft rubber catheters passed through the nares, Fig. 84.— Palate Retractor CJ^ size). brought out at the mouth, and tied over the lip are very convenient for this purpose ; or the palate may be held by means of a broad, strong palate retractor. The palate retractor ordinarily sold (Fig. 84) is only Fig. 85.— Rhinoscope with Uvula Holder two-eighths or three-eighths of an inch in width, and is therefore too small for this purpose. Combinations of mirrors and uvula holders have been constructed, but they do not give general satisfaction. VAULT OF THE PHARYNX. 307 VAULT OF THE PHARYNX AND POSTERIOR NASAL CAVITIES. On account of the small size of the mirror which we are generally obliged to use, and the limited space through which the rays of light can be reflected, it is impossible to obtain a complete image of the posterior region with the mirror in any single position, but by slowly turning it from side to side, elevating or depressing the handle, and introducing the mirror first on one side of the uvula and then the other, part after part can be brought into view. The natural condition of these parts should be thoroughly studied from diagrams or models, before an attempt is made to inspect them in the living subject, and the student should make himself perfectly famil- iar with the description of different parts. When the mirror is first carried into the throat, we usually see in it the image of the upper sur- Fig. 86.— Rhinoscopic Image. 1, Vomer or septum ; 2, 2, free space of nasal passages ; 3, 3, supe- rior meatus : 4, 4, middle meatus ; 5, 5, superior turbinated body ; 6, 6, middle turbinated body ; 7, 7, in- ferior turbinated body ; 8, 8, pharyngeal orifice of Eustachian tube ; 9, 9, upper portion of fossa of Rosenmueller ; 11, 11, glandular tissue at the anterior portion of the vault of the pharynx ; 12, pos- terior surface of velum palati (Cohen). face of the palate, or of the posterior surface of the uvula, or of the pos- terior wall of the pharynx. If either of the first two is brought into view, we then elevate the handle of the mirror, or if the last is seen we depress it, and thus bring into the field of vision the parts just above the soft palate. We then search for the septum narium, which is to be taken as a starting point for further inspection. Having found the septum, we trace it throughout its entire vertical length from the narrow lower extremity, where it joins the palate, to its upper broad base which arches outward on either side at the top of the posterior nares. On either side of the septum the irregular outer border of the posterior opening of the nasal cavity should be traced from above downward past the projecting turbinated bodies to the orifice of the Eustachian tube, and finally to the palate and lateral walls of the pharynx. The middle turbinated body is the most prominent object at the outer part of the nasal opening ; but it seems overlapped at its lower part by the inferior turbinated body. External to the middle turbinated body, and just above that portion 308 THE THROAT. of the inferior turbinated body which seems to overlap it, is a dark space known as the middle meatus; and slightly external to the latter is the orifice of the Eustachian tube. Some physicians, instead of following this course in their inspection, prefer to start from the Eustachian tube, but this is merely a matter of habit. The septum narium divides the rhinoscopic view into halves. It forms a narrow, shining column below, near the palate, which gradually increases in breadth toward its upper part. At the lower part it appears of a pinkish, yellowish, or whitish color, according to the brilliancy of the illumination ; but toward the upper part or base the color deepens to a red like that of the surrounding mucous membrane. The color of the parts, as here described, is that observed by means of arti- ficial light. Natural light gives a paler hue. The sides of the septum, a considerable portion of which may be seen, are usually of a drab or ashy- red color, slightly darker in hue than the posterior edge, probably on account of being less perfectly lighted. The septum seldom occupies exactly the centre of the posterior nares, but inclines slightly to oue side. The middle turbinated bodies are easily found, as they are the most prominent objects in view on the external wall of the nasal cavity, of which they seem to constitute the greater part. They are covered with a thin mucous membrane of a pinkish or yellowish white color. The middle turbinated body sometimes resembles a mucous polypus, for which it may be mistaken by the student. The inferior turbinated bodies lie just below the preceding. They are considerably smaller than the middle turbinated bodies, and do not approach so near the septum. They are of a darker color, probably from deficient illumination. Not infrequently they have the appearance of solid tumors. The Eustachian orifice on either side is found a little external and posterior to the inferior turbinated body, usually on a level with the middle meatus, but sometimes slightly above or below it. Thi opening has an irregularly triangular or crescentic shape. It usually measures about a quarter of an inch in its longest diameter, but it is sometimes large enough to admit the tip of the little finger. The opening looks downward, inward, and slightly forward; it is bounded by two more or less prominent projections called the anterior and posterior walls or lips of the orifice, which are covered with a light red or yellow- ish mucous membrane. The former consists mainly of the fibres of the levator palati muscle, and the latter of the cartilaginous extremity of the Eustachian tube. From the posterior or lower lip a prominent ridge, formed by the levator palati muscle, runs downward and inward to the soft palate. From the anterior or upper lip a dark groove runs upward VAULT OF THE PHARYNA'. 309 and outward toward the vault and the posterior walls of the pharynx. This groove is known as the fossa of Kosenmueller or the recessus PHARYNGEI. The choanje or posterior openings of the nares are seen in front of the retro-nasal space. They are of oval form and usually about one-half an inch wide by three-quarters of an inch in height. Harrison Allen (Transactions of the American Laryngological Association, 1888) has shown that they are not infrequently of unequal size, without deviation of the septum, the left being usually the smaller. The superior turbinated bodies are located at the upper part of the nasal fossae and cannot be distinctly seen. They have the appear- Fig. 87.— Adenoid Tissue at Vault op Phar- ynx. Posterior wall of upper part of pharynx (Luschka). 1, 1, Pterygoid process ; 2, section of vomer ; 3, 3, posterior portion of the vault of the nasal fossae ; 4, 4, pharyngeal orifice of the Eustachian tube ; 5, orifice of the bursa pharyn- gea ; 6. 6, recessus pharyngeus (fossa of Rosen- mueller) ; 7, median folds formed by the adenoid substance of the nasal portion of the pharynx. Fig. 88.— Pharyngeal Bursa. Anteroposte- rior section (Luschka). 1, Section of basilar process of the occipital bone ; 2, body of sphe- noid ; 3, pituitary gland ; 4, adenoid substance of the vault of the pharynx, behind which is seen 5, the pharyngeal bursa. ance of narrow triangular projections, the apices of which point down- ward and inward. Their color is dark red, like that of the base of the septum. The superior, middle, and inferior meatus are the spaces found between the turbinated bodies and the external wall of the nasal cavity. The superior meatus, which is the largest, appears as a large shadow at the upper part of the fossa, just below the superior turbinated body. The middle meatus is seen as a dark opening near the middle part of the fossa, external to the middle turbinated body. The inferior meatus, if seen at all, generally appears simply as a dark line. The' vault of the pharynx is known also as the fornix pharyngis, old THE THROAT. and is sometimes spoken of as the tonsilla pharyngea. It is that por- tion of the pharyngeal wall which begins at the posterior nasal orifices and extends backward along the basilar process of the occipital bone, and then downward to be lost in the posterior pharyngeal wall. In the perspective view, which we obtain of this part by rhinoscopy, it appears shorter than natural. The mucous membrane is of a light red color, studded with minute whitish follicles, and broken on its sur- faces into irregular, more or less longitudinal fissures and ridges, which give it much the appearance of the surface of the faucial tonsil. This appearance of the surface is caused by glandular tissue which has re- ceived the name of tonsilla pharyngea. Near the middle, at the lower part of this glandular tissue, is an opening about the size of a pin's head, which leads up into a small cul de sac, known as the bursa pharyngea. The posterior surface of the uvula, palate, and pillars of the fauces may be seen below the nasal fossae. The palate appears in the rhinoscopic image as a fleshy ledge running at right angles with the septum. CHAPTER XVIII. . DISEASES OF THE FAUCES. ACUTE SORE THROAT. Synonyms. — Erythematous or catarrhal sore throat, cynanche pharyn- geal and others. An acute inflammation may affect the mucous membrane of the palate, pharynx, or tonsils, or all combined. Acute sore throat is found among people of all classes and occurs at all ages, but most frequently in young adults or children. It is said to be more common in those who have suffered from syphilis or who have been mercurialized, and among those who follow sedentary occupations. It is most often observed dur- ing the changeable weather of spring or autumn. Anatomical axd Pathological Chaeactekistics. — There is at first simple active hyperemia of the mucous membrane of the palate, pharynx, or tonsil, either circumscribed or diffused. Later, more or less swelling occurs, generally noticed at first in the uvula. In some cases the mucous membrane lies in thick folds, and occasionally the uvula and posterior pillars of the fauces are cedematous. The superficial blood- vessels are frequently distended, and soon the muscular and glandular tissues become involved, and the secretions, primarily arrested, are again established, but changed both in quantity and quality. In some cases the inflammation may terminate in suppuration. Etiology. — Acute sore throat is commonly caused by exposure to colds or draughts, especially in subjects who are living under the de- pressing influence of poor food, bad air, or scanty clothing; it also arises from sitting in warm rooms with heavy wraps, or working in a superheat- ed atmosphere, and then going out into the cold. Among the occasional causes are extension of inflammation from surrounding tissues, the in- halation of poisonous gases, the abuse of tobacco, the inhalation of steam, the taking into the mouth of irritant poisons or of hot fluids, the im- paction in the fauces of foreign bodies, and possibly the excessive use of spices. Over-use of the voice in poorly ventilated rooms or in the open air, especially at night, may be an exciting cause. Among the jjredis- posing factors are the syphilitic, rheumatic, and scrofulous diatheses. Symptomatology. — In mild cases the patient at first suffers simply from malaise, but soon experiences more or less headache and pain in the neck, back, and limbs. In severe cases the pain and constitu- tional symptoms are marked. Early there is irritation or a sense of itching in the throat, with pricking pain. A few hours later pain be- comes severe, especially as the patient attempts to swallow. 312 DISEASES OF THE FAUCES. When the inflammation is in the upper part of the pharynx, the pain often radiates toward the ears, and there is more or less deafness, due to extension along the Eustachian tubes. If the inflammation is at the inferior portion of the pharynx, the patient suffers from movements of the larynx, which is also sensitive on pressure. In severe cases the skin is hot, the temperature ranging at about 103° F. Indeed, the constitu- tional symptoms are out of all proportion to the amount of inflammation in the throat. The pulse ranges from '.tn to 120 or even 140, according to the extent of inflammation and the susceptibilities of the individual, all the symptoms being more marked in children than in adults. The voice often has a nasal twang, due to swelling of the palate and uvula and to pressure on the pharyngeal and palatine muscles by the inflamma- tory deposit. There is no hoarseness. Cough does not usually disturb the patient, unless the uvula becomes much elongated. There is, however, an annoying tendency to hawk and clear the throat of the secretions, throughout a considerable portion of the disease. At first there is but little expectoration ; later the secretions are more abundant, thick and tenacious, and hard to expectorate; finally they become muco-purulent. The tongue is nearly always furred, the breath is feverish and offensive, the bowels are constipated, and the urine is high colored. Upon exam- ination of the throat, the mucous membrane will be found of a bright red color, which may be limited to patches or diffused over the whole surface. The superficial blood-vessels are often, though not always en- larged; the uvula is usually congested and swollen, and occasionally the same condition extends to the posterior pillars of the fauces. The soft palate may also be considerably swollen, its edges having an cedematous appearance. Whenever oedema occurs, the mucous membrane is some- what translucent and of a lighter red color. The inflammation may extend over the palate, tonsils, and pharyngeal wall, and sometimes the swelling of the mucous membranes causes large longitudinal welts back of the posterior pillars. Occasionally, in severe cases, the parts are al- most livid. The cervical glands are very apt to be slightly enlarged. Diagnosis. — Acute sore throat is to be distinguished from scarlatina, acute tonsillitis, and rheumatic sore throat. The constitutional symp- toms in scarlatina are more marked than in acute sore throat, and usu- ally after a few hours a characteristic rash appears upon the skin. There is at first congestion in acute tonsillitis and pain similar to that in acute sore throat, but shortly the glands swell sufficiently to distinguish it from the disease under consideration. Again in acute tonsillitis the inflammation is apt to be confined mostly to one side for the first two or three days. The pain is greater in acute rheumatic sore throat and the congestion usually, though not invariably, less than in simple acute sore throat, and there is nearly always a rheumatic diathesis or a history of previous attacks, which aid in establishing the diag- nosis. ACUTE SORE THROAT. 313 Pkogxosis. — Acute sore throat runs its course in from seven to ten days, and is not dangerous to life: but often there remains a tendency to frequent recurrence of the attacks. In very rare cases it has proved fatal by extension to the larynx. Teeatmext. — Patients subject to acute sore throat should be espe- cially cautious about exposure; they should so clothe themselves as not to feel sudden changes of temj)erature; they should not sit in damp or overheated rooms, and, in a word, should avoid all the known causes of the affection. The cold sponge bath is of undoubted efficacy in prevent- ing the taking of colds. I direct patients to sponge the trunk once a day with cold water as it comes from the hydrant, either morning or evening as best suits their convenience or inclination. For the rugged, the morn- ing sponge bath is, as a rule, better, but for others I advise sponging at night in a warm room. The bath should be taken quickly, and the skin rubbed vigorously with a coarse towel to establish reaction. Full doses of quinine will sometimes abort an attack of acute sore throat. For this purpose, from six to ten grains should be given in a single dose, accord- ing to the peculiarities of the individual. Early in the attack, ice sucked continuously or applied about the neck in a rubber bag will frequently abort the inflammation. If the disease is not checked by these means, I advise small doses of ojfium, aconite, or belladonna, administered as follows : the tincture of opium, one minim every ten to thirty minutes at first, and less frequently as the patient experiences relief from the throat symptoms; or the tincture of aconite, one minim every fifteen to thirty minutes for three or four hours until perspiration is established, when the throat symptoms are generally relieved; subsequently once in one or two hours according to the fever; tincture of belladonna is given in similar doses with benefit in certain cases. I often rely upon potas- sium bromide alone, or with small doses of opium when the latter is well borne. The bromide is given in doses of ten or fifteen grains every three or four hours, according to the amount of pain. As the disease often occurs in persons of a rheumatic diathesis, and since it is sometimes im- possible to determine whether or not the rheumatic diathesis exists, a good practice is to alternate potassium bromide with sodium salicy- late in doses of seven and one-half grains or more every third hour. If the disease progresses, inhalations, from a steam atomizer, of solutions of the aqueous extract of opium, or of belladonna gr. i. to ij.; or carbolic acid gr. ij. in four drachms each of glycerin and water, will often be found very soothing. If there be constipation, it is desirable to give a saline cathartic. Some physicians favor a mercurial purge at first, especially in patients with engorgement of the portal system. It should be given in a single dose — for example, calomel gr. v., with sodium bicarbonate gr. v. — and followed after six or eight hours by a saline laxative. In nearly all affections of the throat, potassium chlorate is commonly administered; it is not certain that it has verv much influence on these diseases; but 314 DISEASES OF THE FAUCES. used as a hot gargle in connection with potassium nitrate, I find it often beneficial. I order one part of potassium chlorate to two parts of the nitrate in powder, and direct the patient to use of this a heaping teaspoonful dissolved in half a teacup of water, hot as can be borne, every half-hour or hour according to the severity of the symptoms. Sometimes the act of gargling is very painful. In such cases the patient should simply hold the solution in the throat as long as possible. In the latter part of the disease, astringent gargles of alum or tannic acid are usually recommended, but they are very unpleasant to most patients and do not appear to materially shorten the period of resolution. Astringent troches may be easily taken, and will be found beneficial at this time. For this purpose troches of krameria, each containing three grains of the extract, may be given every two or three hours. Guaiacum is recommended in cases of rheumatic origin, given during the first two or three days every two hours, in troches each containing two or three grains of the resin ; or in the ammoniated tincture, best administered in doses of one drachm every three or four hours. I have seen a few cases benefited by it, but ordinarily it has been disappointing. Cocaine has been recommended for the pain, but the practice should be condemned, as an amount sufficient to give relief cannot be applied without produc- ing marked constitutional effects, and the relief will not continue more than fifteen or twenty minutes;* if at the end of this time the applica- tion is repeated, it is sure to do harm. Demulcents, as, for example, flaxseed tea, infusion of slippery elm bark, or rice water, are useful in allaying inflammation and furnishing some nutrition. The patient will be obliged for a few days to take light diet consisting of soups, broths, beef tea, and milk. If the uvula should become very cedematous, it should be scarified or punctured to allow the serum to escape, but it must not be cut off, lest, when the patient recovers, it be found much shorter than normal. If the patient suffers from heat and burning of the skin, sponging the surface with water, or alcohol and water, will be found very grateful. ERYSIPELATOUS SORE THROAT. Erysipelatous sore throat is a rare affection, which, when occurring, is usually associated with facial erysipelas. Oornil {Arch ires Generates de Medecine, 1S62) makes three divisions of the disease: first, erysipelas in which there is diffused redness varying from scarlet to deep lividity of the mucous membrane, with more or less swelling and a shining appear- ance of the surface; second, erysipelas with phlyctenular or follicles ranging in size from a pin's head to a centimetre in diameter, similar to those sometimes found upon the skin in erysipelas, which contain serum at first, but soon rupture, the surface becoming coated with a thin, membranous formation ; third, erysipelas which eventuates in gan- ERYSIPELATOUS SORE THROAT. 315 grene, characterized by a dark pultaceous appearance of the mucous membrane and an odor peculiar to gangrenous tissue. Etiology. — This variety of sore throat is produced by the same con- ditions that cause erysipelas of the face or of other portions of the skin, and is supposed to result from infection by a specific microorganism the streptococcus erysipelatosus. The affection is more frequent during epidemics of erysipelas. Symptomatology. — In most cases the patient is attacked by facial erysipelas, which continues two or three days before the throat becomes involved. In rare instances, the inflammation starts in the fauces, Pre- ceding its development, the patient usually suffers from malaise for three or four days. Constitutional symptoms are more marked in erysipelas of the throat than in simple facial erysipelas. Fever ranging from 101° to 104° F. sometimes occurs before conges- tion is observed either of the throat or skin. Often there is nausea, and pain at the epigastrium. The patient complains of dryness or a sting- ing pain in the throat with stiffness of the jaws, so that there is difficulty in opening the mouth. Usually there is swelling of the submaxillary and cervical glands. Deglutition becomes exceedingly painful, and is sometimes difficult on account of paresis of the muscles. When the muscles of the palate alone are involved, food will be partially regurgi- tated through the nose. Diagnosis. — Upon examination of the throat, in the erythematous variety, the mucous membrane covering the palate, tonsils, and pharynx has a shining surface and bright red color, or in severe cases displays a deep livid hue. In cases marked by phlyctaenulae or gangrene, the appear- ance of the eruption or the color and odor of the dead tissue would sug- gest the character of the affection; in those where the throat is attacked first, the speedy occurrence of an eruption upon the skin will clear up the diagnosis. Usually the skin is first attacked, so that when the throat symptoms appear, the nature of the disease is at once suspected. Prognosis. — The affection may run its course to either recovery or death in two or three days, but in the majority of cases it lasts eight or ten days. One-half of the patients die, and in those who recover resolu- tion is slow. In fatal cases, the disease may extend to the larynx, caus- ing suffocation, or the patient may succumb to blood poisoning or ex- haustion, with or without the formation of abscesses. In gangrenous cases, death is almost certain. Treatment. — In a disease so often fatal, the treatment cannot be very satisfactory, but anything which offers hope should be tried. An application of a sixty grain solution of silver nitrate very early in the attack has seemed to cut it short in some cases. Constant sucking of ice has been found beneficial in moderating the severity of the inflam- mation, and is to be recommended, at least during the first few hours of the disease. As the patient suffers much from pain and restlessness, 31 G DISEASES OF THE FAUCES. opiates should be administered in sufficient quantity to give relief, unless there is an idiosyncrasy to the contrary. Because of the tendency of the disease to death by exhaustion, stimulants and tonics are indicated. Quinine should be given in doses of two or three grains, averaging about a grain for each hour of the day and night. The tincture of chloride of iron has seemed the best internal remedy for erysipelas of the skin, and is therefore recommended in erysipelatous inflammation of the throat. It should be given in doses of ten or fifteen minims about every two hours, diluted sufficiently to enable the patient to take it without pain; glycerin and syrup of ginger best cover its taste. In cases where ap- plications of cold do not check the inflammation, Mackenzie recommends warm fomentations and inhalations of steam, or steam impregnated with toothing remedies, anodynes, or carbolic acid and glycerin. Hot ap- plications should not be made, however, until we have become convinced that the inflammation cannot be aborted. Frequent gargling with a one per cent solution of carbolic acid is sometimes beneficial. If much oedema of the throat occurs, scarification should be practised to relieve the tension of the tissues; and if the disease extends to the larynx, as it frequently does, tracheotomy must be performed. Unfortunately, however, the operation is usually futile' in this affection. In gangrenous cases, antiseptic washes of carbolic acid gr. vi. ad 1 i., potassium per- manganate gr. v. to x. ad 3 i. or listerine 3 ii- ad 3 i. should be frequently used, and we should urge the patient to take freely of alcoholic stimu- lants and liquid food. RHEUMATIC SORE THROAT. ACUTE RHEUMATIC SORE THROAT. Rheumatic sore throat may be considered as of two varieties, the acute and the chronic. The acute affection is often attended by marked con- stitutional symptoms and severe pain, and is especially frequent in pa- tients of a rheumatic diathesis. Anatomical axd Pathological Characteristics. — The throat is more or less red and swollen, but usually much less so than in simple acute sore throat, and seldom sufficiently to account for the severe pain. Etiology. — The disease is produced by the same causes which set up rheumatic inflammation in other parts. Symptomatology. — There is almost always a rheumatic diathesis, the patient being subject to frequent attacks of muscular rheumatism, or having suffered at some time from the articular affection. An attack comes on suddenly and is announced by severe pain in the throat, which is soon followed by constitutional symptoms. These usually continue for a couple of days, and then almost as suddenly dis- appear, the pain shifting from the throat to the muscles of the neck, ACUTE RHEUMATIC SORE THROAT. 317 back, or extremities. Occasionally the disease passes off with acute artic- ular rheumatism. The pain is so peculiar that patients who have once had the disease will usually recognize it immediately from the character of this symptom. It is very severe upon attempts at swallowing even saliva. Sudden shifting of the pain from the throat to the muscles of the neck or back, about the second day, is one of the notable features of the disease. The temperature is raised two or three degrees and the pulse is correspondingly quickened. Upon examining the fauces, we find more or less redness and swelling, which may be uniform, but often consists simply of red stripes running longitudinally behind the posterior pillars of the fauces upon each side, while other portions of the throat are but very slightly congested; yet the patient suffers intensely. Diagnosis. — The disease is not likely to be confounded with any other excepting simple acute sore throat. The distinguishing features are : the peculiar pain, the history of former attacks, the suddenness with which the attack comes on, and the shifting of the pain after thirty-six or forty hours to some other portion of the body. There is generally much less of redness and swelling than in simple sore throat. Prognosis. — The affection usually terminates in from two to four days. There is very little danger so far as life is concerned. I know of only one reported fatal case; in that, the disease extended to the larynx. Treatment. — Prophylaxis is of first importance in this affection. Patients subject to it should wear either silk or woollen underclothing the year round, and should be careful to keep the feet dry and warm, and to avoid all undue exposure. Early, an effort should be made to abort the attack by means of salicylates, alkalies, or guaiacum. Sodium salicylate may be given in the manner recommended for acute sore throat, or salicylic acid in capsules or solution, in closes of five or ten grains every one or two hours. After a few doses, the patient usually breaks out in a profuse perspiration, and the pain subsides. When this occurs, the dose should be reduced one-half, and continued in that quantity for five or six doses, when it should be further decreased or substituted by the alkalies. When this remedy is administered in capsules, the patient should always take freely of water with each dose, to avoid irritation of the stomach. Potassium acetate in doses of twenty to thirty grains, or ammoniated tincture of guaiacum in doses of one drachm may be given every fourth hour, or troches of guaiacum may be taken every two hours. On account of the severe pain, anodynes may be required; of these, opiates are most efficient, but the peculiarities of many patients render this drug obnoxious, and therefore potassium bromide, phenacetine or antipyrine or similar substances are often preferable. Applications to the throat of warm fomentations or poultices often have a beneficial effect. 318 DISEASES OF THE FAUCES. CHRONIC RHEUMATIC SOUK THEOAT. Synonym. — Chronic rheumatic laryngitis. Chronic rheumatic sore throat is a painful affection varying much in severity from time to time and attended by only slight physical changes in the parts involved. Though it usually affects the larynx, and there- fore has been described as rheumatic laryngitis, yet in many cases it in- volves only the fauces, the hyoid bone, or possibly the trachea, without implicating the larynx; therefore the term chronic rheumatic sore throat is preferable. It is comparatively frequent, and has probably ex- isted from time immemorial. I have been unable to find any description of it prior to that which I gave at the Ninth International Medical Congress, held at Washington, D. C, in 1887. The affection occurs mainly in the spring and fall, but may also be observed during the winter, and there are occasional cases in which it continues through the summer months. Though affecting all classes with the same impartiality as rheumatism of other parts, it is more fre- quent in men than in women, and all the cases I have seen have been in adults from twenty to .sixty years of age. Anatomical and Pathological Characteristics. — Xo very marked characteristics appear, although there is usually slight conges- tion, circumscribed in character, but changeable. Etiology. — The disease is due to the same causes as muscular or articular rheumatism. Symptomatology. — Chronic rheumatic sore throat comes on insidi- ously in many cases, in others suddenly. Commonly the patient will have been complaining for months when he applies to the laryngologist for relief. Most of the cases I have seen have previously consulted sev- eral physicians and have received almost as many different diagnoses, but all have feared either tuberculosis, syphilis, or cancer, most of them having a fixed dread of the latter affection. The general health is not impaired. The patient complains simply of a localized jDain, commonly referred to the cornu of the hyoid bone; I have observed it most fre- quently on the right side. Next in frequency, pain is felt in the larynx, as a rule upon one side only. Occasionally, however, it is in the trachea or tonsils, and sometimes in the side of the base of the tongue. This pain is increased by pressure in nearly all cases, perhaps in all, and it may be increased by phonation or deglutition, but often it completely disappears while the patient is eating. In any case it is lia- ble to shift its position from time to time, but it may persist for weeks in one place. Sometimes the person will complain of sensations of fulness or swelling or of dryness, itching, burning, or an indescribable sensation of discomfort instead of an actual pain. Usually the voice is not affected, yet it is common for these patients to complain of fatigue after speaking a short time. There is no fever, and no quickening of the CHRONIC RHEUMATIC SORE THROAT. 319 pulse except from alarm. Usually there is uo cough, but in some cases, especially where the larynx is involved, an annoying, hacking cough is a prominent symptom. The digestive organs may act perfectly, but ordinarily the tongue is more or less covered with a whitish or yellow- ish white coating, and, although the appetite is usually good, the patient is often troubled with flatus and eructations of gas from the stomach. Upon laryngoscopic examination, we may find congestion, confined generally .to a small spot in the region of the pain, and sometimes slight swelling. This condition, however, is liable to diminish, disappear, or change to other localities after a few days, and there is nothing char- acteristic in the appearance of the parts. Diagxosis. — The affection is apt to be mistaken for neuralgia, for enlarged glands or enlarged veins at the base of the tongue, for chronic follicular tonsillitis, glossitis, or pharyngitis, for gouty syphilitic or tubercular sore throat, for tobacco sore throat, or for cancer. The essential points in the diagnosis are the uncomfortable sensations of pain, which change usually with changes in the weather, the existence of the rheumatic diathesis, and the absence of any distinct physical signs. Chronic rheumatic sore throat is to be diagnosticated from varicose veins, enlarged glands at the base of the tongue, and from chronic fol- licular tonsillitis, glossitis or pharyngitis, all of which sometimes present similar symptoms, by a careful inspection of the parts, by the course of the disease, and by the results of treatment. By inspection, we may at once ascertain whether the veins or glands at the base of the tongue are enlarged, but unfortunately we cannot tell whether enlargement of the glands or a varicose condition of the veins is the cause of the symp- toms. Some persons have these conditions and yet suffer no inconven- ience whatever, while in others serious discomfort arises. Therefore, if we find varicose veins or enlarged glands at the base of the tongue, with evidence of what seems rheumatic pain in this locality, these con- ditions must be remedied before we can be certain they are not the cause of the trouble. If careful inquiry reveals evidence of a rheumatic diathesis, it favors the diagnosis of rheumatic sore throat. The signs upon inspection in chronic follicular tonsillitis, glossitis, and pharyngitis are characteristic, and when they are found we may usually take it for granted that the symptoms of which the patient complains are due to these diseases. We might possibly be mistaken in cases of this sort, but, if so, a failure to relieve the symptoms by curing these conditions would soon clear up the diagnosis. Sometimes the diagnosis is extremely difficult; but in the majority of cases, having inquired carefully into the history and ex- cluded the affections here mentioned, we may come to an accurate con- clusion. Gouty affections of the throat as shown by S. Solis Cohen (paper read at first Pan-American Congress) cause painful symptoms similar to the rheumatic affection. They may be distinguished from the 320 DISEASE* OF THE FAUCES. latter by the antecedent history and by the presence of gouty nodules and enlargement of the joints. The affection may be distinguished from syphilis by the history and by the physical signs. In the early period of syphilis, and in the secondary and tertiary stages, there are usually characteristic physical signs which are not found in chronic rheumatic sore throat. Cases of syphilitic sore throat occur, however, in which the signs are not characteristic, but in these I have never known the patient to complain of the persistent pain or discomfort which characterizes the rheumatic affection, and I have seen no reason for confounding the two diseases. "We may distinguish this sore throat from tuberculosis by the absence of constitutional symptoms in the rheumatic affection, and their great prominence in the tubercular disease; the relatively moderate pain or discomfort and the absence of ulceration in the former and in the latter the severe pain, with superficial ulceration, which may extend over a considerable part of the painful region, or occasionally deep ulceration. Chronic rheumatic sore throat may be distinguished from tobacco sore throat by the history, and the absence of plaques which appear very much as if the surface had been brushed over with silver nitrate; these are common in tobacco sore throat, though in some cases we find no physi- cal signs. With tobacco sore throat the patient commonly complains of a burning sensation in the part, usually relieved soon after the tobacco is discontinued. If we find the patient a habitual user of tobacco, if stop- ping its use relieves his discomfort, and if there are no symptoms of rheumatism in other parts of the body, there will be no difficulty in differentiating the disorders. It is often difficult to distinguish rheumatic sore throat from neural' gia. The presence of slight congestion or swelling is of considerable value in the diagnosis, for in neuralgia there are no local signs. In most cases of rheumatic sore throat, pressure increases the pain, while in neu- ralgia it does not increase but may relieve it. In rheumatic sore throat, changes of the weather from fair or clear to cloudy and damp almost always aggravate the symptoms, while in neuralgia they have but little effect. In neuralgia the pain is commonly worse in the latter part of the day, when the patient is fatigued; in rheumatic sore throat it is apt to be worse in the morning, and is not particularly increased by fatigue. The physical signs distinguish cancer. In most cases of cancer that I have seen, there have been in the early stage more or less induration, with gradually increasing, irregular swelling, and finally deep ulceration. These do not occur in rheumatic sore throat. In cancer, patients are not likely to suffer pain for any length of time before some of these physical changes occur; in the rheumatic trouble, pain is the essential symptom, and the physical changes are not marked. Prognosis. — We may expect the cases to continue for several months, or even for years. There is no danger so far as life is concerned. SORE THROAT OF SMALL-POT. 321 Treatment. — In the treatment, our first attention should, be directed to prophylaxis. With this in view, the patient must be well clothed and housed, and protected from undue exposure. Eheumatic patients should wear either woollen or silk next the body both night and day throughout the year — light in summer and heavy in winter. They should be care- ful that all the excretory organs perform their functions properly. They should eat sparingly of albuminous substances and live largely on vege- tables and fruit; the vegetable acids are often advantageous, but, what- ever is eaten, it is especially important that digestion be perfect, so that the formation of ptomaines shall be reduced to a minimum. For the local treatment, sedative or stimulant applications may be made, with almost equal chances of relief. Applications of the tincture of aconite to the painful spot four or five times a day, of morphine in solution or in powder will sometimes give considerable relief.- I have frequently observed much benefit from the application of such stimulants as zinc sulphate or chloride and copper sulphate, in solution ; but I have derived most ben- efit from a solution of morphine gr. iv., carbolic acid and tannic acid aa gr. xxx., in glycerin and water aa " iv. It is applied by spray, and is frequently given to the patient in one-half this strength to be used at home. In some cases swabbing the surface with strong tincture of iodine or a sixty-grain solution of silver nitrate has proved beneficial. These latter applications apparently act much the same as blisters over rheumatic joints. The most important part of treatment is the internal medication. Here salol, sodium salicylate, potassium iodide, guaiacum, Phytolacca, and the oil of gaultherium, one or all may be used at differ- ent times with benefit; sodium salicylate may be given in doses of seven to ten grains, the oil of gaultheria in doses of fifteen minims, the ani- moniated tincture of guaiacum in doses of a teaspoonf ul administered in milk three or four times a day. The resin of guaiac in lozenges fre- quently repeated is of considerable value. I have observed most benefit from the extract of phytolacca and salol combined, aa gr. iij. to iv., with an occasional laxative; but sometimes they have been used conjointly with potassium iodide, or with potassium bromide for its sedative effects. I occasionally give the salol in doses of ten grains. Tinctures of bryonia and of cimicifuga are said to be valuable remedies in rheumatism. I have used them both, with apparently slight benefit in some instances, but the obstinate cases have done better under phytolacca and salol with occasional use of the other remedies already suggested i SORE THROAT OF S1TALL-POX. Sore throat of small-pox is characterized by an eruption similar to that which occurs upon the skin. In many cases it appears before the cuta- neous eruption, in others not until the third or sixth day of the original 322 DISEASES OF THE FAUCES.- disease. The extent of the eruption will vary according to the severity of the variola. Anatomical and Pathological Characteristics. — The mucous membrane is swollen, and the peculiar pustules are found, but without the contracted, depressed centre that is seen upon the skin, because the covering cannot become dry. The ulceration of these pustules fre- quently extends entirely through the mucous membrane to the muscular tissue, which is more or less involved in the inflammatory action. It is probably on this account that patients experience such severe pain in deglutition. Diagnosis. — The diagnosis rests upon that of the constitutional disease. Prognosis. — The throat affection per se is not dangerous; in serious cases of variola there are liable to be grave complications in the throat. Treatment. — Locally, weak astringents and soothing gargles are recommended. SORE THROAT OF MEASLES. An eruption in the throat is present in nearly every case of measles as one of the first indications of the disease, but it generally disappears in a few days. It is usually a simple catarrhal inflammation of the mucous membrane, which may extend from the nostrils to the ultimate bronchial tubes. In comparatively rare cases there is a diphtheritic deposit. Symptomatology. — On examination of the fauces, often one or two days before the disease becomes well marked, several small red points are noticed on the palate, pillars of the fauces, or the pharyngeal wall. At the time the eruption appears upon the skin, we nearly always find much congestion of the throat. In diphtheritic cases there is a fibrin- ous deposit upon the surface. In some instances the inflammation extends deeply into the tissues, and abscesses result. Many cases of measles are attended by hoarseness due to laryngitis, which sometimes becomes a serious complication, particularly where there is a fibrinous deposit. The inflammation and pain often extend to the ears. Diagnosis. — The diagnosis will depend upon the cutaneous eruption and the other symptoms distinguishing measles from other diseases. Prognosis. — So far as the throat is concerned, we expect the ca- tarrhal inflammation to last seven or eight days in the majority of cases and to terminate in resolution. Where fibrinous deposit occurs, the prognosis is grave, especially if it extends to the larynx; of these cases eighty per cent die. In infancy there is peculiar danger from extension of the inflammation to the lungs. Treatment. — The treatment for acute sore throat is appropriate, but often no treatment is necessary except that which may be indicated for the constitutional disease. SOKE THROAT OF SCARLET FEVER. 323 SORE THROAT OF SCARLET FEVER. Sore throat of scarlet fever is characterized by congestion of the palate and fauces, which occurs early in the attack and is present in nearly every case, even in those where the cutaneous eruption is absent or slight. Anatomical axd Pathological Characteristics. — In some in- stances the congestion is slight, in others the parts are of a deep red or livid hue, and in anginose cases there is much swelling, and the palate, pharynx, and tonsils are all involved in the inflammation and the oedema. If the process is intense, the swelling may cause almost complete closure of the throat. The inflammation frequently extends to the submucous tissues, resulting in extensive suppuration, and not infrequently abscesses occur in other portions of the body. In a large number of cases the in- flammation extends along the Eustachian tube to the middle ear, not infrequently resulting in permanent deafness. In some cases there is diphtheritic deposit, but it has not been determined whether this is a peculiar phase of the scarlatina or whether it is an association of the two diseases. Symptomatology. — The attack is usually ushered in by vomiting and fever, and the patient complains of more or less stiffness of the jaws and aching pain in the throat, which in scarlatina anginosa may be very severe. The tonsils and mucous membrane are swollen, and the glands at the angles of the jaws are often considerably enlarged. In many cases, in the beginning of the attack, the temperature rises to 105° F., and oc- casionally even to 106°. It usually continues high several days, and is not apt to disappear before the ninth or tenth day. In severe cases, with much swelling, resjDiration may be seriously obstructed. The tongue at first has a peculiar strawberry like appearance, due to promi- nence of the red papilla?, which are surrounded by a white coating, but later it is red and glazed. The breath is offensive, particularly in diph- theritic cases, and in scarlatina anginosa. Disturbance of the stomach, difficulty in deglutition, and loss of appetite are among the common symp- toms. The degree of redness and swelling varies much. In simple cases there is a bright scarlet appearance of the throat, sometimes ap- proaching a livid hue, and there may be very little swelling, but in the anginose variety the mucous membrane and tonsils are so much swollen as nearly to close the fauces. In many cases, during the first or second day a thin pseudo-membranous deposit occurs upon the inflamed tissues, and in some this becomes thicker and darker in color and finally acquires the appearance of the membrane in diphtheria. Occasionally in the beginning the symptoms and signs are those of tonsillitis only. Diagnosis. — The disease is to be distinguished from acute sore throat, from tonsillitis, and from diphtheria. The essential points in the diagnosis are the history and characteristic eruption of scarlet fever. 324 DISEASES OF THE FAUCES. The appearances are much the same in acute sore throat as in scar- latina during the first two or three days, but the constitutional symp- toms are usually lighter and the subsequent history different. There is apt to he more swelling in tonsillitis, which is often con- fined to one side, and there is no cutaneous eruption excepting in rare instances. A thick false membrane occurs early in diphtheric, while the tempera- ture is comparatively low (101° to 102° F.), and other constitutional symp- toms are not severe; in scarlatina there is high fever at first., with little, if any, fibrinous deposit ; and thick pseudo-membrane, if developed at all, does not often occur until late in the disease. Prognosis. — In mild cases the throat symptoms usually disappear in from six to ten days, but in scarlatina anginosa or in malignant cases the throat may not be involved until the eighth or ninth day. but then exten- sive swelling takes place in the course of a few hours, and in a short time extensive pseudo-membranous deposits may occur. In simple cases there is no danger so far as the throat is concerned: twenty-five per cent of the anginose cases die, and of diphtheritic cases fifty per cent are fatal. Treatment. — Emollient applications and antiseptic gargles or sprays are usually recommended. Solutions of carbolic acid gr. v. to viij. ad 5 i. of glycerin and water, weak solutions of potassium permanganate gr. v. to x. ad 3 i., or some of the other antiseptics may be employed for this purpose. As the patient progresses toward recovery, the ferrugi- nous and bitter tonics will be found beneficial. If there is much depres- sion, alcoholic stimulants are indicated, and should be given freely. Potassium chlorate has been recommended highly in the treatment of the throat affection of scarlatina, in quantities proportionate to the age of the patient: for an adult, gr. xl. to lx. daily in divided doses. It should be promptly discontinued if it causes irritation of the kidneys. SIMPLE MEMBRANOUS SORE THROAT. Synonyms. — Herpetic sore throat, aphthous sore throat. This is a form of sore throat characterized by the occurrence of small blisters and herpetic patches in the fauces and on the pharynx, which, after a short time, rupture, and the surface becomes covered with an inflamma- tory deposit or false membrane similar to the membrane in diphtheria, though less dense and much more friable. The affection occurs most fre- quently in damp climates and in the colder months of the year, particularly when there are sudden changes, as in the spring or fall. It is more fre- quent in women and children than in men, and is observed oftenest among those who are naturally delicate. It occurs frequently during epidemics of diphtheria, and is occasionally associated with tuberculosis or syphilis. Anatomical and Pathological Characteristics. — In the begin- SIMPLE MEMBRANOUS SORE THROAT. 325 iiiug of the attack there are found several small distended follicles, about the size of a pin's head, with more 01* less reddening and tumefac- tion of the surrounding mucous membrane. These may occur singly or in patches, and may terminate in one of three ways: first, by resorption, in which case they may disappear in two or three days and the mucous membrane may be left in" a healthy condition; second, they may burst and small deep ulcers may remain, which may either heal rapidly in twenty-four to forty-eight hours, or may become covered with membra- nous deposit; third, several of these ulcers may coalesce, forming a large patch which becomes covered over with false membrane. I have fre- quently seen, in the beginning of such an attack, patches five to ten mil- limetres in diameter, covered with this false membrane, which to all appearances, were not preceded by the small inflamed follicles. Etiology. — The disease is attributed to exposure and to certain miasmatic influences not well understood. In occasional cases occurring at the menstrual period it is attributed to uterine disturbances. Certain epidemic influences appear to favor the disease, for it is more frequent when diphtheria is prevalent. Symptomatology. — The attack usually comes on with a slight chill, followed by fever and attended by severe pain in the throat. For the first clay or two the patient complains only of the symptoms of simple acute sore throat. Usually there is first a sensation of dryness, and after a short time a severe burning or smarting pain, which, so far as we can judge from the patient's description, is more intense than that of any other acute affection of the throat. This pain sometimes radiates toward the ears, and is said to extend occasionally to the nasal cavities, and in rare instances to the larynx. Xearly always we find a herpetic eruption upon the lips at some time during the course of the disease. The fever is occasionally very high for a few days; in other instances there is but very little elevation of temperature. The pulse is accelerated ; the tongue is usually flabby, indented at the edges by the teeth and covered with a thick, white fur; there is great difficulty in swallowing, because of the pain, which, however, varies with the location of the diseased follicles or patches. Upon inspecting the parts, we find small inflamed follicles or pustules, often not more than two or three in number, on the palate, fauces, or the side of the mouth; or in place of these small ulcers, or ulcers covered with false membrane; sometimes the pustules and ulcers are found together, because the inflamed follicles come out in successive groups for four or five days. Often early in the attack there is general redness of the parts with localized patches of deeper congestion, which may appear before the pustules are developed. In the majority of cases, the most pronounced physical sign will be the presence of one or more patches, round or oval in form, usually from five to ten millimetres in diameter but sometimes a little larger, and covered by a thin yellow- ish white false membrane which can be readily removed with a swab 326 DISEASES OF THE FAUCES. of cotton. These are found on the side of the tongue, fauces, or inner surface of the cheeks, and sometimes even upon the lips. Under this membrane we may find an irritated and easily bleeding surface. In some instances, on removing it we find the mucous membrane beneath in a perfectly healthy condition. Occasionally early in the attack there is a thin membrane spread over the tonsils, with very little erosion. During the attack false membrane will sometimes form upon sores in other parts of the body. Usually the disease is more pronounced upon one side only, but it may spread over both sides and the pharynx, al- though it seldom or never extends forward upon the hard palate. The membrane is not apt to be continuous like that of diphtheria, but occurs in scattered patches. Diagnosis. — The disease is liable to be mistaken for diphtheria only. Late in the attack it may sometimes be distinguished from diphtheria by the slight constitutional symptoms; though often there is high fever in the beginning of the attack. In simple membranous sore throat, herpes appears upon the lips during the first three or four days; not so in diph- theria. The membrane, in membranous sore throat, is superficial and thin, about one millimetre in thickness, and it may be easily detached, leaving beneath simply an excoriated, congested, or sometimes healthy surface. In diphtheria the membrane is three or four millimetres in thickness, is detached with difficulty if at all, seeming to extend into the original tissues and be a part of them, and leaves an irregular and deeply ulcerated surface. Membranous sore throat is occasionally followed by paralysis, leading one to question the accuracy of the diagnosis. In some cases the symptoms and signs are clearly those of membranous sore throat, but after a few days diphtheria becomes implanted upon it, giving all the characteristics of the latter disease. Some authors believe these affections identical, but the weight of authority is against this view. Pbogstosis. — The disease maybe expected to terminate in recovery in from eight to ten days; there is sometimes, however, a tendency to recurrence. We may assure the friends that there is no danger from the disease alone, but it is well to warn them of the possibility that diph- theria may become implanted upon it. Treatment. — In the treatment of the disease a medium dose of magnesium sulphate or citrate is desirable early. This may be followed by quinine and anodynes to relieve pain. Arsenious acid in small doses has been highly recommended. I have given potassium bromide inter- nally, for its anodyne effects, with benefit, and it is recommended in solution as an inhalation from a steam atomizer. The vapor of com- pound tincture of benzoin, 3 i. ad i. of hot water, is also recommended as an inhalation. Weak antiseptic gargles of potassium permanganate, carbolic acid, listerine, or Dobell's solution are useful to clear the throat of the mucus. Charles E. Sajous recommends that the false membrane be detached and the exposed surface touched every three hours with a SIMPLE MEMBRANOUS SORE THROAT. 327 ten grain solution of potassium permanganate (Diseases of the Xose and Throat, 1885). I have derived most benefit from a solution of morphine, tannic acid, and carbolic acid (Form. 139). Applied to the ulcerated surface, this will often give relief for ten or twelve hours. Oc- casionally solutions of silver nitrate act well, but in some cases I have been unable to find anything that would give much relief. The free use of demulcents, such as rice water, an infusion of slippery elm bark, or flaxseed tea, is soothing to the parts. With these may be combined a little lemon juice if more agreeable to the patient. Potassium chlo- rate has been highly recommended for this, as it has for nearly every other disease of the throat: but in every instance in which I have given it trial, it has caused intolerable smarting. In cases subject to frequent recurrence of this disease, J. Solis Cohen especially recommends touch- ing the spots with dilute nitric acid. Good diet is to be recommended, and the patient must avoid exposure. CHAPTER XIX. DISEASES OF THE FAUCES.— Continued. DIPHTHERIA. Synonyms. — Diphtheritis, angina diphtheritica, angina membranosa. Diphtheria is a specific contagions disease, characterized by pro- nounced constitutional symptoms and inflammation of the mucous mem- brane of the fauces and upper air passages, with exudation of inflam- matory lymph, which rapidly becomes formed into false membrane. It has long been recognized by the best authorities as one of the zymotic fevers. Many English authorities, with whom I am fully in accord, look upon this as a constitutional disease with local manifestations, but many continental authors and some American writers regard it as a primary local affection with secondary constitutional manifestations. The dis- ease occurs sporadically, endemically or epidemically, and appears to have no geographical limitations, but is most frequent in temperate climates. It is most common in cold, damp weather and during the spring or fall months, but is often seen in winter, and not infreqnently during warm weather. Lennox Browne states that those who have enlarged tonsils are especially receptive of the contagium (Diseases of the Throat, 2d ed.). The great majority of cases are observed in children under six years, but adults are not exempt. The disease is not often observed twice in the same individual. Anatomical and Pathological Characteristics. — In the begin- ning of diphtheria there is congestion of the mucous membrane of the fauces, usually uniform, but occasionally in patches. This may gradually extend to the entire mucous membrane of the throat, and it is soon fol- lowed by the exudation of inflammatory lymph, which in most instances proceeds within a few hours to the formation of false membrane. The deposit originates generally in one place and gradually extends to the sur- rounding tissues, but it may commence in several spots at the same time. It is usually first found upon one or both tonsils, from which it grad- ually extends, according to the severity of the disease, to the palate, pharynx, naso-pharynx, and other portions of the air passage. Rarely, it is found lining the oesophagus and other parts of the alimentary canal. Wounds upon the skin are liable to become covered by the same pro- cess. Extension of the disease to the air passages gives rise to diph- theritic croup, or pulmonary collapse. Blood clots in the ventricles of DIPHTHERIA. 329 the heart or large arteries are not infrequently found in post-mortem examinations. Enlarged lymphatic glands are common, occasionally sup- purating, and in the majority of cases the kidneys are congested or actu- ally inflamed. Various bacteria have been found in the diphtheritic membrane, but most or all of these inhabit the mucous membrane of the mouth of healthy individuals. Etiology. — The disease is generally conceded to be contagious, and may be communicated from man to the lower animals and vice versa ; it is believed by most physicians to be due to a specific micro-organism. The researches of T. M. Prudden {American Journal of Medical Sciences, April and May, 1889) pointed to a streptococcus as the probable cause of diphtheria, but the results of his later investigations harmonize with those of most bacteriologists, who now attribute the disease to the Klebs-Lofner bacillus. This is a microscopic rod about the length of the tubercle bacillus, but twice its thickness. It is usually more or less bent, with rounded ends, one or botb of which may be thickened, giving the club or dumb-bell appearance; it is immobile and contains no spores. These bacilli do not readily absorb the common aniline stains, but are easily colored by a solution of Loffler's methylin-blue, the coloration often being most intense at the extremities. According to Armand Euffer {British Medical Journal, July 26th, 1890), these bacilli are found most abundantly in the superficial portions of the false membrane, and nearly all experiments go to prove that they do not usually enter the lym- phatics or blood vessels; therefore, of itself the bacillus is innocuous, but it produces a virulent ptomaine which is readily absorbed and which may cause the constitutional symptoms of the disease. Numerous clin- ical observations and experiments, however, have demonstrated with an equal degree of certainty that pseudo-membranous inflammation is often produced independent of the Klebs-Lofner bacillus, as, for example, that resulting from surgical operations in the throat; or from injury inflicted, boiling water, steam, cantharides, chlorine, and ammonia; or the exudative inflammations supposed to be of microbic origin, fre- quently observed in scarlet fever and measles. This latter variety of inflammation is termed by Smith and Warner {Annual of the Univer- sal Mediccd Sciences, 1891) pseudo-diphtheria, and, as stated by them, can only be distinguished from true diphtheria due to the Klebs- Lofner bacillus by the fact that it is not followed by paralysis and is not attended by a peculiar form of albuminuria unassociated with dropsy or uraemic poisoning. The necessity for assuming that there are two varieties of diphtheria, one produced by the Klebs-Loffler bacillus, the other by other bacteria, seems to justify the statement, that the identity of the specific micro-organism, believed to cause the disease, is as yet uncertain. Eoux and Yersin {U Union Medicate, Paris; Annual of the Universal Medical Sciences, 1892) report that in the secretions from the mouths of fifty healthy children, living in a village near the 330 DISEASES OF THE FAUCES. coast, where diphtheria was unknown, they found in 52 per cent a bacillus morphologically identical with the ordinary Klebs-Loffler bacillus and behaving in cultures exactly like the latter, excepting in the number of its colonies. This they believe to be the Klebs-Loffler bacillus in a non- virulent condition. There can be no doubt that primary simple inflammation favors the production of diphtheria, but it is doubtful whether it is ever in itself capable of producing the disease. Infection may occur from another patient or from articles contaminated by him. Commonly its origin is referred to the use of certain drinking water or milk or the inhala- tion of emanations from sewers, or from damp, unhealthy cellars or decaying refuse. The most common predisposing cause, I believe, is the exposure of young children to the chilly atmosphere of our houses in the spring and fall months or during the warmer portions of winter, when fires are not considered necessary by adults. Symptomatology. — After a period of incubation varying from one to eight days, the disease usually commences in young children with well- marked constitutional symptoms, such as headache, drowsiness, more or less fever, thirst, vomiting or diarrhoea, and stiffness of the neck at the angle of the jaw, with more or less soreness of the throat. In older children and adults, the invasion is more gradual. In from twelve to thirty-six hours from the first symptoms, the false membrane can usually be detected in the throat, and in some cases it is deposited in considerable quantities before the person is thought to be ill. The patient usually complains of a sensation of dryness and a desire to hawk and clear the throat, with some pain, especially upon deglutition. Ex- ceptionally an erythematous eruption makes its appearance on the skin during the first few hours of the affection. The pulse is rapid, small, and feeble, and as the disease progresses it may be intermittent. "Finally, it grows exceedingly feeble and slower than normal as death from exhaustion approaches. The temperature usually rises to 101° or 102° F. during the first hours of the attack, but with the deposit of false membrane it generally falls and may even become subnormal. After two to four days it may again rise, indicating in favorable cases suppuration and separation of the false membrane, or in others an ex- tension of the disease to the larynx, lungs, kidneys, or other parts. In the later stages of the disease, sudden fall to the subnormal point is a serious symptom indicative of failing strength. The voice is often altered, weak, and hoarse, even before the larynx is affected, but when false membrane has extended to the glottis hoarseness becomes more pronounced or the voice may be entirely lost. With involvement of the larynx, dyspncea appears, and it may steadily or suddenly increase, ag- gravated, however, from time to time, by spasms of the glottis. Respi- ration becomes noisy and stridulous, there is an irritating laryngeal cough, and with the spasms of the glottis all the symptoms of suffoca- DIPHTHERIA. 331 tion appear; the false membrane may be loosened, and fragments of considerable size are often expectorated. Sometimes complete casts of the trachea or bronchi are thrown off in this way. When the disease extends to the naso-pharynx and nostrils, there is obstruction of the nose and a fetid, sanious discharge, frequently accompanied in grave cases by epistaxis. The tongue is coated with thick, yellowish fur, and the breath has a peculiar odor most characteristic of the disease. In malignant cases this odor is so pronounced as to permeate the entire apartment. The tongue is coated from the first, and in unfavorable cases it becomes harsh and dry and covered with a thick, dark coat. The appetite is poor and in severe cases may be entirely lost; nausea and vomiting are not infrequent, particularly when the kidneys are in- volved. Swelling of the cervical glands occurs in most severe cases, especially at the angles of the jaw; the submaxillary and parotid glands are sometimes involved. The throat is at first deeply congested, but soon the false membrane is deposited, primarily upon one or both tonsils. In the beginning, this membrane is white in color, but it soon becomes yellowish, and with the advance of the disease grayish, brownish, or even almost black. It has the appearance of involving the mucous membrane and being slightly elevated above the surface. If the mem- brane is exfoliated or forcibly removed, an ulcerated, granular, and bleeding surface remains, which is again soon covered with false membrane. This membrane is firmly adherent to the surface, and can- not be removed by brushing with a swab of cotton, as can the mucus which collects in other forms of sore throat. With the laryngoscope, false membrane may be discovered in the naso-pharynx or the larynx. When the latter becomes obstructed, a sinking in of the softer portions of the chest is noticed with each inspiration, well marked above and below the clavicles, but especially at the lower part of the sternum. As the glottis becomes more and more obstructed, the skin is pallid and bathed in cold perspiration, the lips, ears, and extremities appear blue; the pa- tient grows restless, throwing himself from side to side of the bed every few moments, and with the paroxysms of dyspnoea he throws his arms about and clutches at his throat in the vain effort to obtain more air. As the disease progresses, the signs of carbonic acid poisoning are more and more marked, the patient becomes listless and drowsy, and finally dies in a comatose condition; or he may be suddenly carried off by a spasm of the glottis, a general convulsion, or heart failure. Diagnosis. — Diphtheria may be confounded with simple catarrhal, or rheumatic pharyngitis; tonsillitis simple or follicular; erysipelas, scarlatina, and other constitutional diseases, or with simple membranous sore throat. The essential points in the diagnosis are the history, the rapid progress of the case, the appearance of firmly adherent whitish or yellowish gray membrane in the throat, and the condition of the urine. In catarrhal or rheumatic pharyngitis the temperature is higher, the pain is greater, and there is no formation of false membrane. DISEASES OF THE FAUCES. In erysipelas of the throat the eruption is developed more slowly, and the history is entirely different, Scarlatina is developed more rapidly, the temperature rises early to 1<>3 or 105 F. and remains so for several days; in diphtheria it seldom rises higher than 101° or 102° F. in the beginning. In scarlatina, after a short time a characteristic rash ap- pears upon the skin; the appearance of the throat is not greatly different in the commencement, though the congestion is generally more uniform than in diphtheria, and in uncomplicated cases there is no false mem- brane. In tonsillitis the temperature is much higher, the disease comes on more rapidly, there is more pain in the throat, and usually there is difficulty in opening the mouth which does not occur in diphtheria. In simple tonsillitis there is more swelling, but no deposit of inflammatory lymph. The history of follicular tonsillitis is essentially that of the simple form, hut numerous yellowish points or spots appear upon the tonsils at the orifices of the lacuna?. These, however, differ from the appearance of diphtheritic membrane, in that they are more numerous, smaller, are not elevated above the surface of the mucous membrane, are confined to the tonsil in the majority of cases, and never found upon the palate. Simple membranous sore throat, if seen at the beginning of the attack when the vesicles first appear, is not very likely to be mistaken for diphtheria; but if the patient does not come under observation until two or three days later, the diagnosis may be difficult or even impossible, especially if diphtheria is prevalent at the same time. In most cases of membranous sore throat the patient complains of much more pain and the false membrane is more easily detached and is much thinner than in diphtheria. In some cases a herpetic eruption in the throat and on the lips reveals the true nature of the disease. In phlegmonous or erysipelatous sore throat the patient suffers more pain, the temperature is higher, and the tissues are very oedematous and livid, the invasion and course of the disease are different, and diphther- itic membrane is absent. Prognosis. — The prognosis is always grave, for no matter how mild tiie case in its commencement, it is impossible to predict what the com- plications may be before it has run its course; and although the large majority of cases recover, it is never safe to make a favorable prognosis without warning the friends of possible danger. In fatal cases death occasionally occurs within twenty-four hours after the first appearance of the disease, and in the majority the fatal termination is within five days; but in some the struggle for life continues five or six weeks be- fore the patient succumbs. In favorable cases convalescence is usually established about the end of the third week, but especially where com- plications have existed, the duration may be much longer. As a rule, the younger the patient the greater the danger. Among the symptoms and signs indicative of gravity are deposits of membrane in the nose, DIPHTHERIA. 333 pharynx, or intestines; extreme pain in the ears or throat, pnrpuric spots on the skin, epistaxis, and other hemorrhages, persistent anorexia, vomiting, diarrhoea, and suppression of the urine. Asthenia, a typhoid condition, or signs of heart failure are often precursors of death. When the larynx is involved, it is probable that without surgical interference the mortality reaches ninety-five per cent, and with it about sixty per cent. Patients not infrequently die suddenly of heart failure, and often the pulse becomes weak and intermittent on the slightest effort, and clearly points ,to the necessity of relieving the heart from all undue ex- ertion in order to save the patient's life. As the case progresses toward recovery, the appetite returns, the tem- perature diminishes, difficulty with respiration disappears, and articula- tion again is normal; however, the difficulty in swallowing of ten becomes greater, from exposure of ulcerated surfaces which cause more pain on deglutition, or from paresis of the deglutitory muscles. Not infrequently paralytic symptoms follow the attack closely, about the end of the third week, but, except in cases where the respiratory or circulatory centres are involved, recovery usually occurs, though it may be delayed for several weeks or even months, Owing to danger from the sequela?, especially heart failure, we can never fully relieve the anxiety of friends until our patient has been well for about three weeks. Teeatmext. — There are few diseases in which the methods of treat- ment recommended are more numerous, a fact which is explained by the inutility of a great majority of the means adopted. So much depends upon the nature of the epidemic, the condition of the patient when first at- tacked, and his surroundings, that it is very difficult to arrive at accurate conclusions regarding the effects of remedies. . During the earlier por- tion of many epidemics a large proportion of those attacked die, and therefore whatever remedies have been used seem to be fruitless ; whereas in the latter part of the same epidemic a large majo:'ity of the cases recover, no matter what treatment is employed, and the remedies in use at the time get the credit. Many physicians have favorite prescriptions, on which they place great reliance until called upon to treat serious cases; then, unfortunately, all methods often fail and the physician comes to believe that little can be accomplished by treatment. The methods to be adopted are: first, prophylactic; second, dietetic; third, local; fourth, internal or general; fifth, operative. Prophylaxis is of prime importance in relation to diphtheria. The most useful measures consist of thorough ventilation and proper drainage, pure water supply, proper clothing, and proper heating of living apart- ments, and as far as possible protection especially of children, from the contagium. It must be remembered that sometimes the specific poison may be carried from one to another by domestic animals, or in the cloth- ing, or about the person of one who has been visiting the sick or at- tending funerals. As the disease is generally prevalent during the cool 334 DISEASES OF THE FAUCES. and damper portions of the year, when the need of fires is not appreci- ated by adults, it is of special importance that children be cared for at this time, that they have proper clothing, and that a suitable temperature of the house be maintained. It has appeared to me that during the spring and fall months children are much more liable to catch cold and consequently to have diphtheria, in the house with a temperature of about 65° to 68° F. than when the temperature is even colder. An effort should be made to maintain the temperature of the house as nearly as possible at 70° P., and children should not be allowed to run about in their night clothing morning ami evening or to stand about while dressing with the temperature at from 55° to 65° F., as it is liable to be. They need to be carefully protected at night from exposure due to kicking off the bedding. If the disease has made its appearance in a household, other children of the family must be pre- vented from all intercourse with the patient, and the sick one should be given an airy, comfortable room, which may be freely ventilated without exposing the patient to draughts. Daniel E. Brower, of Chicago, advo- cates an excellent method of ventilation during an attack of this dis- ease, consisting of changing the patient two or three times a day from one room to another, the vacated room being thoroughly ventilated in the interim. It is a useful precaution to hang over the door of the sick- room sheets kept moistened with carbolic acid to prevent contamination of the air of the house during the necessary opening of the door. The temperature of the sick room should be kept at from 70° to 75° F., and in all cases an abundant supply of fresh air provided. All utensils or clothing used in the room should be disinfected or destroyed, and finally the room should be thoroughly fumigated before it is again used. Orancher, of Paris (Revue d* Hygiene et de Pol ire sanitaire, December, 1890 ; Annual Universal Medical Scu na s, 1 892), expresses the opinion that in nearly all instances diphtheria is propagated by infected clothing or furniture. He states that in a diphtheritic ward in Paris, among 1,741 admitted were 153 that did not have diphtheria at the time, yet none of them contracted it. The means of prophylaxis employed in this ward were: a metallic screen about the bed; disinfection of articles used by the patient by boiling in about a six per cent solution of sodium carbon- ate; disinfection of the bedding and clothing by heat, and of the walls and furniture by washing with a solution of mercury bichloride. At- tendants and doctors wear blouses that are disinfected by heat daily and wash themselves in a bichloride solution or in a five per cent solution of carbolic acid. Ice taken frequently in the mouth tends to relieve thirst and reduce congestion. When children will not take this, Lennox Browne (Diseases of the Throat, 2d ed.) recommends the use of frozen milk or frozen beef tea. Of nutritious drinks, milk is the most important; beef tea and the various broths may be given in addition when the child will DIPHTHERIA. 335 take them, and these may be supplemented by rice water or barley water ; the latter is sometimes taken more readily if flavored with lemon juice. As soon as the appetite becomes impaired, these liquid nutrients must be given at regular intervals, and in as great a quantity as the patient can be induced to take. To a child ten years of age as much as half a pint of milk or its equivalent should if possible be given, every third hour night and day. Sometimes with children it is necessary to with- hold water in order that they may take the liquid nourishment. Fontaine, acting on the principle that germs cannot exist in acid solutions, recommends frequent drinks or gargles acidulated with citric acid. On the same principle, pineapple juice has lately been highly rec- ommended, particularly by the laity. When patients cannot take food, • or when it will not be retained by the stomach, nutritive enemata become necessary; in this case the various preparations of peptonized meat are exceedingly useful. Alcoholic stimulation is of great importance, and is usually recom- mended early in the attack, but I doubt its value at this time. The form in which it is administered is of little importance, so long as it is accept- able to the patient; whisky or brandy is most commonly used, but children will generally take much more readily alcohol diluted with two parts of syrup of tolu, given in as much water as desired. The early continued application of cold externally is often of the greatest service; for this purpose the throat may be fitted with a coil of rubber or metallic tubing through which a current of ice water is kept constantly passing, or the ioe bag may be used. When the latter is em- ployed, the ice should be broken into small pieces and changed about once an hour; the bag should not be more than half filled, so that it may be accurately applied to the surface. When the false membrane begins to separate, hot applications have seemed more beneficial than cold, and occasionally, even in the early part of the attack, the patient so seriously objects to the cold that hot applications may be used instead, the effect being much the same providing the application is continuous and as hot as can be home. Topical Treatment. — A variety of substances have been used with the hope of removing 'the false membrane. The simplest of these is steam, applied either with the croup tent or the steam atomizer. This may be im- pregnated with the time honored lime water, or with various other sub- stances according to the fancy of the physician. There can be no doubt that lime water is cajDable of dissolving the false membrane when the latter is immersed in it for a sufficient length of time, but probably it has very little influence upon the membrane in the throat. Liquor potassa, one part to four of water, may be used with equally good results. Mackenzie (Diseases of the Throat and Nose) highly recommended lactic acid applied freely with a brush or pledget of lint. He did not so state, but left us to infer that it was applied in full strength. He 336 DISEASES OF THE FAUCES classed it as among the most reliable solvents of diphtheritic membrane. Lennox Browne recommends a solution of lactic acid to be applied every two or three hours by the nurse in from one to six parts of water, and to be used pure once or twice a day by the surgeon. Trypsin, papain, and resorcin have all been recommended for their supposed solvent effects. Tannic acid, alum, and sulphur have been used in the form of powder by many physicians, but are of doubtful utility. Various local antiseptic applications are useful when they can be made without too much objec- tion by the patient; but I believe that whatever is used should be so mild as to cause but little pain, otherwise it is apt to do more harm than good. Of these, mercury bichloride, carbolic acid, potassium permanganate, sodium chlorate, glveerole of borax, chloral, and the tincture of iron are most efficient. The first is used in the proportion of 1 to 4,000 of water, or even as strong as 1 to 1,000, but this is too strong for ordinary use. Carbolic acid is used in the strength of from one to five per cent; the latter is especially recommended by Oertel (Ziemssen's Cyclo- pedia, English translation. Vol. II.). Potassium permanganate may be used in the strength of gr. v. ad \ i., the liquor soda> chlorata? four drachms to ten ounces, or potassium chlorate a saturated solution. Hugh Hemming, of Kimbolton, England, advocates the syrup of chloral, gr. xxv. ad 3i., applied everyone or two hours. Sulphurous acid properly diluted is also beneficial. Hydrogen peroxide has been highly recommended as a spray either in its full strength (Marchand's) as obtained from the druggist, or diluted according to the degree of smarting produced. Pure alcohol is used by some as a gargle or spray, with apparent advantage. Tincture of myrrh has also been extolled as a local application. Tincture of the chloride of iron may be used either in the form of a spray or by means of a swab. G. Y. Black, of Jacksonville, 111. {Dent id Review, March 15th, 1S89, p. 128), has shown that the officinal cinnamon water, although harmless to the patient, is one of the most efficacious antiseptics; and Koux and Yersin {Annates de Gynecologie et d' Obstetrique, September, 1889; Paris) have demonstrated that the toxicity of cultures of diphtheritic bacilli is greatly diminished by the addition of carbolic acid, borax, or boric acid; I have, therefore, been induced to try as a local application a sat- urated solution of boric acid in cinnamon water. This is neither pain- ful, unpleasant, nor dangerous, and has seemed to me more efficient than other local remedies which I have employed. Any of these appli- cations may be of more or less value when the patient does not rebel against their use; if a contest becomes necessary every time the remedy is applied, it will probably do more harm than good. The tinc- ture of iron, when administered internally frequently and in compara- tively large doses as recommended below, has all of the local influence that is usually necessary, and obviates the necessity of sprays or gargles. When the diphtheritic process extends to the nose, the nares should be DIPHTHERIA. 337 washed three or four times daily with a saturated solution of boric acid or some mild alkaline wash, which should always be used warm. The washing may often be accomplished by an atomizer. Whenever it is necessary to employ a syringe, the patient should be placed face down- ward so that the fluid will not run into the throat and cause strangling. After the washing, a powder consisting of iodol, sugar of milk, and pa- pain — equal parts, may be freely blown into the nose. Internal Treatment. — Physicians generally are agreed that the treat- ment of diphtheria should be supporting and stimulating from the be- ginning. With this in view, iron, quinine, strychnine, and alcoholic stim- ulants have been employed for generations, and they still hold the first place with a majority of the profession. No infernal remedy has seemed to be more effective than tincture of the chloride of iron given in fre- quent and comparatively large doses, amounting to about one minim of the medicine for each year of the child's age administered every one or two hours, according to the severity of the case. I usually combine it with a small quantity of glycerin and sufficient syrup of tolu to make one drachm, and direct the patient to take it without dilution, provid- ing it does not cause smarting. As the throat becomes more sensitive, the remedy is diluted sufficiently to avoid much discomfort. To pre- vent any irritation of the stomach, it is well for the patient to take a drink of water before the medicine is given, and as much more as desired five minutes afterward. Quinine may be given at the same time, prefer- ably in pills or capsules ; otherwise the patient may become so disgusted as to refuse it altogether. Alcoholic stimulants should be given freely when the pulse becomes weak and the vitality diminished. If there is a tendency to heart failure, no remedy is of greater value than nux vomica in some form. Strychnine may be given, but the tincture of nux vomica has seemed to me more effectual, and it should be given in comparatively large doses, sometimes as much as half a minim for each year of the child's age, being required every one or two hours. Within the past few years mercury bichloride has been largely used in the treatment of this disease with apparent success, and other prepara- tions of mercury are recommended by various authors. Pilocarpine is advised by Oertel, who believes that it hastens separation of the mem- brane but its depressing effect upon the heart is a serious objection to its use. Among other remedies which have received the sanction of good authority are cubebs, copaiba, potassium chlorate, the sulpho-carbolates, sodium and potassium sulphites, salicylic acid, the salicylates, and potas- sium, sodium and ammonium benzoates. Indeed, there are few remedies of any potency in any disease that have not been tried for this affec- tion, and which have not, for a time at least, received unmerited praise. When the disease extends to the larynx, remedies calculated to re- move the membrane or to prevent spasm of the muscles have been rec- ommended. For this purpose emetics are chiefly employed; among 338 DISEASES OF THE FAUCES. those in common use are alum, ipecacuanha, tartar emetic, zinc sulphate, copper sulphate, apomorphine, and turpeth mineral. Of these, ipecacu- anha and alum are the simplest and safest, though the turpeth mineral is largely employed, and copper sulphate is highly recommended by good authorities. These, however, should only be employed early in the attack. I fully indorse the ancient belief that in this condition mercurials have considerable power in preventing the dejsosit of membrane, and remov- ing that which has already been formed. I prefer the mild chloride of mercury, administered in doses of about half a grain for each year of the child's age, every one or two hours until it acts upon the bowels. The frequency of the dose is then gradually diminished, and, as soon as dyspnoea has been relieved, the drug is withdrawn. It is surprising how slight its effects are upon the bowels in this condition; a child two years of age will frequently take twenty to forty grains of calomel without serious disturbance of the bowels. I have never seen any ill effects from its use in this way, and I believe it can do no harm. As obstruction of the glottis increases, the lips and finger nails be- come blue, there is recession of the softer portion of the chest walls during inspiration, with labored and stertorous respiration, and other signs of approaching suffocation. At this time operative measures should not be delayed. The operation to be preferred depends some- what upon the age of the child and its surroundings. Other things being equal, in children under five years of age, I decidedly prefer in- tubation by O'Dwyer's method. In older children, intubation is not quite as satisfactory as tracheotomy, still it has been found useful in many cases, particularly where the graver operation will not be permitted; therefore I would advise that it be tried first; it does not preclude the subsequent performance of tracheotomy. These operations are described under the treatment of membranous croup. CHAPTER XX. DISEASES OF THE FAUCES.— Continued. ACUTE FOLLICULAR PHARYNGITIS. Acute follicular pharyngitis is an acute inflammation of the follicles in the mucous membrane of the pharynx, occurring most frequently in cold and damp climates, and in young or middle-aged people. Those suffering from a rheumatic diathesis are peculiarly prone to it. Anatomical and Pathological Chakacteristics. — As a result of the inflammation, the mucous follicles become closed and finally dis- tended by their altered secretions, in some cases the distention becom- ing so great that the follicle is ruptured and a small ulcer results. Etiology. — The most frequent causes are: exposure to inclemency of the weather; the abuse of tobacco; and excessive use of the voice in badly ventilated rooms or out of doors, especially in the night air. The inhalation of irritating particles of dust or of smoke is an occasional cause. Symptomatology. — Mild cases begin with malaise, which may last for a few days, the patient complaining in the mean time of some little fever and more or less discomfort in the throat. Early in the attack, the patient usually experiences dryness, smarting, or pricking sensations. In severe cases pain and swelling are excessive and the constitutional symp- toms very pronounced, the fever running up several degrees. There is often a slight hacking cough, with expectoration of a small amount of glairy, tenacious mucus. Hoarseness is present in most instances, due to extension of the inflammation to the larynx. Upon examination of the throat, the mucous membrane is found congested; and in patches, corresponding to the follicles, there is swelling and deeper congestion. Several of these swollen follicles may be visible, especially just back of the posterior pillars of the fauces. Some are round, others oval, and all more or less elevated above the surface. Some with yellowish sum- mits look like pustules. At other points where rupture of the follicles and escape of their contents has occurred, small ulcers are visible, and remain for a few days. Where the contents of a follicle are retained for a number of days, they become somewhat cheesy. Diagnosis. — Acute follicular pharyngitis is apt to be mistaken for simple acute sore throat. The essential points in the differential diag- nosis are the round or oval follicles more or less elevated above the sur- face, accompanied by pustules or small ulcers. 340 DISEASES OF THE FAUCES. Prognosis. — The disease usually terminates in resolution within a few days. In most cases, however, there is a tendency to recurrence, and the attack may be repeated many times. I have seen one patient who has had an attack every three or four weeks during the last two years. Nearly always there is some disease of the nasal passages or of the naso- pharynx associated with this predisjDosition to acute follicular pharyn- gitis. Treatment. — In cases where the portal circulation is sluggish, the administration of salines and an occasional mercurial cathartic will work much benefit. In lieu of mercurials, the mineral acids, especially hydro- chloric, will be found useful as hepatic stimulants. Many of these patients are troubled with poor digestion, which may be best relieved by the use of bitter tonics. Quinine is useful, more especially in ultra-malarial districts, but under ordinary conditions I have found hydrastine muriate and extract of nux vomica more efficient; but whatever bitter tonics are prescribed, the doses should be small. The local treatment, which has the prestige of antiquity, consists of the application of solutions of silver nitrate in strength of from gr. xxx. to cxx. ad 3 i. It should be made with an absorbent-cotton swab or large brush, saturated with the solu- tion, but not so wet that drops fall from it. The tongue should be de- pressed as far as possible, and the application made quickly from the lower part of the pharynx upward, by which procedure the whole pharynx can be treated at once. Applications of silver nitrate often cause strangling, even if apjdied only to the pharynx; they taste badly and cause prolonged smarting if used in strength sufficient to be of value. For these reasons I seldom emjfioy this remedy, and I have an impression that it is of no more therapeutic value than less disagreeable agents. In these cases the astringent and sedative spray containing morphine, carbolic acid and tannic acid (Form. 93) has not been disap- pointing. In obstinate cases some authors recommend the actual cautery, in the form of a small wire with a little bulbous end, which is heated and touched to the inflamed follicles. This results in a more acute inflammation for a short time, followed by thorough resolution. The galvano-cautery is much more easily applied than the actual cautery, and is to be recommended when needed. In cauterizing, not more than two or at most three small spots should be touched at a time, otherwise too much inflammation will be caused. The cautery is not often needed in acute cases. CHRONIC FOLLICULAR PHARYNGITIS. Synonyms. — Granular sore throat, clergyman's sore throat, chronic pharyngitis, sometimes kno»vn as hospital sore throat. The disease is a chronic inflammation of the pharyngeal mucous membrane, the brunt of which is expended upon the follicles. It is CHRONIC FOLLICULAR PHARYNGITIS. 341 characterized by hypertrophy of the mucous membrane and irregular plastic exudation upon it, occurring in patches, especially about the fol- licles. It is most marked in damp and chilly climates, occurs most often in those of delicate constitution, and is perhaps the most frequent of all chronic affections of the fauces or throat. Three varieties of the disease have been described: the hypertrophic, the most common; the atrophic, not very frequent; and the exudative, which is rare. Lennox Browne does not recognize an exudative form, but I have seen several well marked cases. Anatomical and Pathological Characteristics. — In the hyper- trophic variety the mucous membrane of the pharynx is studded with swollen follicles varying from two or three to ten or twelve in number. These are red or yellowish red in color, oval or round in shape and ele- vated one to three millimetres above the surrounding surface. Those of a yellowish red color sometimes appear like small blisters, with gelati- nous contents. Often two or three of these follicles are grouped closely together or united; this is much more frequent at the angles of the pharynx just back of the posterior pillars, where they often form long red welts. One or more of the superficial veins are usually enlarged, sometimes to a diameter of one or two millimetres, and they occasionally seem to terminate in the enlarged follicles. Where the inflammation has existed for a long time, it finally results in more or less atrophy. Some of the enlarged follicles may remain, but the mucous membrane between them looks thin and whitish and sometimes seems to be covered with muco-pus; an appearance due to the atrophied whitened tissue shining through the secretions. In the hypertrophic form, the bulk of the enlarged follicles has been found microscopically to be made up of swollen epithelial cells. In the exudative form, yellowish spots will be seen at the mouths of some of the follicles, similar to the yellow spots seen in chronic follicular tonsillitis, due to cheesy secretions from these diseased glands, mingled with viscid mucus. Etiology. — The disease may be caused by the constant inhalation of vitiated atmosphere, by frequent exposures to cold or damp, and by the use of tobacco — particularly, there is reason to believe, by excessive smok- ing. Occasionally it seems to have been caused by the inhalation of acrid fumes, as for example, those to which tinsmiths are exposed. Over- use of the voice, particularly in badly ventilated rooms or in the open air, is evidently a frequent cause. The ingestion of spices is possibly an occasional cause of the disease. It has been attributed also to digestive disturbances, with which it is frequently associated. The most common cause is obstruction of the nasal passages by swelling of the turbinated bodies, polypi, and deflection or exostosis cf the septum. As a result of such obstruction, normal nasal respiration gives place to mouth-breathing, which by rarefaction of air in the naoO-pbarynx with each inspiration, finally causes congestion of the throat, and if prolonged terminates in 34*2 DISEASES OF THE FAUCES. disease of its mucous membrane. That the affection is hereditary in some instances there can he no doubt. It is claimed that the arthritic, rheumatic, and scrofulous diatheses favor the production of this disease. The frequent recurrence of acute attacks is apparently the cause in some instances. Chronic follicular pharyngitis is sometimes found following one of the eruptive diseases. It is favored by chronic alcoholism, and exposure to prolonged dry heat is a not very uncommon cause. Mental depression, portal congestion, and torpor of the liver may be put down as among the rare causes. Symptomatology. — Usually there is at first passive congestion, which may run into the chronic condition of inflammation without greatly at- tracting the patient's attention. The first complaint is liable to be of slight discomfort in the throat, which may be a feeling of simple dryness, or some peculiar sensation, or may amount to actual pain. Patients usually speak of dryness or pricking sensations in the fauces, sometimes of a hair, or lump, or burning pain, which may be continuous or only occur at periods during the day. Pronounced instances of this character are more prone to occur in the exudative variety of the disease. Partial deafness sometimes occurs, and it may even become complete. This is due to an extension of the inflammatory process into and along the Eustachian tubes. The giving way of the voice is usually, however, the first thing which admonishes the patient to seek medical advice. When the voice is used more or less continuously for half or three-quarters of an hour, the person becomes fatigued, and the enunciation is likely to fail. Although hoarseness is not a constant feature, yet nearly all pa- tients are troubled with it to a greater or less extent upon slight expo- sure or free use of the voice. Short of hoarseness, the expression of the voice will be found feeble or muffled, and the singing voice is generally lost. A few patients may even suffer from complete aphonia as a result of the extension of the disease to the larynx. All the symptoms are variable, and are apt to change in the same patient; the}* are gener- ally intensified during the cold and changeable seasons, while an im- provement occurs in the summer. In nearly all cases, careful investi- gation will lead to the discovery that there is oral respiration. Many patients, who affirm that they breathe perfectly, will be found to breathe with the mouth open, particularly during the latter portion of the night. The constitutional effects of follicular pharyngitis depend upon the im- peded nasal respiration, or upon the digestive disturbances which may be a causative factor of the disease. The frequent hawking attempt to clear the throat is often one of the most noticeable symptoms of this affection, and is due to the uncomfortable sensation produced by the tenacious mucus adhering to the palate or pharynx. In a few cases there is severe cough, particularly in the morning, and mucous pellets are expectorated early in the day, more especially when the disease has ex- tended to the larynx. In some cases there is muco-purulent expectora- tion, and occasionally the sputum is streaked with blood; this, however, CHRONIC FOLLICULAR PHARYNGITIS. 343 is of no consequence in the diagnosis or prognosis, though it is often alarming to the patient. In many cases the secretions which form in the naso-pharynx and nose gradually find their way downward and back- ward into the pharynx, or even into the larynx, and may be seen adher- ing to the posterior pharyngeal wall as thick, dry or moist scabs, or they may hang in stringy masses from the edge of the palate. There will usually be found a considerable amount of mucus in the naso-pharynx, and some adhering to the mucous membrane of the larynx, where it may cause cough. Commonly there is a coated tongue, together with other evidences of digestive derangement. Where pain is experienced, it may be during the act of swallowing, but in some cases the discomfort may be relieved by deglutition, and not reap- pear until an hour or so after eating. Liquids are easily swallowed by some pa- tients, but solids cause pain; with others the opposite is true; while to still others neither will cause any discomfort. Upon examination of the throat, the surface (Fig. 89) will be found congested and swol- len in patches, the blood vessels in many cases enlarged, and the follicles of abnor- mal development. About the latter there is usually a narrow zone of congestion. At the base of the tongue diseased follicles similar to those upon the pharyngeal wall may be observed. In the exudative type of the affection, two or three yellowish points similar to those of chronic follicular tonsillitis may be seen at some part of the pharynx. Small ulcers are described by Cohen and others as being present occasionally, though I have never seen them. The tonsils are often involved, in either chronic follicular inflammation or simple hypertrophy. The palate may be relaxed and the uvula elongated ; and the larynx is not infrequently the seat of more or less congestion, more particularly the posterior ends of the vocal cords, especially after using the voice. Examination of the naso-pharynx will reveal congestion of its mucous membrane, with, generally, abundant secretion. Often there is submucous thickening at the sides of the vomer, which may appear grayish white and slightly nodular, and is sometimes sufficiently large to almost occlude the posterior nares. Such obstruction may also result from hypertrophy of the posterior ends of the turbinated bodies. When the secretion is scanty and the mucous membrane dry and thin,white atrophied tissue is seen between the follicles — a condition known as pharyngitis sicca, or atropine follicular pharyn- gitis. Sometimes the entire pharyngeal wall will be found covered with dried secretions. Fig. 89.— Chronic Follicular. Pharyngitis (Cohen). 344 DISEASES OF THE FAUCES. Diagnosis. — Syphilis is the only disease with which the affection is likely to be confounded. When there is simple congestion, with very slight enlargement of the follicles, it may be difficult or impossible to distinguish it from some cases of syphilitic sore throat, but in the latter there are usually either the mucous patches of the secondary stage or the ulcers or scars of the tertiary period, the presence of which renders the diagnosis plain. The remote possibility of mistaking the ulcer of chronic follicular pharyngitis — which is very rare — for that of syphilis may be remembered. Chronic follicular pharyngitis may possibly be confounded with tuberculin- sore threat, but in this the ulcers are super- ficial and irregular, and the edges not distinctly marked ; whereas in chronic follicular pharyngitis they occur, if at all, but rarely, and then only as small, round ulcers where distended follicles have ruptured. The presence or absence of the constitutional evidences of tuberculosis will have great weight in determining the true nature of the disease. Prognosis. — Chronic follicular pharyngitis may continue for years unless efficiently treated. In many cases the inflammation gradually extends to the ear, or to the larynx, giving rise to deafness, or to loss of voice. Again, the hypertrophic form of the disease may terminate in the atrophic, which is far more troublesome to the patient and very diffi- cult to cure. The exudative form of the affection is generally more ob- stinate. Treatment. — The old adage that an ounce of prevention is worth a pound of cure could well be applied in this disease, were it not that the opportunity is generally lacking to the physician, inasmuch as the patient does not present himself soon enough. A caution should be given, however, regarding those exposures already mentioned which are known to exert a damaging influence upon the parts, for they not only cause the disease, but favor its continuation. Faulty digestion and elim- ination should be corrected. In many cases a course of diuretics and bitter tonics is indicated. Arsenious acid is often of special service. Those predisposed to rheumatism must have appropriate constitutional treat- ment. Locally, silver nitrate is an old time remedy, but one which I rarely recommend. It may be applied in strong solution or in the solid stick, but, if the latter, only a small area should be treated at one sitting. I have had excellent results from powdered hydrastine (Form. 17-4) by in- sufflation into the naso-pharynx in cases presenting several enlarged folli- cles of a deep pink color, providing the surrounding mucous membrane is moist, and the secretion — except in the naso-pharynx — is not excessive. The powder remains in the nasopharynx several hours, gradually work- ing down the pharynx and thereby prolonging the effect. At first only a small quantity should be used, in order to ascertain the susceptibility of the patient, since in some cases the remedy applied in this way causes severe pain. Ordinarily it produces no discomfort. In mild cases, and often in those more severe, local astringents are CHRONIC FOLLICULAR PHARYNGITIS. 345 desirable, and troches of krameria, either simple or compound (Form. 38 and -il), will be most conveniently used by the patient. Sprays to the oro-pharynx of copper sulphate in solution of ten. or twenty grains ad 3 i., zinc chloride or zinc sulphate in the same proportion, or mercury bichlo- ride gr. ss. ad 3 i. are also useful, Somewhat weaker solutions of the same may be used for the naso-pharynx, which in nearly all instances requires treatment; indeed, it is often more important to medicate the naso- Fig. 90.— Ingals' Modification of Shuhly's Battery. This has two large cells. The ele- ments consist of large zinc and carbon plates, which may be depressed to any desired depth by the screw shown in the centre. Thus the current may be accurately regulated. The cautery battery here shown. I have used for years with much satisfaction, though for the past two years I have more commonly employed a storage battery so connected that I can easily charge it from the Edison current. It is somewhat more convenient, when working well, than the battery here shown, but more expensive and less reliable. pharynx than the other parts. When the follicles are much enlarged, the above treatment will not be sufficient, and there will be no great relief until they are cured. To accomplish this, they may be cauterized with nitric acid, chromic acid, or London paste, a small quantity being applied directly to the surface of the follicle, not to the surrounding membrane; only two or three of the follicles should be treated at each sitting. This procedure may be repeated every four or five days until all are removed. Sometimes it is well to split the follicle with a sharp knife, and then crowd into the incision the pointed end of a stick of silver nitrate. 346 DISEASES OF THE FAUCES. Some are in favor of scraping off these follicles with a curette. The actual cautery may be employed — as recommended for acute follicular pharyngitis— but the galvano-cautery (Figs. 90 and 91) is the best means for getting rid of the hypertrophied follicles. In using it the electrode is applied cold, the current is then turned on for a second and the fol- licle destroyed. The next day after using the canter}', a whitish pel- licle is observed about this cauterized point, which may extend for four or five millimetres in every direction from the burn, and appears very much like a diphtheritic membrane. This remains from five to even twelve days, depending upon the rapidity of the reparative process and, perhaps, atmospheric conditions. Frequently the patients retch and Fig. 91.— Ingals 1 Cautery Electrodes (3-5 size). 1, Guarded electrode used for superficial cauterization in hay fever ; 2, knife-like electrode used in hypertrophic rhinitis ; 3, 4, and 5, electrodes for cauterizing; the tonsils, follicles in pharynx, and small spots in the nose ; 5, electrode for base of tongue, or. when guarded by a piece of vulcanite fibre, for naso-pharynx ; 5, 6, and 7. tubular elec- trodes, into which various shaped points of platinum wire may be inserted for various purposes. gag easily, and in such cases it is evident how difficult it would be to use the actual cautery. Where there are enlarged veins, it is better to cut them off with silver nitrate or the galvano-cautery — the latter being much the more satisfactory in its action. Though the exudative form of the disease has been considered peculiarly obstinate, it has, in my ex- perience, proved less stubborn than some other forms, when treated by the galvano-cautery in the manner just described. Cases of simple chronic congestion without enlargement of the follicles are most difficult to cure. In these all sources of irritation must be avoided, and the patient should make applications to the pharynx of some mild astrin- gent two or three times daily. Sometimes such patients will find it nec- essary to remove to a different climate before relief is found, but ordi- narily it is not well to advise such a course, for the climatic influence is very uncertain. CHRONIC FOLLICULAR GLOSSITIS. 347 ACUTE FOLLICULAR GLOSSITIS. Acute follicular glossitis is an inflammation of the follicles at the base of the tongue, in which severe pain is caused by an attempt at deglutition. Its causes are probably not unlike those of acute follic- ular pharyngitis, and its pathology is also similar. Symptomatology. — Pain is felt not only in the throat, but radiating to the ears, and some patients speak of it as being almost altogether in the ears, or near the orifices of the Eustachian tubes. Upon examina- tion of the parts, we may find several small, rounded elevations of a whitish hue somewhat resembling pustules, which may be distributed all over the base of the tongue, or confined to one or the other side, particularly to that jnortion of the base which is often hidden from view by contact with the external wall. In some cases, instead of these small follicles, one or more superficial ulcers are to be found. I have seen one at least a centimetre in diame- ter, where small ulcers had coalesced after rupture of several follicles. These ulcers are more apt to be found at the side of the base of the tongue, where they may escape notice except upon careful inspection. Diagnosis. — The disease is liable to be mistaken for inflammation in the naso-pharynx, because the patient often refers the pain to that locality. The diagnosis will be made by a careful laryngoscopic inspec- tion of the base of the tongue, particularly of its sides, which must be exposed by crowding the organ over with a spatula. Peognosis. — Left to itself, the condition lasts a week or ten days. Teeatment. — The most satisfactory treatment consists in the appli- cation of a sixty grain solution of silver nitrate to the follicles or super- ficial ulcers. The rapidity with which the affection may be cured by this method is sometimes surprising. I recollect one case especially, where an ulcer a centimetre in diameter was found, in which the pain was relieved within a few minutes after the first application, and in forty-eight hours the ulcer practically healed. CHRONIC FOLLICULAR GLOSSITIS. Chronic follicular glossitis is not infrequently associated with chronic tonsillitis, and is characterized by chronic inflammation of the follicles at the base of the tongue, which become more or less filled with secre- tion producing numerous yellowish white spots similar to diseased folli- cles in the tonsils, and attended by various uncomfortable sensations referred either to the tonsils or, more accurately, to the base of the tongue. The nature of the affection is essentially the same as that of chronic follicular inflammation of the tonsils, and it is apparently de- pendent upon like causes. 348 DISEASES OF THE FAUCES. Symptomatology. — The principal symptoms of which the patient complains are sensations of pricking or of a foreign body in the throat, which may be present continuously or only a part of the time, and which may or may not be aggravated by the act of deglutition. DIAGNOSIS. — The diagnosis is made by an examination of the base of the tongue with the laryngeal mirror, without which it is seldom possi- ble to see the diseased follicles. PROGNOSIS. — The affection tends to run on for many months or years, during which time the patient is much annoyed by offensive breath and by harassing fears of tuberculosis or cancer. Treatment. — When due to a rheumatic diathesis, or to disturbance of the digestive organs, the treatment suited to these disorders is indi- cated. Locally, astringent troches as represented by the troches of krameria (Form. 38 and -il) are sometimes beneficial, and applications of more active astringents, of stimulants, or of strong solutions of silver nitrate sometimes prove curative. A more efficient method, and one which finally must be the resort in most cases, is cauterization with the galvano- cautery. This is usually followed by the most satisfactory results. Two or three follicles should be cauterized at each sitting, by a small electrode, which should be passed to the bottom of each, and the operation should not be repeated until two or three days after all soreness from the previ- ous cauterization has disappeared. This treatment should be continued until all of the diseased follicles have been dealt with and a complete cure may be confidently predicted. SCROFULOUS SORE THROAT. Scrofulous sore throat is a chronic inflammation, sometimes observed in scrofulous children, which in the simple form has the appearance of ordinary catarrhal inflammation; when more pronounced, it resembles the inflammation of tuberculosis or syphilis. In many instances it con- sists of simple inflammatory thickening of the mucous membrane of the fauces and naso-pharynx or palate, but in the more advanced conditions — which, indeed, are the only ones rightly classed under this head — ulcer- ation occurs. This at first superficial and always indolent, finally be- comes extensive, sometimes spreading over a large portion of the pharynx or involving the palate, and causing perforation, or even destruction of the uvula with considerable portions of the velum. Etiology. — J. Solis Cohen (Diseases of the Throat) believes that most of these are cases of simple chronic inflammation occurring in those of inherited syphilitic taint, while others regard it as a manifesta- tion of lupus. Still others ascribe some of the cases to tuberculosis or the rheumatic or arthritic diathesis. Whatever the remote cause, it is certain that a low form of inflammation, with ulceration, occurs in chil- SCROFULOUS SORE THROAT. 349 dren presenting what was formerly known as the scrofulous diathesis; aud it is more than possible that, in most of these, hereditary syphilis or tuberculosis could be traced if an accurate history could be obtained. Symptomatology. — There are no positive symptoms or signs of this affection, but usually the child is pale and less vigorous than other chil- dren of the same age and surroundings; there is sometimes a tendency to clear the throat of secretions frequently, but usually this is not a pronounced symptom, and even when extensive ulceration has taken place the patient does not complain of pain. Difficulty in deglutition or alteration of the voice may be caused by partial destruction of the soft palate or extensive ulceration of the pharynx. Sometimes a history of inherited syphilis or tuberculosis can be obtained, and upon examination of the fauces more or less extensive ulceration will be found. These ulcers are at first superficial, but later are deep, with bevelled edges, in- dolent surface, and slight discharge. Diagnosis. — Scrofulous sore throat is to be distinguished from lupus, tuberculosis, and syphilis. External manifestations which may. at once decide the diagnosis, nearly always attend lupus. Upon the base and about the edges of the ulcer are red nodules, which do not appear in the scrofulous ulceration. Scrofulous sore throat is distinguished from tuberculosis by the comparative absence of pain, by a well marked instead of an indistinct border, by the absence of fever and other evidences of tuberculosis. Scrofulous sore throat is distinguished from syphilitic ulceration of the throat by the absence of a syphilitic history and the general signs of the disease, by the age of the patient, slow progress of the ulceration, slight discharge and bevelling of its edges, which do not have the punched- out appearance common in syphilis. Scrofulous sore throat and lupus of the pharynx present the following points of difference: Scrofulous sore throat. Lupus of the pharynx. Generally seen in children. Usually Generally in young- adults. Usually evidences of constitutional disturb- associated with disease of the face, ance. Ulcers superficial or deep, with bev- Congested, irregular nodules about elled edges, indolent base, and slight edges or on base of ulcers, which are discharge; no cicatrices. usually extending in some places, while healing at some other part of their border; usually old cicatrices. Scrofulous sore throat and syphilitic -sore throat can be differentiated as follows: Scrofulous sore throat. Syphilitic sore throat. Generally seen in children. Ulcer in- Generally seen in adults. Ulcer dolent and usually has a bevelled edge sharp cut, indurated, sometimes un- not indurated or undermined. dermined. 350 DISEASES OF THE FAUCES. The differential diagnosis of tubercular sore throat and scrofulous sore throat, will be further considered under the head of acute tubercular sore throat. Prognosis. — If left to itself, the ulceration gradually extends, and may continue for many months; I have seen cases which had lasted for over a year. With improvement of the general condition and appropri- ate local treatment, healing may be expected within a short time. Treatment. — Good hygienic surroundings and tonics are most im- portant. Calcium iodide and chloride internally in moderate doses are beneficial, and cod-liver oil is generally recommended. The local treat- ment consists of frequent cauterization or stimulation by less active agents. In practice, the thorough application of strong tincture of iodine to the ulcer two or three times a week has given best satisfaction. Under its influence and the general treatment, healing soon begins, and an ulcer an inch in diameter may be expected to heal within six or eight weeks. ACUTE TUBERCULAR SORB THROAT. Acute tubercular sore throat is a rare affection occurring in about one per cent of all cases of tuberculosis of the respiratory tract (Browne, Diseases of the Throat, third edition). It runs a rapid course, being char- acterized by ulceration and great pain and the constitutional symptoms of tuberculosis. Anatomical axd Pathological Characteristics. — At first there appear numerous small, gray granulations grouped in patches beneath the epithelium, and if abundant, closely resembling the mucous patches of syphilis, but they lack the inflammatory areola? which are found about the latter. These granulations are said to bleed easily when touched, but this has not been my experience. They may be located upon the palate and the pharynx, and late in the disease may be found on the epi- glottis and in the larynx. As the affection progresses they lose their transparency, become hidden in a purulent or pultaceous covering, and finally undergo ulceration. These ulcerations are shallow, have no well marked borders, but rather a worm eaten, irregular edge, and bleed easily when touched. Etiology. — The cause is the same as that of tuberculosis in other localities. Symptomatology. — Usually there are evidences of primary pulmo- nary or laryngeal phthisis. The consumptive appearance, persistent fever, rapid pulse, cough with or witnout expectoration, anorexia, and other symptoms of tuberculosis are apt to be marked, but the pharyngeal lesions may be independent of laryngeal or pulmonary disease, these subsequently supervening. The one prominent, sometimes the first, symptom of tubercular sore throat is intense pain, sometimes experienced upon phonation and upon attempts at deglutition. It becomes agonizing, ACUTE TUBERCULAR SORE THROAT. 351 largely preventing the taking of food, with consequent speedy loss of strength and rapid advance of the disease. An early examination may reveal congestion of the pharynx similar to that found in simple inflammation, but in most cases the mucous membrane presents a characteristic grayish pallor with numerous semi-transparent granula- tions which speedily give place to ulceration. The tubercular ulcer is superficial, with irregular ill defined borders, which are not undermined, and it is sometimes surrounded by a faint blush, though usually there is no areola of hyperemia. The floor presents indolent, gray granulations* and scanty secretions. In exceptional cases the tubercular ulcer has a sharply defined border, which may be slightly thickened and congested; it has a depth of about one and one-half millimetres, and its base is covered with a grayish white coating presenting an appearance about midway between that of the ordinary superficial ulcer described above and the deep ulcera- tion of syphilis. Diagnosis. — Tubercular sore throat may be mistaken for syphilitic or scrofulous sore throat. Syphilitic sore throat is not accompanied by the excessive pain, the fever, and the constitutional symptoms of the tubercular affection; and instead of the marked anasmia of the mucous membrane and small gray granulations, or shallow irregular ulcers with ill defined, pale borders, and scanty, grayish, viscid secretion, it is characterized by the large, sharply defined inflammatory ulcers of the secondary stage, or the deep ulcers of the tertiary form with raised and often undermined edges, granular floor, and profuse purulent secretion. As also noted by Lennox Browne (op. cit.), the enlargement of the parotid, submaxillary, and cervical glands, both superficial and deep, so commonly observed in the tubercular affection, is relatively infrequent in the latter part of the secondary, and in the tertiary stage of syphilis. From syphilitic sore throat, tubercular sore throat may be distin- guished as follows : Tubercular sore throat. Syphilitic sore throat. No syphilitic history, Generally in Syphilitic history. If hereditary, it adults. may appear in children ; otherwise in adults. Marked constitutional symptoms. Constitutional symptoms may be marked. Fever, rapid emaciation. Usually no fever. Severe local pain. Frequently no pain. Aphonia, dysphagia. Hoarseness, but usually no aphonia or dysphagia. Ulcer usually superficial, with gray- Ulcer sharp cut, with areola of red- ish, worm eaten appearance and rapidly dened, thickened tissue about it, some- progressive, times undermined edge. Short duration. May progress rapidly but usually relatively longer in duration. DISEASES OF THE FAUCES. Scrofulous sore throat, unlike the tubercular, occurs in children in- stead of young adults, and lacks the severe pain, the fever, and the irreg- ular, superficial, poorly defined ulcers of the latter affection. Between tubercular sore throat and scrofulous sore throat the follow- ing are the chief points of difference : Tubercular sore throat. Scrofulous sore throat. Rarely seen in children. Ulcer super- Generally seen in children. Ulcer ficiul, with poorly defined borders. deep, with sharply defined edges. Hectic fever. Considerable cough. No fever. Little or no cough. Rapid emaciation. Slow physical change. Severe pain, frequently the first But little or no pain, symptom. Dyspnoea, dysphonia or aphonia, No dysphonia, aphonia, or dyspha- dysphagia. gia. Pulmonary tuberculosis usually pres- No signs of pulmonary tuberculosis, ent. Prognosis. — Tubercular sore throat usually runs its course in from six to twelve weeks, and nearly always terminates fatally. In exceptional instances the duration is as much as six months, and in extremely rare cases recovery may occur, or the disease may progress slowly, the patient under favorable conditions living for several years before succumbing to the constitutional disease. Death is caused commonly by asthenia. Treatment. — The treatment recommended by Krause and Herying, by thorough curetting the ulcers, followed by the application of lactic acid, with occasional use of the galvano-cautery, has effected a few cures (Gleitsmann, New Tori- Medical Journal, 1891), and similar results have been attained by the use of lactic acid alone in solutions varying in strength from twenty to seventy-five per cent. Sedative applications are of much benefit, chief among which are steam impregnated with bella- donna, hyoscyamus, stramonium, or opium, as recommended (Form. 56, 57, and 59). Sajous (Diseases of the Nose and Throat) recommends a ten per cent solution of cocaine applied often enough to relieve pain ; but the evil effects of this drug are so pronounced that extreme caution should be used in its employment. Painting the throat with solutions of silver nitrate as advised by some, has usually proven more hurtful than other- wise. I have found most satisfactory, for relieving pain, a spray of mor- phine, carbolic acid, and tannic acid (Form. 93). This may be used by the patient also, diluted, with one or more parts of water, according to the amount of smarting occasioned. Troches of morphine or lactuca- rium, or althea (Form. 25, 29, and 36) are sometimes efficient in reliev- ing the distress, bat the good effect of opiates is usually counteracted by the excessive dryness which they cause. When dysphagia becomes ex- treme, the feeding bottle may be used, as recommended by Delavan (Transactions of the Ninth American Laryngological Association) or SYPHILITIC SURE THROAT. 353 nutritive enema ta may be employed, but in well marked cases all that we can hope for is to render the patient as comfortable as possible. SYPHILITIC SORE THROAT. Syphilis may affect the fauces in any of its three stages, but the earliest manifestation is seldom seen in the throat, though the secondary and tertiary forms are common. The chancre or primary lesion of syphilis, when present in the mouth, is similar to that which may occur in other parts, and lasts for five or six weeks; in the secondary stage the erythematous or mucous patches, and in the tertiary stage gummata or deep ulcers, are characteristic. When the disease is inherited, the sec- ondary symptoms usually occur within two to six weeks after birth ; the tertiary, in early childhood or at any time before the sixteenth year. Anatomical axd Pathological Characteristics. — When chan- cre occurs in the throat, it is nearby always located on one tonsil. In the secondary affection, usually at first the fauces present a uniform dull red erythema; this in part gradually fades away, leaving erythematous patches which tend to symmetrical arrangement upon the two sides of the palate or pillars of the fauces, and sometimes upon the pharyngeal wall. These patches are separated, from healthy tissue by a distinct line of demarcation. Mucous patches (also termed mucous tubercles cr broad condylomata) when occurring in infants, are usually found in the upper part of the pharynx and on the fauces; but in adults on the pillars of the fauces, or the velum palati'and the sides and base of the tongue. They are circular or elliptical in form, slightly elevated, at first of a deep red, later of a grayish white color, and, as a rule, symmetrically situated on each side of the throat. These subsequently become the seat of superficial ulcers; their borders are distinctly marked and surrounded by an areola of hyperemia, slightly elevated, and from three to five millimetres in width. Occasionally deep and rapidly extending ulcera- tion follows; these ulcers are two or three millimetres in depth, with a light pinkish or grayish surface, and have sharply defined but not in- durated edges. In the tertiary stage, ulcerations are deep and usually preceded by gummata. A gumma, situated as a rule under the mucous membrane, is at first small varying from three to eight millimetres in diameter, and causes no disturbance, but as it increases in size the mucous membrane covering it becomes congested, and finally, as the gumma softens, a yellowish spot appears at the surface, soon to be fol- lowed by ulceration. Two varieties of ulceration occur in this stage, the superficial and the perforating. The former is most frequently found on the velum, but is also seen upon the pillars of the fauces and tonsils; often having a depth of one or two millimetres. The ulcers have irregular, sharply defined borders and secrete foul, dirty pus, which when cleared away 354 DISEASES OF THE FAUCES. reveals a floor pale and smooth, with here and there fungoid granulations. Fissures sometimes extend from the edges into the surrounding tissue. Deep ulcers situated on any part of the fauces or pharynx are com- monly from three to five millimetres in depth with clear-cut edges, often undermined and indurated. Ulcers of the third stage, whether sequela? of gummata or not, are apt to extend rapidly, destroying all tissue in continuity, not excepting cartilage and bone. Frequently perforation of the palate occurs (Fig. 92) as if by magic, sometimes as the result of a gumma, which in the palate occurs preferably upon its upper sur- face. Such ulceration may destroy a considerable portion of the velum within ten or fifteen days. Etiology. — Syphilis, whether inherited or acquired, is probably due to a specific virus, not yet identified. Symptomatology. — The primary affection usually causes no symp- toms, in the throat unless phagedenic ulceration occurs, giving rise to pain and fever. In the secondary stage, there is dryness of the throat, Fig. 92.— Perforating Ulcer of Palate, Syphilitic. with more or less soreness and occasionally a slight febrile reaction. In some cases, owing to the location of the ulcer, there is great pain upon deglutition. Papillary eruptions upon the skin usually appear at this time. The tertiary form sometimes develops insidiously, and may have produced great mischief without having caused the patient much discomfort. In other cases, owing to the location of the ulcer, severe pain is experienced, especially on deglutition. In such cases constitutional symptoms are then apt to be pronounced, and after a few weeks the patient may present much the same symptoms, with fever and emaciation, as one suffering from advanced tuberculosis. Diagnosis. — The primary affection is apt to escape observation, but careful examination of the throat may discover a small ulcer situated on an indurated base surrounded by a slightly cedematous, elevated mucous membrane. If this is associated with a suspicious history, and remains obstinate to all treatment for four or five weeks, we may be nearly certain of our diagnosis. The secondary affection, in the beginning, is liable to be mistaken for catarrhal sore throat, but after three or four days the development SYPHILITIC SORE THROAT. 355 of symmetrical, erythematous patches distinctly outlined, or the grayish elevated mucous patches or superficial ulcers, with areola? of inflamma- tion, will at once suggest the true nature of the disease. However, even then it is possible to confound the affection with simple membranous or herpetic sore throat; but the specific history, if it can be obtained, or, if not, the progress of the case for the next few days, will settle the diag- nosis. The superficial ulceration of this stage should not be confounded with acute tubercular sore throat, if the history, constitutional symptoms, and appearance of the ulcer are taken into account. The tertiary stage is liable to be mistaken for scrofulous or tuber- cular sore throat, the distinctive features of which were pointed out in considering these diseases. The characteristic features of tertiary syphilitic ulceration of the throat are : commonly absence or insignificance of pain and of constitutional symptoms; also the edges of the ulcer are sharp cut, indurated, and sometimes undermined, and the process is rapid. In a very rare form of diphtheroid syphilitic ulceration of the throat I have seen three cases that have been mistaken for diphtheria. Prognosis. — The primary disease continues five or six weeks, and then terminates spontaneously. The secondary affection usually comes on in from six to twelve weeks after inoculation, and, as a rule, disap- pears in from six to eight weeks, or sooner under proper treatment; but sometimes renewed eruptions make their appearance from time to time for several months. The gummata of the tertiary stage sometimes dis- appear as they came, but usually soften and ulcerate, the ulcers spread- ing rapidly for two or three weeks afterward; subsequently they may continue to progress more slowly for several months if left to them- selves. The primary affection makes little impression on the general health; the secondary is seldom dangerous to life, but the tertiary is often grave. The ulceration in the latter may perforate the hard palate and destroy large portions of the soft tissues, and may sometimes cause death by erosions of a large blood vessel or by narrowing of the air passages. Cicatrization after ulceration frequently narrows or completely closes the opening to the naso-pharynx or causes stenosis of the larynx, inter- fering with respiration and phonation. Destruction of the palate in- terferes with phonation, and with deglutition by allowing fluid to re- gurgitate through the nose. Adhesion of the base of the tongue to the pharyngeal wall sometimes seriously interferes with both respiration and deglutition. In one case which has come under my observation, an opening was left only two or three millimetres in width by six or eight in length. Under appropriate treatment the majority of cases can be relieved and the disease checked, but sometimes, in spite of everything, it goes on or the exacerbations frequently recur until death results. Teeatmext. — For the primary affection cauterization is recom- mended by some, while others favor a negative course. Even for the 356 DISEASES OF THE FAUCES. secondary lesions some are in favor of confining the treatment in the majority of cases to local measures. Mackenzie (Diseases of the Throat and Nose, Vol. I.) seldom uses constitutional remedies in the secondary stage, relying mainly upon local applications of the zinc chlo- ride gr. xx., ad 3 i. for the erythematous eruption, or the tincture of iodine for mucous patches, but he recommends mercurials for the in- herited syphilis and in obstinate cases of the acquired affection. Sajous (Diseases of the Nose and Throat) advises for the secondary affection local applications of silver nitrate, iodoform, and tincture of the chloride of iron. For the secondary affection, I usually employ a spray of zinc chloride gr. xxx. ad \ i. two or three times a week, directing the pa- tient to use at home the same remedy twice daily in the form of spray gr. x. ad i i. For the mucous patches I sometimes rely upon these ap- plications, and at others I use the strong tincture of iodine or a solution of copper sulphate gr. xx. ad § i., having the patient use the spray at home as just recommended. Usually small doses of mercury bichloride and potassium iodide are administered after each meal, and in many cases ferruginous or bitter tonics are given before eating, depending upon the patient's general condition. For the ulcers of tertiary syphilis the strong tincture of iodine is the most efficient application, though occasionally the sulphate of copper, as recommended above, willbefound useful. Much, I believe, depends upon the manner of applying the tincture of iodine. The ulcer should be touched repeatedly at each sitting (four to eight times), and a minute allowed between each applica- tion for the parts to dry. When the application is completed the sur- face of the ulcer should appear dry and glazed and of a dark brown color. These treatments should be repeated daily for ten to fifteen days and subsequently less frequently until the parts are healed. At the same time the patient should be given the iodides of sodium and potas- sium in doses of from 5 to 10 grains each three or four times a day. Under this treatment even lame chronic ulcers may be expected to heal in from two to four weeks. If there is a tendency to closure of the entrance to the naso-pharynx, or other vicious adhesions are forming, bougies should be passed frequently until complete cicatriza- tion has occurred; but this should not be attempted until the reparative process has been fully established. It is especially important to be faithful in dilatation just as the last vestiges of the ulcer are disappear- ing, for at this time contraction takes place with wonderful rapidity. Syphilitic sore throat in infants, is a congenital manifestation of syphilis usually characterized by ulceration, the favorite seat of which is the palate, naso-pharynx, or posterior pharyngeal wall. According to J. X. Mackenzie, of Baltimore, nearly fifty per cent of the cases occur within the first year of life, and as many as thirty-three per cent within the first six months. In some, however, the development is delayed until near the age of puberty. SYPHILITIC SORE THROAT. 357 Anatomical and Pathological Characteristics. — Mucous patches are rare, this stage having probably been passed in intra-uterine life ; when found, these patches are apt to be located in the upper por- tion of the pharynx. Ulceration is more commonly present, its favorite seat in order of frequency being the fauces, naso-pharynx, posterior pharyngeal wall, nasal fossae, septum, tongue, and finally the gums. The ulcers present the appearance of tertiary syphilis in adults, already de- scribed, and are peculiarly prone to attack the bones and cartilages. Etiology. — The affection is either inherited during the intra-uterine life or contracted during parturition. Symptomatology. — This condition of the throat is usually associated with syphilitic lesions in the nose, giving rise to embarrassment of the nasal respiration and difficulty in nursing. This in a short time is followed by a serous discharge from the nose, that becomes thick and purulent, sometimes sanguinolent within a few days. The lips are frequently ex- coriated, and specific fissures, pustules, and ulcers develop upon the alaa of the nose, the lips, and angles of the mouth, extending outward upon the cheek. Ulceration of the pharynx also may seriously interfere with deglutition. Diagnosis. — The disease is distinguished from simple catarrhal in- flammation by the profuse discharge from the nose, the obstruction to nasal respiration, the occurrence of pustules and ulcers upon the lips, and the peculiar ulceration in the pharynx. Prognosis. — When occurring within the first year of life the disease is nearly always fatal. Older children may recover, but are apt to be left with disfigurement of the nose and partial destruction of the palate with consequent interference with the voice and respiration. Often deaf- ness results. The later the appearance of the disease, the better the chance of cure; but it is apt to break out anew from time to time. Treatment. — The treatment is essentially the same as for adults, though children bear mercurials better. Local applications should be so mild as to cause but little pain. CHAPTER XXI. DISEASES OF THE FAUCES.— Continued. DISEASES OF THE UVULA. ACUTE INFLAMMATION AND (EDEMA OF THE UVULA. Acute (edematous inflammation of the uvula is a rare affection ex- cept as associated with pharyngitis or tonsillitis. It usually causes but little pain, but is attended by some discomfort in eating and by frequent desire to swallow. The uvula when (edematous sometimes becomes so large as to interfere with respiration, and if it be long enough to touch the base of the tongue or epiglottis it causes an irritating throat cough. The affection is not difficult of recognition. Treatment. — The proper treatment consists in the application of astringent sprays or the use of astringent troches or gargles, and, if the oedema is great, a few punctures may be made near the lower end of the uvula to allow the serum to escape, but the organ should not be cut off during the acute inflammation unless it seriously interferes with respiration or deglutition, and then only a part ought to be removed. If the punctures are not sufficient to allow the serum to escape, the re- moval of a small bit of mucous membrane from the tip of the organ is generally effectual. CHRONIC INFLAMMATION AND ELONGATION OF THE UVULA. Elongation, though sometimes occurring without chronic inflamma- tion, is generally associated with it. It is apparently due to the same causes as chronic pharyngitis or tonsillitis. Sometimes it takes place without any appreciable cause. In health the uvula is from one-fourth to three-eighths of an inch in length. Sometimes when diseased, it may become three-fourths of an inch in length without causing inconvenience; but in other patients, even moderate elongation causes frequent desire to clear the throat, with expectoration of small masses of mucus, and an irritating cough which occasionally becomes so excessive as to interfere with the patient's rest, and in rare instances, by this means, to bring on symptoms similar to those of serious pulmonary disease. An elongated uvula sometimes causes spasmodic attacks of retching and vomiting and occasionally reflex spasm of the glottis. The symptoms are usually MALFORMATIONS AND NEW GROWTHS OF THE UVULA. 359 worse when the patient lies down. In a few cases it gives rise to pain and fatigue after using the voice, and more rarely to hoarseness. Diagnosis. — Elongation of the uvula may be easily detected by in- spection. Treatment. — When all other causes of the symptoms have been excluded, the superfluous part of the organ should be removed by the uvulatome, scissors (Fig. 93), or the nasal snare (Fig. 208). Various uvula- tomes have been devised for the purpose, but they are not better than the scissors shown in Fig. 93, which are simple and well suited to the purpose. The nasal snare will be found much more convenient. By it, abscission can be doue more accurately, and excessive bleeding is less likely to occur. The snare for this purpose is armed with Xo. 5 steel wire, a loop just large enough to easily enclose the tip of the uvula is formed, the physician depresses the tongue with one hand, and with the other slips the snare under the tip of the uvula, carrying it up to within from one-half to three-eighths of an inch of its base. If ^HP.W &w\h Fig. 93.— SrtssoRS for Amputating the Uvula (J^size). the uvula appears swollen at the time, less should be removed than otherwise, and it is best never to make it shorter than normal. The wire is tightened down until the tissue is secured, then the tongue depressor is removed, and the physician, seizing the cross bar of the snare with his left hand, suddenly draws upon the wire with the combined strength of the fingers of both hands, cutting through the tis- sue as quickly as by a knife. After the operation, the patient should be supplied with troches of althea to use as often as desired to soothe the pain, and a one per cent gargle of carbolic acid may be advanta- geously used several times daily until the wound has healed. In a few in- stances alarming hemorrhage has taken place after cutting off the uvula. ilALFORMATIOXS AXD NEW GROWTHS OF THE UVULA. The uvula may be asymmetrical or absent, but the most frequent malformation is bifurcation. This requires no treatment unless the organ is also elongated, when a portion should be removed. Papillary growths are not infrequently found on the uvula, and if large, by their mechanical effects they may give rise to the same symp- toms as elongation. They are easily diagnosticated, and may be readily removed bv the snare. 360 DISEASES OF THE FAUCES. Malignant growths rarely, if ever, first attack the uvula, though it may be involved by extension of the disease from the tonsils and palate. The organ is often involved in syphilitic inflammation and ulceration, but these cases require no special consideration, as they were sufficiently described in speaking of diseases of the adjacent parts. LEUCOPLAKIA BUCCALIS. Synonyms. — Leucoplakia buccalis et lingualis, ichthyosis lingua?. Leucoplakia buccalis is a chronic affection of the buccal mucous membrane, characterized by thickening of the epithelium and the forma- tion of white, opaline, elevated patches, which usually become fissured and painful, and, after continuing for a long time, are inclined to ter- minate in epithelioma. The disease is very rare, occurring almost in- variably in men over forty years of age. Anatomical axd Pathological Characteristics. — The patches are limited to the buccal cavity, and are generally found on the dorsum of the tongue or inner surface of the cheeks and lips, but seldom, if ever, on the lower surface of the tongue or back of the anterior pillars of the fauces. They consist of one or more small, irregular or oval spots which may become confluent. A considerable portion of the tongue alone may be involved, or the dorsum of the tongue, buccal mucous membrane, and the gums, one or all may be affected. The first appearance of the white patch is preceded by hyperemia, and subsequently in the early stages a hyperamiic areola is found about its borders. Before long the patch itself becomes thickened, sometimes to the extent of six or eight milli- metres, and the epithelium which has become hard and dry may be easily removed, or in spots it may be spontaneously exfoliated, leaving the ap- pearance of an ulcer. The surface of the patch is marked by numerous fine lines or furrows which by intersecting each other divide it into small polygonal spaces. Some of these lines may extend as deep fissures down through the thickened epithelium, involving the submucous tissue in a painful excoriation. In cases of long standing, the papilla? may be much enlarged, giving the surface a warty appearance, tinder the microscope, the epithelium is found greatly thickened, the papilla? enlarged and flattened, and the blood vessels dilated, with an accumulation of leucocytes about their walls. The superficial layer of the. mucous corium is infil- trated with embryonic cells, and the deep layer is involved in vascular alterations. Etiology. — Excessive tobacco smoking is ranked as one of the most frequent causes of the disease, but it is probable that prolonged irrita- tion of any character may have a similar effect on those predisposed to it. Thus, highly spiced food and alcoholics seem to excite it in some in- stances; and the occurrence of the affection in several members of the same family led Bazin to believe that it is often the result of constitu- LEUCOPLAKIA BUCCALIS. 301 tional syphilis. It is also attributed to the arthritic or dartrous diath- esis. Symptomatology. — The clinical history of the disease is not defi- nitely known, because generally it has been discovered accidentally and found to have existed for some months or years before it has come under the physician's observation. This is due to the fact that at first the affection causes no inconvenience. The small patch which first appears gradually increases in size and at length stiffness occurs or painful fis- sures form which first attract the -patient's attention. Ultimately, in the majority of cases, epithelioma results and runs its usual course. Sometimes the affection remains stationary for months, or under the in- fluence of some irritant it may rapidly progress, but it may again become dormant if the irritant is removed. Cases associated with syphilis or that have developed into epithelioma are attended by much swelling of the parts, and sometimes deep ulceration, which may erode the vessels and cause severe hemorrhage. In these, the lymphatic glands soon be- come involved, a sign not observed in the earlier stages of idiopathic leucoplakia. Often the first symptom is merely an uneasy sensation, but in others the mucous membrane early becomes more or less painfully sensitive to spices, hot food or drinks, alcoholics, or tobacco. With the occurrence of fissures, pain may become more intense and almost con- stant, although in some it is present only at intervals. There are no constitutional symptoms until epithelioma is developed. Late in the disease, speaking, mastication, and swallowing usually become difficult, especially when epithelioma occurs. In such cases also profuse saliva- tion is often a very annoying symptom. Diagnosis. — Leucoplakia may be misinterpreted for what Guinaud has termed the professional patches found in glass blowers, for smokers' patches, mercurial patches, psoriasis linguas, syphilitic patches, and epi- thelioma unconnected with leucoplakia. The professional patches occur only in old glass blowers, particularly bottle-makers, and are found symmetrically upon both sides of the mouth, on the lateral surface of the gums, and around Steno's duct. Smoker's patches are more irregu- lar than those of leucoplakia, and are commonly located near the com- missures of the lips, but not upon the dorsum of the tongue or the inner side of the cheek. Again, the epithelium covering their surfaces is thin and closely adherent, so that it cannot be removed, as in the disease un- der consideration. Mercurial patches are not so thick as those of leuco- plakia, are never quite white, and are found on all parts of the tongue, but particularly where it is pressed against the teeth. In psoriasis linguae which sometimes accompanies psoriasis of the skin, the patches of epithe- lium assume a white, opaque appearance and after a day or two they are thrown off, the epithelium being speedily restored ; but soon other patches appear and go through a like course until after a time a large part of the dorsum of the tongue may become denuded and of a uniform red color, 362 DISEASES OF THE FAUCES. with crescentic markings or depressions entirely unlike the apjiearance of leucoplakia. Syphilitic patches are not bo white as those of leucopla- kia; they are usually round or oval and more regular in form, seldom occurring on the cheek, but found principally upon the tip or margin of the tongue and ofteu on its lower surface, which is never invaded by leu- coplakia. The syphilitic patches are thinner than the patches of leuco- plakia, and the lymphatic glands are much sooner involved. The pain is more severe in leucoplakia than in the syphilitic disease, and anti-syphi- litic treatment causes no improvement, but on the contrary may aggravate the affection. "When syphilis and leucoplakia coexist, the diagnosis is difficult. Cancer arising without previous leucoplakia is distinguished from the latter by its history; the induration of the tissues and the final ulceration are not preceded by the chronic white patch, but are attended by more constant pain, with profuse salivation and a very offensive odor. Prognosis. — The duration of the disease varies from a few months to several years. The majority of cases ultimately terminate in epithe- lioma, which runs its course to a fatal issue. Treatment. — All sources of irritation, particularly the use of tobacco, alcoholic stimulants and strong condiments, should be at once removed. If the digestive organs are deranged, they should receive proper attention. Aside from these measures, most authors believe treatment to be of little or no avail. Arsenious acid, the alkalies, mercury, and the iodides have been recommended, though in the absence of syphilis the latter seem to be injurious. For local application various caustics, such as silver nitrate, zinc chloride, tincture of iodine, and the solution of mercury nitrate have been recommended, but none of them seem of any value except in cases complicated by syphilis. On the contrary, soothing applications seem to have been the most beneficial, though giving only temporary relief. I have succeeded in curing one well-marked case by repeated careful ap- plications of the galvano-cautery, made to a small spot at each sitting and in such manner as not to destroy the healthy tissue beneath. For a more complete exposition of this subject the student is referred to my paper, Leucoplakia Buccalis. etc.. in the Transactions of the American Laryn- gological Association for 1885, page 57. ACUTE TONSILLITIS. Synonyms. — Amygdalitis, cynanche tonsillaris, quinsy. The tonsils, which are located between the pillars of the fauces, are, in the normal condition, scarcely visible and never large enough to project beyond the edges of the anterior pillars. They are essentially lymphatic glands, but their function is unknown. It is believed by some that they absorb a portion of the starchy foods, which their secretions are capable of converting into sugar, but this is certainly an unimportant function. ACUTE TONSILLITIS. 363 Upon the free surface of these glands are the orifices of from twelve to eighteen lacunae or crypts which are lined with a continuation or pouch of the mucous membrane and surrounded by numerous spherical and lymphoid follicles. These, together with softer lymphoid tissue, consti- tute the substance of the tonsil, and are the parts more or less involved in the disease under consideration. Acute tonsillitis is most prevalent in humid climates and during the spring and winter months. It is more frequently observed between the ages of fifteen and thirty years, especially in subjects of the rheumatic diathesis. It is peculiarly prone to attack those patients in whom the tonsils are hypertrophied; and those who have once suffered from it are liable to repeated attacks. It is only occasionally witnessed in young children or the aged. Anatomical ax'd Pathological Characteristics. — The inflam- mation may attack the mucous membrane covering the surface of the tonsils, it may be mainly confined to the follicles, or it may involve the whole substance of the gland, with or without the peritonsillar connec- tive tissue. It is frequently confined to one side, but in many cases, when the disease has nearly run its course in one gland, the other will become likewise affected. The mucous membrane covering the tonsil, the pillars of the fauces, and a portion or all of the pharynx is red and swollen. The uvula is generally swollen and elongated, and is frequently seen adhering to the affected tonsil. In the follicular variety of the dis- ease, the orifices of the crypts may become occluded and the lacuna? dis- tended by the changed secretion, in which event rupture may finally occur, with a discharge of the contents, or, on the other hand, the pent up secretions may become the centre of a suppurative process leading to a tonsillar abscess. Etiology. — The disease is usually attributable to exposure, the rheu- matic diathesis, or chronic enlargement of the glands. Among the oc- casional causes of the attack are : errors of diet, suppression of the menses, a strumous constitution, and heredity. Higston Fox (Transactions of the Medical Society of London, Vol. IX, p. 255) believes that, where both glands are simultaneously involved, the disease is almost invaria- bly of septic origin. The follicular variety of the disease is thought by some authors frequently to result from diphtheria. This view, however, does not accord with the experience of the great majority of physicians, though undoubtedly a few cases are of diphtheritic character. Symptomatology. — Most patients give a history of previous similar attacks. The disease is usually 23receded by malaise for several hours and attended by aching of the back and limbs, and is often ushered in by a slight chill and fever. This is speedily followed by sensations referable to the throat, with swelling of the glands and more or less pain and difficulty in moving the jaw. In the later stages of severe cases there may be great depression, cold perspiration, insomnia, rest- lessness, and sometimes delirium. The patients are usually worse during 364 DISEASES OF THE FAUCES. the night, and experience most pain early in the morning on account of the dryness of the throat. In the inception of the attack there are usu- ally sensations of dryness or pricking in the parts, soon followed by pain, which is aggravated by deglutition and after a time becomes very severe, even on attempts at swallowing the saliva. This pain is referred to the region surrounding the angle of the jaw, and radiates toward the ears. Occasionally there is severe headache, which is aggravated by movements of the head. Owing to the tumefaction, the patient is frequently unable to open his mouth more than half an inch; partial deafness is common; and the senses of taste and smell are sometimes obtunded. The face be- comes puffy and swollen, the skin hot, the pulse rapid, and the temper- ature may rise to 103°, 104° or 105° F. A high temperature is more to be expected in children or in persons suffering their' first attack. Artic- ulation is difficult and enunciation muffled. The swollen glands may seriously interfere with nasal and oral respiration, so much so that patients frequently fear suffocation, which indeed in extremely rare cases, is an actual danger. There is little or no cough, but the patient is frequently impelled to clear the throat of a thick, viscid secretion which causes much discomfort. The tongue is coated with a yellowish white fur, while the breath is very offensive. There is increased thirst, and usually loss of appetite. Even when there is a desire for food, the patient can seldom take it on account of the painful deglutition, while attempts at swallowing fluids oftentimes result in their regurgitation through the nose. The bowels are nearly always constipated. Upon examination of the fauces, the congestion and swelling of the parts will be readily distinguished. It is often desirable to make the examination with the aid of a laryngoscopic reflector, for the patient is unable to open the mouth sufficiently to permit a thorough inspection with ordi- nary illumination. In the follicular type of the disease, the orifices of the crypts may be filled with a yellowish white secretion which causes round or oval patches from four to eight millimetres in diameter. In exceptional instances a rash has been observed upon the skin. Diagnosis. — Acute tonsillitis is to be distinguished from scarlatina, diphtheria, phlegmonous tonsillitis, and syphilis. The essential points in the diagnosis are the history, swelling of the parts, difficulty in open- ing the mouth, and severe pain on deglutition. In children, scarlatina is usually ushered in by vomiting, which is not the case with tonsillitis. The fever is often higher, is always more persistent, and after a few hours a bright red rash appears upon the sur- face of the body. Usually the congestion of the fauces is much more diffuse in scarlatina than in tonsillitis, and the swelling of the parts is much less. The peculiar appearance of the tongue in scarlatina is not observed in tonsillitis. Acute tonsillitis may be distinguished from scarlatina as follows: ACUTE TONSILLITIS. 365 Acute tonsillitis. Scarlatina. Inflammation and swelling of tonsils. General redness of fauces, some- But little redness of pharynx or palate. times appearing in patches, sometimes little or no swelling of tonsils. Pain about angle of jaw, often re- Pain, usually confined to the throat, f erred to the ears. until late in the disease. Difficult}- in opening the mouth. No difficulty in opening mouth. Tongue coated yellow. Strawberry red tongue. Usually no eruption on skin. Characteristic rash on skin. The fever is at first commonly lower in diphtheria than in tonsillitis, there is no difficulty in opening the mouth, and usually there is but little pain. Upon examination of the fauces, there is found a thick, grayish white membrane uniformly covering a large portion of the throat or confined to one or two patches upon the tonsils. These patches are much larger than the yellowish masses seen at the orifices of the crypts, and are less numerous, and they appear to be laid upon the mucous mem- brane instead of being beneath it or even with its surface. In cases of bilateral follicular tonsillitis, the disease is frequently septic, and paraly- sis of the pharyngeal muscles may follow, very closely simulating that of diphtheria. Probably some of these are truly diphtheritic in char- acter. Acute follicular tonsillitis and diphtheria present the following dif- ferential points of diagnosis : Acute follicular tonsillitis. Diphtheria. Tonsils inflamed, enlarged. Tonsils not always enlarged. "Whitish or yellowish deposit at Thick, grayish white membrane on orifices of crypts. fauces or tonsils, or possibly confined to one tonsil, much larger than the deposit of tonsillitis. High fever. Oftentimes subnormal temperature. Difficulty in opening mouth. No difficulty in opening mouth. Phlegmonous tonsillitis is more likely than acute tonsillitis, to be con- fined to one side of the throat. The swelling and pain are greater, the difficulty of opening the mouth is more pronounced, and after four or five days rigors indicate the formation of considerable pus, while fluctu- ation may occasionally be detected, especially if one finger is placed on the tonsil and the other behind the angle of the jaw externally. We can usually readily distinguish syphilitic sore throat from acute tonsillitis, but there are cases in which a diagnosis is attended with much difficulty. In specific sore throat, there is generally little or no fever, and ordinarily but little pain ; the redness and swelling of the parts usually occur in symmetrical patches upon both sides; and the conges- tion is seldom of that bright red character seen in tonsillitis. In the 366 DISEASES OF THE FAUCES. secondary disease superficial ulceration and mucous patches, with possi- ble eruptions upon the skin, and in the tertiary form, deep ulceration with moderate congestion, a peculiar swelling, together with the history and other symptoms, will usually enable the physician to make the diagnosis easily. From syphilitic sore throat the disease is distinguished by the fol- lowing points of difference: Acute tonsillitis. Syphilitic sore throat. No specific history. Inflammation Syphilitic history. Comparatively and swelling. Parts bright red. little inflammation or swelling. Often collection of yellowish secre- Mucous patches usually symmet- tions in follicles. rical. High fever, acute pain. But little fever or pain. Difficulty in opening mouth. Usually no difficulty in moving jaw. Prognosis. — There is very little danger to life from the disease, al- though death has been known to occur in a few instances. The affection often terminates in chronic hypertrophy of the glands, and not infre- quently a simple inflammation eventuates in suppuration. It is usually the forerunner of other similar attacks, and is occasionally immediately preceded or followed by acute articular rheumatism. It often termi- nates in four or five days ; sometimes, however, it lasts ten days or two weeks, and in exceptional cases as long as three weeks. Treatment. — Persons subject to tonsillitis should avoid all exposure likely to excite the inflammation, and should be careful to keep the digestive organs in perfect condition, attending especially to regularity of the bowels. Guaiacum has been highly recommended for aborting the disease. It is given in the form of troches, each containing two or three grains, every two hours during the beginning of the attack, or the ammoniated tincture in doses of a drachm every fourth hour may be administered in milk. Although this remedy has the sanction of high authority, I must admit having seen very little, if any, benefit from its use. Brushing the tonsils with a sixty grain solution of silver nitrate will cut short the attack in probably about one in four cases. Aconite, opium, and belladonna given in small doses, frequently repeated, have the power of speedily abbreviating the disease in some instances. Aconite may be given in doses of half a minim of the tincture every fif- teen minutes until sweating or other constitutional effects are produced; and thereafter less frequently, about once an hour for four or five hours, and still later once in two, three, or four hours, according to the febrile symptoms. The tincture of opium may be given in doses of one minim every fifteen minutes at first until the patient experiences relief from the sensations in the throat, and subsequently once in from two to four hours, according to its influence upon the pain. Tincture of belladonna may be given in a similar way in doses of a half-minim. By ACUTE TONSILLITIS. 367 some of these measures the disease may frequently be aborted; but it will be found that a remedy which acts well in one person will often be entirely inefficient in another. In the beginning, constipation should be relieved by the employment of a mercurial or saline cathartic. Ice held continuously in the mouth, or applied externally by means of ice bags, will frequently check the commencing inflammation. Fre- quent gargling with strong solutions of potassium chlorate and nitrate, in water as hot as can be borne, is very beneficial after the disease is fairly established. For this purpose it is my custom to order one part of the chlorate and two parts of the nitrate, and direct the patient to use a heaping teaspoonful of this in half a teacup of hot water every half hour. Gargling with a one-half per cent to two per cent solution of carbolic acid is also useful in many cases. A one per cent solution of salicylic acid is also recommended. Lemonade may be taken frequently to clear the throat of the tenacious mucus. DobelPs solution is also an excellent mouth wash for this purpose. Whenever there is evidence of a rheumatic habit, guaiacum is indicated and may be advantageously combined with small doses of opium and medium doses of the potassium bromide, which relieve the pain and lessen congestion. If, in spite of these various remedies, the inflammation progresses and the tonsils become much swollen and painful, scarification, deep incisions, or four or five simple junctures will often give great relief. In making an in- cision, the bistoury should be passed with its back toward the outer por- tion of the tonsil and the cut made toward the median line. Where the gland is very large, two or three of these cuts should be made. When the patient is subject to frequent attacks and the tonsils remain large after the inflammation has subsided, removal of the glands should be advised. There are some patients who suffer from recurring attacks of acute tonsillitis in whom the glands subside after each inflammation so that during the period of health they appear but little if any larger than normal. In such cases it has been recommended that the glands be re- moved during the period of an acute inflammation, while they are con- siderably enlarged. The main objection to this procedure is the exces- sive hemorrhage which sometimes follows. These cases may be very satisfactorily treated by repeated punctures with the galvano-cautery. In carrying out this treatment two or three punctures should be made at each sitting, this not to be repeated until two or three days after the soreness occasioned by the last cauterization has subsided. The treat- ment is necessarily protracted, as ten or a dozen cauterizations will usu- ally be found necessary. In some of these cases I have obtained excel- lent results by passing a vulsella forceps through the fenestra of the tonsillitome, seizing the gland, drawing it well out, and then cutting it off with the latter instrument. 368 DISEA8E8 OF THE FAUCES. PHLEGMON< >l*S T< >NSILLITI8. Synonyins. — Suppurative tonsillitis, abscess of the tonsils, quinsy, phlegmonous sore throat. Phlegmonous tonsillitis is a suppurative inflammation of the tonsil and peritonsillar tissue, characterized by the formation of a circum- scribed abscess. It occurs most frequently in children or young adults; seldom before the tenth year of age, and not commonly after the thirtieth year. Persons who have had it once are much more liable to attacks than others; and those having chronic enlargement of the tonsils are peculiarly subject to this variety of inflammation. Anatomical axo Pathological Characteristics. — The inflam- mation attacks the mucous membrane, the glandular, or the periton- sillar tissue — sometimes part and sometimes all of the tissues — and fre- quently extends down to the sheaths of the muscles. Sometimes the muscles themselves are involved, but usually the force of the attack is expended upon the connective tissue about the gland. The swelling is nearly always unilateral, and the abscess which forms is, I think in at least four-fifths of the cases, outside of the gland itself. Etiology. — The causes of the disease are the same as those of acute tonsillitis, with the addition usually of some debilitating circumstance which has rendered the patient peculiarly susceptible to suppurative in- flammation. Symptomatology. — Inquiry into the history of such a case frequently reveals that the person has had kindred attacks several times during the previous two or three years. The local and constitutional symp- toms in these cases are essentially the same as those of ordinary acute tonsillitis of the severer grade. Superadded to these we nearly always find rigors at the time suppuration takes place, and sometimes a pecul- iar, sharp pain is associated with the formation of the abscess. Swell- ing of the part is excessive, so great in some instances, even though con- fined to one side, as to fill the whole fauces. As the disease progresses, the spot at which an opening is about to take place may be distinguished. This is at first more livid than the surrounding tissue, and after a time it becomes yellowish and slightly prominent, and finally the tissue gives way and juts escapes. Diagnosis. — The disease is to be differentiated from the same affec- tions that are liable to be mistaken for acute tonsillitis. It is not always easy to distinguish it from acute inflammation of the glands without suppuration. The essential points in the diagnosis are the sharp pain and rigors at the time of suppuration, and the occurrence of fluctua- tion, occasionally to be detected by palpation. However, in many cases the tissues are so tense that palpation will not give distinct fluctuation even though considerable pus be present. Then an exploring needle must be employed. PHLEGMONOUS TONSILLITIS. 3G9 Prognosis. — We expect suppuration to occur from the third to the sixth day. If the case is left to itself, the abscess will usually open spon- taneously about the tenth clay, and the patient will so far recover as to be out of doors within three or four days after the abscess has been evacuated. So far as life is concerned, the prognosis is favorable. There have been, however, a few exceptions to this rule. Convalescence is usually very rapid, though sometimes the inflammation is followed by some paralysis of the muscles of the fauces, which may last several weeks. Paralysis of the palate causing indistinctness of speech, and regurgita- tion of fluids through the nose when the patient attempts to swallow, is the most jDrominent of these manifestations. In rare instances typhoid symptoms supervene upon the acute inflammation. Treatment. — Early in the attack the disease may be aborted as in acute tonsillitis — in about one case out of four — by the application to the inflamed gland, once or twice a day, of a sixty grain solution of silver ni- trate, two or three applications usually being sufficient. If the case is seen early, I would advise this treatment, for, even if it does not succeed, it is not harmful. Care should be exercised that none of the solution drops into the lower pharynx or the larynx, where it would be likely to cause spasm of the glottis. Guaiacum has been highly recommended as a spe- cific for this disease, used in the form of troches, or the ammoniated tincture as already recommended for simple tonsillitis; but it is useless to continue with it longer than forty-eight hours. My personal experience with this remedy has been unsatisfactory; I have never seen an attack aborted by it, though some have apparently been shortened. If abortive measures prove unavailing, we seek to conduct the inflammation to a speedy resolution. For this purpose, aconite, opium, and anti-rheumatic remedies are of chief value. Tincture of aconite or tincture of opium should be given in minim or half-minim doses once in fifteen to thirty minutes until the patient is relieved or the constitutional effects of the remedy appear; afterward once an hour for a few doses, and sub- sequently less frequently as the symptoms subside. Ordinarily eight or ten doses must be given close together, and as many more once an hour. In most of these cases, after the first twenty-four hours, sodium salicylate gr. viiss., with potassium bromide gr. x., every fourth to sixth hour, are especially beneficial. Local applications are valuable in the onset of the disease, ice being the best remedy. It may be held in the throat constantly, or may be applied in ice bags externally, or cold applications may be made by means of the Leiter coil. Some patients, however, are made uncomfortable by cold; in such we recommend gar- gling once an hour of the solution hot as can be of potassium nitrate and chlorate, recommended for acute tonsillitis. Usually in the first stage of the disease cold applications are to be recommended, and after the second day hot applications. Many of the patients are constipated; this is best overcome by saline cathartics. Scarification of the tonsils will 24 370 DISEASES OF THE FAUCES. sometimes give great relief, even before suppuration lias taken place. Pus should be evacuated us soon as discovered. Pain from the incisions may be in great part prevented by a few applications of a ten per cent spray of cocaine. Some patients think that if the tonsils are cut they are more liable to subsequent attacks, but there is no foundation for such belief. HYPERTROPHY OF THE TONSILS. Synonym. — Chronic tonsillitis. This includes chronic follicular ton- sillitis. Hypertrophy of the tonsils is an affection characterized either by a collection of secretions in the crypts of the gland and consequent irrita- tion, with or without hypertrophy of the parenchyma known as — chronic follicular tonsillitis, or by simple hypertrophy of the glandular tissue with but little involvement of the lacuna?. About two-thirds of the cases occur in boys. It is most frequent in youth or in young adults, but it is also very common in children, and is congenital in rare instances. The ten- dency to the disease diminishes with advancing years. The hypertrophied tonsil presents a yellowish-pink or dusky red color; it varies in size from a large almond to a large walnut, and may weigh from one to three drachms. At times the gland is very friable; again it is firm, cutting with a creaking sound, owing to increase in the connective tissue. Some of the lacuna? may be filled with an extremely offensive secretion of yel- lowish color and cheesy consistency. When the follicles are involved, with but little hypertrophy of the glandular tissue, this secretion will be found in several of them. Etiology. — The disease is most frequently the result of repeated acute attacks of inflammation of the gland, especially when occurring in subjects of a strumous or rheumatic diathesis. But the starting point often seems to have been an attack of diphtheria, scarlatina, or measles. Again it has also been attributed to chronic follicular pharyngitis and to acquired syphilis, while occasionally it is supposed to be of hered- itary origin. The view lias been advanced that follicular disease of the tonsil is caused by bacterial development in the lacuna?, but as many varieties are found in such cases and as bacteria are always present in de- caying organic substances and associated with dead tissue, their presence here is not sufficient reason for believing that they cause the disease. Symptomatology. — Sometimes there is the history of a hereditary tendency to the disease, and usually a history of noisy or snoring respira- tion with altered voice, and frequent acute attacks of tonsillitis. In children particularly, partial deafness is a frequent symptom. In rare cases the senses of smell, taste, and sight are said to be affected. Pain is seldom present, except when the lacuna? become much distended by the secretions, but the patient often experiences more or less dis- comfort in deglutition, and sometimes complains of a sense as of a for- HYPERTROPHY OF THE TONSILS. 371 eign body in the throat. Where the glands are large, particularly in children, the open mouth, dull eye and stupid appearance are almost characteristic of the disease. The voice is usually thick, as though the patient had something in the mouth when speaking; it may be husky or hoarse, or may possess a guttural or nasal quality. Some of these patients are easily fatigued by speaking for any length of time. Eespiration is obstructed in proportion to the enlargement of the glands. This is more especially noticeable during sleep, when the respiratory movements are often painful to behold. As a result of poor aeration of the blood, there is frecjuently great deterioration in the general health. There is but rarely actual danger of suffocation, though serious symp- toms pointing in this direction are occasionally observed. Cough is not usually present, but it may sometimes occur in severe paroxysms. In many patients there is a frequent desire to clear the throat of mucus. I have seen children who have coughed much at night, especially during the winter, in whom the cough has been immediately and permanently relieved by removing the enlarged tonsils. Continued difficult breathing in children may cause deformity of the elastic chest walls, which take the form of the pigeon breast, or the pyriform chest in which the upper part is prominent and the lower contracted. These distortions only oc- cur when the tonsils are extremely large, and possibly when the bony and cartilaginous structures are unusually soft. Impairment of the special senses and the obstruction of respiration with its sequences, commonly attributed to hypertrophy of the tonsils, are probably the result, in most cases, of associated hypertrophy of the pharyngeal tonsil. The enlarged glands may sometimes be evident externally, at the angles of the jaw, and occasionally the cervical glands are also enlarged. Upon examination of the throat the appearance of the tonsils already described may be seen at once. Diagnosis. — There can be no difficulty in making the diagnosis if the throat is inspected, except in rare instances where the anterior pillars of the fauces are adherent to the tonsils and hide them from view. In such cases the Occurrence of retching usually rolls the glands out so that they can be readily seen; but if this does not occur, palpation, with one finger on the tonsil and the other externally, will readily detect the enlarge- ment. Prognosis. — The disease may be expected to extend over several years; but when occurring in childhood, spontaneous recovery not infre- quently occurs at puberty. In young adults, the trouble usually subsides by the thirtieth year. There is little danger from the disease excepting that it may impair the general health or the special senses, as already indicated. Persons with these glands hypertrophied are subject to fre- quent attacks of acute tonsillitis, and it is probably a fact that in them the throat affections of scarlatina and diphtheria are more dangerous than in those whose glands are normal. Treatment. — In young children where the glands are soft, the re- 372 DISEASES OF THE FAUCES. peated application of powdered alum or other astringents, or the use of counter irritation at the angle of the jaw, or the internal administration of the syrup of the iodide of iron, or some other preparation of iodine, will occasionally cure the disease, but this manner of treatment is too un- certain to be recommended excepting where the patient will tolerate no other. Enlarged tonsils may sometimes be reduced by repeated injections, into the substance of the gland, of iodine, ergot, or carbolic acid ; or by electrolysis, by the galvano-cautery, or by cauterization with chromic acid or other caustics. The galvano-cautery is especially useful in the treat- ment of chronic follicular tonsillitis. It is highly recommended by Fig. 94.— Mathiei t "s Tonsillitome (2-5 size), with fenestra at right angles to handle. C. H. Knight, of New York, and others for reduction of hypertrophy in these glands, but it is a tedious process; usually from ten to twenty or thirty sittings will be required before the desired end is accomplished, and each of these will cause but little less discomfort than excision, yet the method is to be recommended where there is danger of bleeding, where the disease is mainly confined to the follicles, and in some cases where the chronically inflamed gland is not sufficiently large to be removed by other means. Electrolysis may be useful in some in- stances, but it is tedious and not very satisfactory. Enucleation of the whole gland by the finger has been recommended, but its ac- complishment is difficult unless the mucous membrane has been first Fig. 95.— The same as Fig. 94, fenestra placed obliquely cut around at the base, and even then there is unnecessary bruising of the surrounding tissues. In adults, the quickest, easiest, and al- together most satisfactory procedure is removal by means of the ton- sillitome, which is far preferable to the old method by means of the for- ceps and bistoury, because of the rapidity of the operation and the small danger of bleeding. Many varieties of the tonsillitome are used, but Fahnestock's, also known as Mathieu's (Figs. 94 and 95), has proved most satisfactory. It is suitable for all cases, and will sometimes engage a gland which cannot be secured by other varieties of the instrument. In performing the operation, the patient is to be placed in a good light, and an assistant should make pressure behind the angle of the jaw with the finger so as to crowd the gland well into view. The operator should then depress the tongue, encircle the tonsil with the ring of the tonsilli- HYPERTROPHY OF THE TONSILS. 373 tome, press the instrument firmly down to the base of the gland and cut it off with a single movement. The other may be removed in the same way a few minutes later. The glands may first be partially anesthetized by a spray of cocaine, but the operation is not usually very painful without it, and cocaine is somewhat objectionable as it tends to increase the bleeding, which sometimes comes on two or three hours later. It is well to have the patient use frequently a gargle of a solution of one and one-half per cent of carbolic acid, until the wound has healed. Some recommend that only a slice be removed from the tonsil, with the hope that the remainder will atrophy; but the entire gland is dis- eased and, if any considerable part of it is allowed to remain, the patient is almost sure to suffer from a recurrence of the growth, or at least from repeated attacks of acute inflammation; therefore it is better, when possible, that the whole gland be removed. There are some cases of chronic inflammation of the tonsil in which the gland becomes large only during the acute exacerbations. These may be treated by the galvano-cautery or, as recommended by Lennox Browne, the gland may Fig. 96.— Ingals' Tonsil Forceps (2-5 size). be removed during an acute attack of inflammation, notwithstanding the increased danger of hemorrhage. In such cases I have obtained very gratifying results by using a vulsella forceps and the tonsillitome, as indicated under acute tonsillitis. In adults, as a rule, ecrasement is a less satisfactory operation than excision by the tonsillitome; but for young children it is much pref- erable, because it may be done under the anaesthetic influence of chloroform with much less shock to the friends, and with but little fright to the child, and also because it is nearly or completely blood- less. My method of performing this operation is to give the patient chloroform, place him in the prone position, seize the enlarged gland with the tonsil forceps (Fig. 96) which I have had constructed for this purpose, and then slip over the forceps and down over the gland the steel wire loop of the snare which is used for removing nasal polypi. As the loop is drawn tight, it slips under the blades of the forceps and either cuts the gland close to its base, or better yet, by slid- ing beneath, completely removes it. During the operation the child's mouth is kept open by a gag. I have found it preferable to remove the undermost gland while the patient is lying upon one side of the face, then turning him over to remove the other. In seizing the gland, the forceps should be carried back to the pharyngeal wall, opened out, and 374 DISEASES OF THE FAUCES. then drawn forward until they strike the anterior pillar. At the same time, pressure is made externally behind the angle of the jaw, the for- ceps are crowded down, the blades engage the upper and lower portion of the gland, grasping it firmly, and the handles are locked. The snare is then slipped over the forceps and the gland cut off and removed. This may often be done without the loss of a drachm of blood. To avoid removing the uvula at the same time considerable care is necessary that it be not caught in the forceps or snare with the tonsil. Where the an- terior pillar of the fauces is adherent to the gland it should first be sep- arated by a blunt hook and the finger. A strong uvula holder similar to that shown in Fig. 8-A, though less bent at the hook and with a larger handle, answers well for this purpose. Treatment of follicular tonsillitis is unpromising by the ordinary methods, yet the disease may sometimes be cured by inserting into the follicles, one after another (two or three at each sitting), a small quantity of silver nitrate or chromic acid, the re- tained secretions having first been squeezed out. Treatment by means of the galvano-cautery is usually very satisfactory, and in using this in- strument there is no necessity of first squeezing the secretions out of the follicles. I use an electrode with a point consisting of a loop of plati- num wire about a centimetre in length by four millimetres in breadth. The tonsil is first anesthetized as well as may be by cocaine ; the point is then passed into the diseased follicle, heated, and moved about for a second so as to touch its entire surface. Two or three follicles are treated in this way at each sitting, and excepting in rare instances a few days later these points will be found to be completely cured. From five to a dozen sittings may be required to cure cases of this kind. The treatment should not be repeated for five or six days; that is, till two or three days after any soreness occasioned by the preceding cauterization has disap- peared. Excessive bleeding is not common after tonsillotomy, but a few cases of alarming hemorrhage have occurred, and there is a possibil- ity of death from this cause. Though the danger of this is so small as hardly to merit consideration, yet we should always be prepared to check any undue hemorrhage as speedily as possible. The methods which have been found most effective for this purpose are : the sucking of ice, rubbing powdered alum upon the cut surface, compression of the stump of the tonsil by the finger or thumb or by means of a sponge saturated with a strong solution of tannin or of iron persulphate, which may be applied by the finger, or by one blade of a pair of forceps the other being pressed against the external parts. Mackenzie recommended a mixture of two drachms of gallic to six of tannic acid, and enough water to make an ounce, which is to be gradually sipped, instead of being used as a gargle. This will prove efficient in nearly every case. In two such cases I have resorted to the galvano-cautery, once with perfect success, but in the other 1 was obliged later to use compression by CONCRETIONS IN THE TONSIL. 375 means of cotton saturated with persulphate of iron. Hot water and various other substances have also been used successfully; but in the most severe hemorrhage that ever occurred in my experience, after all other methods had failed, the bleeding stopped as soon as. fainting occurred, and did not reappear. This harmonizes with the suggestion made by D. Bryson Delavan, of New York, who recommends that in ex- cessive hemorrhage after tonsillotomy the limbs and arms be corded so as to retain as much blood in them as possible, and that fainting be en- couraged; he having observed that, in all serious cases, as soon as this took place the bleeding stopped. When advising removal of the ton- sils, we are often asked as to its probable effect upon the voice, and occasionally as to its influence upon the generative organs. To the first we may answer positively that it will improve the voice if it alters it in any way; to the second, we may answer that there is no reason for believing that the tonsils have any influence whatever upon the gen- erative organs, though the statement of Chassaignac indicates his be- lief that hypertrophy of the tonsils tends to arrest growth of these parts, and removal of the tonsils favors their development. CONCRETIONS IN THE TONSIL. Synonym. — Calculus of the tonsil. Concretions in the tonsil consist usually of a collection in the lacuna? of desiccated secretions from the follicles, by which the gland may be much enlarged or inflammation excited. Some of these are hard and others soft. The hard consist of the phosphate and carbonate of lime; the soft, of the debris of the epithelial cells, cholesterin, pus cells, and bacteria, with more or less chalk. This latter condition was considered under the head of chronic follicular tonsillitis. Etiology. — The affection is due to inflammation of the lacunas. Symptomatology. — There is usually a pricking sensation in the tonsil, with sometimes a little difficulty in swallowing. The gland is swollen, and upon inspection we find a yellowish white spot where the mucous membrane is distended by the mass, or some portion of the cal- culus may be seen and felt protruding from the surface. By touching the mass with a probe, we can readily determine whether it is hard or soft. Prognosis. — Where small, the concretions are frequently expelled spontaneously. Their persistence predisposes to hypertrophy of the tonsils and acute or phlegmonous tonsillitis. Treatment. — Remove the concretion, and if necessary cauterize the empty crypt. 376 DISEASES OF THE FAUCES. MYCOSIS OF THE TONSILS. Mycosis of the throat is a parasitic disease of the tonsils and upper portions of the throat, characterized by yellowish white deposits resem- bling in some cases those of chronic follicular tonsillitis. Anatomical and Pathological Characteristics. — The deposit usually occurs in numerous small, yellowish or yellowish white patches from two to five millimetres in diameter. These are found sometimes within the crypts of the tonsil or more frequently close to their orifices, but are not uncommonly seen upon the pillars of the fauces or the pharynx, and often in considerable numbers upon the base of the tongue. The deposit may in some cases be so soft as to be easily scraped off, but in other instances it is quite hard. Sometimes it is so prominent as to become almost pedunculated, and often it presents a papillary or warty appearance. According to Delavan, scrapings from the diseased part, when examined microscopically, show the presence of granular matter, pus corpuscles, leucocytes, cholesterin, and, most important of all, the leptothrix buccalis (Reference Handbook of Medical Sciences, Vol. VII). This organism attacks mainly the outer layers of epithelium, but sometimes extends deeply into the mucosa, which explains the difficulty, in certain instances, of its removal by swab- bing or scraping. Etiology. — The causes of the affection are not definitely under- stood, but it is said frequently to arise from carious teeth, where the leptothrix finds a congenial soil. Symptomatology. — Frequently mycosis gives rise to no inconven- ience and is only discovered by accident; but in other cases pricking sensations and other symptoms similar to those of chronic follicular ton- sillitis are experienced. Diagnosis. — The affection is liable to be mistaken for acute or chronic follicular tonsillitis or glossitis, upon which, indeed, it may be engrafted. From the acute affections, it may readily be distinguished by the absence of congestion and swelling of the parts and febrile symp- toms, and by its prolonged course. From chronic follicular affections of these parts, it is to be distinguished by the position and appearance of the deposits, and by a microscopic examination, which in this disease reveals a large number of the micro-organisms already referred to. The deposit in mycosis is either soft or hard; and it occurs, as a rule, in smaller masses than that of chronic follicular inflammation; although in many cases it is found within the crypts, on careful inspection it will be observed in some places clinging to the surface of the mucous membrane at the orifice of the crypts or even remote from them. The wart like and sometimes pedunculated appearance which obtains with some of the masses is never found in follicular tonsillitis or glossitis. The foreign MYCOSIS OF THE TONSILS. 377 products are usually smaller and much more numerous in mycosis than in either of the diseases just named. Mycosis may be differentiated from acute follicular tonsillitis as fol- lows: Mycosis. Acute follicular tonsillitis. No inflammation or swelling. Inflammation and swelling. Absence of febrile symptoms. Fever. Prolonged course. Brief history. Deposit soft or hard and in small Collection of soft, yellowish secre- masses; may be found either at orifices tions in the lacunas. of crypts or remote from them. From chronic follicular tonsillitis, mycosis is to be distinguished by the following characteristics:' Mycosis. Chronic follicular tonsillitis. Often history of carious teeth only. Often history of strumous diathesis, or of diphtheria, scarlatina, or measles. Tonsils usually of normal size. Tonsils usually enlarged. Deposit in small masses ; found on Deposit within the lacunae, often in mucous membrane, and may be remote large masses, not adherent to the from orifices of crypts. They often mucous membrane, appear like decolorized warty growths, firmly attached to the mucous mem- brane and standing out two or three millimetres from the surface. Prognosis. — The affection, if left to itself, is of long continuance, and, if the masses are scraped off, they tend to recur speedily, though spontaneous recovery sometimes takes place. Treatment. — The usual forms of treatment advised for chronic affections of the throat have little or no influence upon mycosis, and, in order to eradicate it, thorough and radical measures must be adopted. Delavan recommends frequent applications to the throat of gargles or sprays containing either mercury bichloride gr. i. ad 3 iv. or sodium bibor- ate gr. xx. to xl. ad 3 i. ; but especially scraping off the deposit with a sharp curette and then applying the galvano-cautery to the site of the growth. I have seen no benefit from local applications of an antiseptic, stim- ulant, or caustic character, excepting the treatment by the galvano-cau- tery which has proven very efficient, and it has not been found necessary to scrape the part before its application. Cocaine is first applied, and then the masses are each carefully touched by the galvano-cautery point, four or five being treated at each sitting, and the process repeated once in four or five days until all the growths have been destroyed. There is but little tendency to recurrence of any of the masses which have been thoroughly treated by the galvano-cautery. Carious teeth should, of course, receive proper attention. 378 DISEASES OF THE FAUCES. TUBERCULAR ULCERATION OF THE TOXSILS. Tubercular ulceration of the tonsils is extremely rare as a primary lesion, but is not uncommon as a concomitant of advanced tuberculosis. Anatomical and Pathological Characteristics. — Usually the surface of the tonsil is pale and more or less covered with a viscid, yellowish gray secretion, beneath which the tissues appear eroded or worm eaten by irregular superficial ulcers, which may by extension involve the pharyngeal wall or larynx. The borders of these superficial ulcers are not sharply defined, but irregular, and there is little or no swelling of the surrounding parts. Sometimes, however, the ulcers are much deeper, and exceptionally the edges may be sharp cut and elevated, everted, or according to some authors even undermined, but these latter appearances are extremely rare. Sometimes the parts are slightly more congested than the surrounding tissue. In the deep ulceration which I have seen, the borders have been clearly cut, but never undermined as in syphilis nor indurated as in malignant disease. The surface has pre- sented a pale, granulated appearance, bleeding easily upon being touched. Microscopical examinations of scrapings from the parts show a small amount of fibrous tissue, epithelial and pus cells, with abundance of granular matter, and occasionally giant cells, but the bacillus tuber- culosis cannot often be detected. Symptomatology. — In all the cases which have come under my ob- servation, painful deglutition has been the most prominent symptom, and in the major number this has been severe. Usually, even though the tubercular process is slight in other organs, the constitutional symp- toms are very pronounced. The pulse is rapid, the temperature rises two or three degrees every day, the strength fails, night sweats are com- mon, and the appetite is usually poor. Cough and expectoration may, however, be absent or but slightly troublesome if the lesion is confined to the faucial region. As the disease progresses, constitutional symp- toms become more and more marked and the evidences of tuberculosis in other organs rapidly develop. Diagnosis. — The disease may be confounded with syphilis or cancer. The essential points in the diagnosis are: painful deglutition, the con- stitutional symptoms, and the comparative absence of induration. It is distinguished from syphilis by the absence of a specific history, bv the pain upon deglutition, which is usually much more severe than in syphilitic ulceration, and by the pronounced constitutional symptoms. Again, when the ulcer is superficial, its worm eaten and irregular ap- pearance, with the pallor of the adjacent surface and absence of indura- tion, are distinguishing features; and when the ulceration is deep, the slight induration, if any, the irregular border of the ulcer — neither everted nor undermined and seldom sharply cut — and its comparatively TUBERCULAR ULCERATION OF THE TONSILS. 379 light color and granular, easily bleeding surface, will serve to distinguish, it from the specific affection. Anti-syphilitic treatment, when vigorously pushed, usually causes rapid improvement in the specific disease, whereas it aggravates the tubercular affection. Tubercular ulceration of the tonsil is to be distinguished from syphili- tic ulceration bv the following characteristics: Tubercular ulceration of tonsil. Little, if any, swelling'. Ulcer is usually superficial, not sharply defined, but may be deep and irregular. Pain, fever, rapid pulse, usually evi- dences of tuberculosis in other organs. Syphilitic ulceration of tonsil. Syphilitic history; induration. Ulcer may be superficial or deep, edges well defined, may be undermined and everted: indurated base. Usually little or no pain or fever, with normal pulse. The deep tubercular ulcer is distinguished from cancer of the tonsils by the comparative absence of induration, which is usually pronounced in cancer even for several weeks or months before ulceration takes place; by the appearance of the edges of the ulcer, which are not everted in tuberculosis, and by the character of the surface of the ulcer, which is much cleaner in the tubercular disease than in cancer. The super- ficial ulcer of tuberculosis does not resemble the ulceration of malignant disease, and is not at all likely to be confounded with it. Pain usually occurs earlier in cancer than in tuberculosis, and is of a lancinating character and present for some weeks before ulceration takes place. In the early stages, constitutional symptoms are more marked in tubercu- losis than in cancer, and the peculiar cachexia which develops in the later stages of carcinoma is not apparent in tuberculosis. From cancer of the tonsil tubercular ulceration may be distinguished as follows : Tubercular ulceration of tonsil. Little, if any, swelling, with pallor instead of congestion of parts. Usually ulcer is superficial and irreg- ular, not sharply defined; whitish se- cretions. Pain does not occur until after ulcer- ation has commenced, and then is ex- perienced especially on swallowing. Fever, rapid pulse. Usually no enlargement of cervical glands. Generally associated with pulmo- nary tuberculosis Prognosis. — "When the disease occurs primarily in the tonsil, many cases mav be cured if taken early and given thorough and energetic Cancer of the tonsil. Parts swollen, indurated, and con- gested. Ulceration deep with abrupt borders and reddish or grayish white surface, fetid yellowish secretions, and fungous granulations. Pain mai'ked before, as well as after, ulceration, and often sharp even when throat is at rest. During- first few months little if any fever or acceleration of pulse. Enlarged cervical glands compara- tively early in the disease. Usuallv marked cachexia. 380 DISEASES OF THE FAUCES. treatment; but when it develops subsequent to tuberculosis in other organs, little more than temporary relief of the disease can be hoped for* Treatment. — Where the ulceration is secondary to general tubercu- losis, constitutional treatment is of the most value. When the disease is primary, destruction of the affected tissues by scraping, and the ap- plication of lactic acid, or the galvano-cautery will occasionally be fol- lowed by perfect recovery. The part should be anaesthetized by cocaine, and it may then be scraped with the curette, and subsequently the lactic acid may be applied; but some cases do quite as well if the acid is thoroughly applied without previous scraping. Lactic acid is used for this purpose in strength varying from thirty per cent to one hundred per cent, and must be applied daily, and with thoroughness, for three or four days, and afterward less frequently for two or three weeks until the ulcer heals. As a rule, when the strong acid is employed, previous curetting is unnecessary. If the ulcer is not large and does not readily yield to the lactic acid treatment, the surface should be touched with the galvano-cautery, and subsequently lactic acid may be employed. For temporary relief, the parts may be sprayed with a two to four per cent solution of cocaine two or three times daily, or, in place of this, with a solution of morphine, or, better yet, the solution of morphine, carbolic acid, and tannic acid (Form. 93) recommended for tubercular laryngitis. Whatever local measures are adopted, all sources of irrita- tion, especially tobacco smoking, should be removed. Constitutional treatment will be of the utmost importance. CANCER OF THE TONSIL. Cancer of the tonsil is a comparatively rare affection ; but seven cases have come under my observation within the last five years, one being of the melanotic variety. One or both tonsils may be the seat of the dis- ease which commences as a tumor in the substance of the tonsil and gradually and steadily extends, involving not only the whole gland, but the surrounding tissues. Ulceration usually occurs within five or six months from the commencement. The affection is attended by more or less constant pain, especially upon deglutition. This is frequently lan- cinating in character and radiates toward the ear. A pronounced cachexia is developed in some instances, during the later portion of the disease. Diagnosis. — Cancer is to be distinguished from hypertrophy of the tonsil by the history, age of the patient, and course of the dis- ease. Hypertrophy of the tonsil is a disease of early life, seldom ob- served after the thirtieth year, whereas cancer usually occurs after the age of forty. Hypertrophy of the tonsil is not attended by pain or constitutional symptoms, and is not followed by ulceration; furthermore unlike the malignant disease, it may last for years without seriously affecting the patient's general health. CANCER OF THE TONSIL. 381 Cancer is to be distinguished from hypertrophy of the tonsil as follows : Cancer of tonsil. Generally seen in those past middle life. Induration of surrounding- tissues and congestion. Unilateral. Late ulceration with reddish or grayish white surface, fetid secretions, fungous granulations. Severe pain. Usually characteristic cachexia. Hypertrophy of tonsil. Generally seen in children and young adults. Hypertrophy with but little if any redness. Generally bilateral. No ulceration. Whitish deposit found in the lacunae, no peculiar se- cretion. No pain. Frequently open mouth, dull eye, and stupid appearance, but no cachexia. Cancer of the tonsil and syphilitic ulceration of the tonsil present the following differential diagnostic points: Cancer of tonsil. Much swelling and induration, mem- brane darkly congested. Unilateral. Late, ulceration with reddish or grayish white surface, profuse fetid secretions and fungous granulations. Lancinating pain, frequently marked before as well as after ulceration. Usually marked cachexia. Syphilitic ulceration of tonsil. Comparatively little swelling and induration. Usually bilateral. Syphilitic history. Ulcer may be superficial or deep and undermined with indurated base and everted edges. Little or no pain. No peculiar cachexia. Cancer of the tonsil is distinguished from tubercular ulceration by the signs pointed out in considering the latter affection. Prognosis. — The disease usually runs its course in four to eight months, and probably is always fatal. Treatment. — If seen early, the tumor should be removed by snare or galvano-cautery ecraseur if possible; or later, if the growth is so large as seriously to interfere with respiration and deglutition, a similar pro- cedure, though giving no hope of cure, may happily be followed by devel- opment of the tumor in some other direction less immediately dangerous or distressing. I have seen two cases in which removal of the cancerous tonsil was followed by perfect cicatrization and no subsequent trouble in the fauces, whereby the patient was saved from much of the distress which would otherwise have attended the later stage of the disease. Recently I have succeeded in retarding the growth for several months by frequent injections into the substance of the tumor of six to ten minims of a twenty-five to fifty per cent solution of lactic acid. After ulceration has taken place, surgical procedures are not likely to be of benefit, but detergent and antiseptic gargles and sprays may give temporary relief. The spray of carbolic and tannic acids with morphine (Form. 93) may be employed with no little satisfaction. CHAPTEE XXII DISEASES OF THE PHARYNX. FOREIGN BODIES IN THE PHARYNX. Foreign bodies of great variety have been found lodged or impacted in the pharynx, the most frequent being pieces of meat, fragments of bone, bristles, false teeth, buttons, coins, and needles or pins. Some people in whom there is impaired sensibility of the mucous membrane are specially predisposed to such lodgements. Large bodies generally lodge at the lower part of the pharynx or in the valleculas between the base of the tongue and the epiglottis. Small or sharp pointed bodies may become fixed at any part of the throat, but they are more apt to lodge in the crypt of a tonsil or in the depressions between the gland and the pillars of the fauces. Symptomatology.— Large bodies, unless speedily removed, may cause suffocation, but this usually ensues only when the substance has become impacted in the larynx or oesophagus. Hard or sharp substances cause pricking sensations or more or less severe pain, especially on deglutition, and, if they remain, inflammation and swelling soon follow. Even after the body has been extracted or has passed into the stomach the patient often complains of similar sensations for some time. Ulceration and even abscess may follow if the occluding substance remains for any length of time. Diagnosis. — The diagnosis must be based upon the history given, and a careful inspection of the part; but it is to be remembered that sensations of pricking or actual pain are often felt even after the source of the trouble has been removed. Hysterical women especially, often insist for weeks or months that the foreign body remains, in spite of all assurances to the contrary. It is to be remembered also, that small bodies may actually remain for a long time in the crypt of a tonsil, or in the valleculas, escaping observation. Prognosis. — Occasionally immediate death from suffocation is caused by impaction of a foreign body in the pharynx. A fatal issue may like- wise result from perforation of large arteries or other vital parts by ulceration, but often the body is either swallowed or expelled by the pa- tient's own efforts. In many instances these substances remain several weeks, giving the patient much discomfort but not endangering life. Treatment. — The foreign body should be removed as soon as practi- RETRO-PHAR YNGEAL ABSCESS. 383 cable. Unless seen at once, a most thorough and painstaking examina- tion should he made, with the parts well under the influence of cocaine, and if nothing is found, a pledget of cotton should be brushed over every part with the hope of removing or bringing into view the possibly- hidden object. Two bodies, especially in the case of fish bones, are not infrequently present in the same case: therefore if the unusual sensations persist, another examination should be made. As a rule, when the sub- stance has been removed, the sensations disappear within a few hours, but sometimes they continue for a long time, usually as the result of an injury or small ulceration produced by the object. Generally such lesions yield speedily to the application of astringents or silver nitrate. RETROPHARYNGEAL ABSCESS. Retro-pharyngeal abscess, is a circumscribed suppuration of the sub- mucous tissues of the pharynx, giving rise to swelling, in consequence of which there is interference with respiration and deglutition. . The affec- tion occurs most frequently in infants, having been observed even in the new born: but as a result of syphilis it is comparatively common in adults. Anatomical axd Pathological Characteristics. — The abscess may be located in the posterior wall of the naso-pharynx, the oro- pharynx, or the laryngo-pharynx. It may be developed near the median line, but in about three cases out of four it is confined to one side. The loose attachment of the mucous membrane by cellular tissue to the muscles beneath favors the formation of an abscess in this locality and allows pus to burrow easily in any direction, though it is inclined to gravitate downward. It sometimes extends even to the mediastinum. I recollect one case in which the sinus, left after the abscess had opened, could be traced from the lower part of the oro-pharynx downward and backward ten inches. The tumor formed by an abscess has a broad base, and the surface is smooth and usually not much discolored, especially when occurring in feeble children; though in adults an abscess resulting from syphilis, is often considerably congested. Etiology. — The affection in children is usually idiopathic: yet if the ultimate cause could be traced, it would probably be found to depend in most instances upon an inherited scrofulous or syphilitic diathesis. The exciting cause is often exposure to cold or to the prolonged heat of summer. It may follow simple acute pharyngitis, scarlatina, erysip- elas, or tonsillitis. In adults it most commonly follows syphilitic disease of the cervical vertebra?. Some cases follow wounds inflicted by swal- lowing pins, bones, and other foreign substances. It is said to have fol- loAved stricture of the oesophagus, owing to the mechanical irritation at- tending forced deglutition. 384 DISEASES OF THE PHARYNX. Symptomatology. — The affection usually comes on somewhat slowly, being first indicated by stiffness of the neck, with deep seated pain, which is referred to the palate when the abscess is far up, but is com- monly felt deeper and may extend over the entire throat. Dyspnoea and dysphagia generally arise from mechanical obstruction, a result of the swelling. In children, convulsive symptoms often occur. According to Bokai, idiopathic abscess may develop in forty-eight hours, and secondary abscess in from seven to ten days; while that form proceeding from dis- eased bone is still more chronic in its course. Primarily, the patient usually experiences slight chilly sensations, but occasionally distinct rigors, with headache and slight rise of temperature. The pulse is usually weak and compressible, the head is thrown backward or inclined to one side, and sometimes there is painful tumefaction of the sides or front of the neck. If the abscess is located in the naso-pharynx, it interferes only witli nasal respiration; if in the oro-pharynx, it does not affect respira- tion unless of large size. If, however, the disease should be situated in the laryngo-pharynx, a comparatively small abscess, by crowding the mucous membrane forward over the larynx, may speedily cause severe dyspnoea subject to frequent exacerbations and accompanied by cough and stertorous breathing. Abscess in the naso-pharynx gives the voice a nasal twang, and in the laryngo-pharynx may cause hoarseness or com- plete aphonia. Deglutition may be seriously disturbed by large abscesses in the naso-pharynx. Those located in the oro-pharynx or laryngo- pharynx are frequently attended by choking from the passage of fluids into the larynx. Abscesses in the naso-pharynx may escajie observation on inspection, but ordinarily a dusky red tumor is visible which is doughy to the touch, yet somewhat elastic, but late in the affection may yield distinct fluctuation and have the appearance of pointing. Diagnosis. — A differentiation is here to be made from croup, oedema of the glottis, foreign bodies in the larynx, and cerebral or digestive dis- orders causing convulsions. Retro-pharyngeal abscess is distinguished from oedema of the glottis by inspection, which reveals the pharyngeal instead of laryngeal swelling; furthermore, by lifting the glottis, the dyspnoea is relieved in an abscess situated very low, but not in oedema. Retro-pharyngeal abscess may be diagnosticated from oedema of the glottis by the following points of difference: Retko-pharyngeal abscess. CEdema OF THE GLOTTIS. Pharyngeal swelling. Laryngeal swelling. May be located in oro-pharynx or Located at glottis, ] a ry ngo-p h ary n x . Lifting larynx relieves dyspnoea. Lifting larynx does not relieve dysp- noea. May interfere with nasal or obstruct Does not interfere with nasal respira- laryngeal respiration. tion. Rather insidious in its development. Conies on suddenly. Comparative!}' long duration. Short duration. RETRO-PHARYNGEAL ABSCESS. 365 Loss of voice or extreme hoarseness, symptoms not present in retro- pharyngeal abscess, attend croup/ in croup there is no swelling or dysphagia, both of which are marked in retro-pharyngeal abscess. It may be distinguished from foreign bodies in the larynx by the history and signs found by inspection and palpation, together with the quality of the voice. Between retro-pharyngeal abscess and foreign bodies in the larynx, the following are the chief points of difference : RETRO PHARYNGEAL ABSCESS. FOREIGN BODIES EN THE LARYNX. Inspection reveals a tumor in the oro- History of accident. Inspection and pharynx or laryngo-pharynx. Rather palpation may reveal presence of slow development. foreign body. Sudden obstruction to respiration or deglutition. No hoarseness. Voice usually much altered or lost. It can only be diagnosed from convulsive disorders by a careful ex- amination of the parts and detection of the tumor. Prognosis. — The affection usually terminates in recovery, idiopathic cases convalescing in from three to five days, and secondary cases in from seven to ten days, though fatal results are not inf equent. Abscess due to spondylitis may last from three weeks to several months, and usually proves fatal in the end. In favorable cases the abscess opens spontane- ously, unless sooner relieved, and with the escape of pus the more violent symptoms at once subside. Pus may burrow into the areolar tissue of the neck or into the ary-epiglottic folds and obstruct respiration even to suffocation; or it may escape into the larynx, with a similar result. Pus burrowing into the mediastinum may be discharged into the oesophagus or pleural cavity, an accident which is serious iu either instance. Death has been known to result from ulceration of the internal carotid artery. Treatment. — If the case is seen early, the abscess may sometimes be aborted by the continued sucking of ice, or by cold applications to the neck. When pus forms, it must be evacuated as soon as discovered. The incision should be made as near to the median line as possible, in order to avoid injury to the internal carotid artery; and as soon as the open- ing is made the patient's head should be thrown quickly forward to pre- vent the passage of pus into the larynx; or, better still, the operation may be done with the patient lying upon the abdomen, with the face extending slightly over the edge of the table. An ordinary bistoury, guarded to within a quarter of an inch of its point by a wrapping of cloth or adhesive plaster, is a good instrument for the purpose. Tonics and supporting treatment are necessary; the syrup of the iodide of iron being a most useful remedy. The phosphates of iron and quinine, or the compound syrup of hypophosphites, may be given with benefit. Cod-liver oil is generally recommended, but should not be given unless it thoroughly agrees with the stomach. In children when 25 386 DISEASES OF THE PHARYNX. there is a tendency to convulsions, potassium bromide should be admin- istered freely in the early stage. TUMORS OF THE PHARYNX. Non-malignant tumors, especially of the papillary variety, are com- paratively frequent on the pillars of the fauces, tonsils, or posterior wall of the pharynx. These usually vary in size from three to ten millime- tres in diameter. Large fibrous (Fig. 97) and fatty tumors are also some- times seen. Small tumors cause but little inconvenience, except oc- casionally a troublesome cough or sensation as of a lump in the throat during the act of swallowing. When coming in contact with the epi- Fig. 97.— Fibroma of Laryngo-Pharynx. This was a large fibrous growth attached to the lower portion of the pharynx by a pedicle about half an inch in diameter. It was removed by the steel wire snare shown in speaking of nasal polypi. The base was subsequently cauterized with the galvano-cautery. No recurrence. glottis or larynx, large growths may interfere with respiration and deg- lutition. Treatment. — Small growths may be readily removed by the forceps, snare, or galvano-cautery. Large formations, if pedunculated, may be removed by the ordinary snare, the galvano-cautery ecraseur, or ecraseurs of other forms. In cases of large or vascular growths, care must be taken not to cause suffocation during their removal, and sometimes pre- liminary tracheotomy may be necessary. CANCER OF THE PHARYNX. Cancer is rare in the upper portion but not so infrequent at the lower part of the pharynx, where it joins the oesophagus. Anatomical and Pathological Characteristics. — Cancers of the laryngo-pharynx usually first attack the posterior wall, and passing around the sides subsequently invade the larynx. They are more com- monly of the epitheliomatous variety, but those of the pharyngo-oral cavity are very often of the scirrhous form. Symptomatology. — When the disease occurs in the pharyngo-oral space, it usually causes constant pain, often radiating toward the ear, and CANCER OF THE PHARYNX. 387 is greatly aggravated by deglutition, especially after ulceration begins. The voice is indistinct, and there is profuse fetid expectoration. When the tumor is situated in the lower part of the pharynx, it is not usually painful, although there may be difficulty in swallowing, and as the disease advances respiration becomes embarrassed. Cancer at the lower jDortion of the pharynx usually commences on the posterior wall near the level of the arytenoid cartilages, but gradually extends until 'it involves the larynx, causing tumefaction, hoarseness, and dyspnoea. Scirrhous growth in the upper pharynx makes its appearance as a hard, imperfectly circumscribed mass beneath the mucous membrane, which in the early stages remains of normal appearance. As the dis- ease progresses, induration extends and may involve the palate, pillars of the fauces, and even the posterior nares. Ulceration follows and ex- tends over all the affected tissue, the ulcer presenting a reddish or grayish white surface covered with fetid secretion and here and there fungous granulations. The cervical glands at the angles of the jaw are usually involved, comparatively early in the disease. Cancer at the lower part of the pharynx usually appears first as a grayish white, fungous vegetation covered with secretion and surrounded by a zone of red and swollen mucous membrane. As it progresses, extensive ulceration may occur, and all the surrounding tissues may become indurated, but tho cervical glands are not usually much enlarged. Diagnosis. — Cancer of the pharynx is not apt to be mistaken for anything excepting syphilitic disease or fibrous tumors. "We may generally readily distinguish fibrous growths by their pedun- culated form, firm consistence, and by absence of pain and ulceration. As a rule, syphilis can be distinguished by the history, the less amount of pain, the presence of old cicatrices, or by the results of medication. Under the influence of j)otassiuni iodide given freely, the syphilitic patient usually increases in weight and improves in general health, . whereas in a person suffering from cancer, although this treatment may appear to be beneficial for a few days, the weight does not increase, and it is soon apparent that the general condition is growing worse. Treatment. — Palliative measures only can be adopted. Opiates, when well borne, may be given internally in sufficient quantities to relieve pain. The spray of morphine, carbolic acid, and tannic acid (Form. 93) will be found beneficial from its property of mitigating the pain, modi- fying the offensive odor of the discharge, and exerting some restraining influence upon the ulceration or subjacent inflammation. More than this cannot be accomplished in the present state of our knowledge. When deglutition becomes difficult, food may be administered per rec- tum or by the oesophageal tube. 388 DISEASES OF THE PHARYNX. NEUROSES OF THE PHARYNX. ANAESTHESIA OF THE PHARYNX. Anaesthesia of the pharynx, a rare affection, is characterized by the patient's inability to feel the bolus of food, some portions of which are liable to remain in the pharynx and subsequently to be drawn into the larynx during inspiration. Etiology. — Transient local anaesthesia is produced by the internal administration of morphine or the bromides in large quantity, or by local or general anaesthetics. As found in practice, tins affection is usually a sequel of diphtheria or the result of progressive bulbar paralysis. It sometimes occurs in hysteria, and is present in some cases of typhus fever, cholera, and the general paralysis of the insane. It also occasion- ally attends epilepsy. Owing to the liability of portions of food to be drawn into the larynx, patients come to dread taking anything but liquids or semi-solids. Prognosis. — Following diphtheria, or when associated with hysteria or acute disease, the prognosis is favorable, but in other instances recov- ery cannot be expected. Treatment. — When well marked, food should be given through the oesophageal tube. In remediable cases, tonics and galvanism are indi- cated, but especially the internal administration of strychnine in large doses. When faithfully followed out, promising results maybe expected. Strychnine should be given in small but steadily increasing doses and carried t'o the point of physiological toleration indicated by mild muscu- lar spasms. The dose should then be diminished, but may be again in- creased, after a few days, to an amount just short of that which caused the spasms; this dose may be continued with benefit for days or weeks. HYPERESTHESIA OF THE PHARYNX. Hyperesthesia of the pharynx is of common occurrence, but can hardly be called a disease. It is often associated with acute inflamma- tion of the pharynx, and is frequently found in persons given to the excessive use of tobacco or alcoholic stimulants. It may be produced by elongation of the uvula, and it is one of the manifestations of hysteria, but it is also sometimes present in persons otherwise in perfect health. In marked cases the sensitiveness may be so great as to interfere some- what with deglutition of solids, so that patients prefer to take liquid or semi-solid food; but usually the condition causes no inconvenience ex- cepting when the physician attempts to examine the fauces or introduce the throat mirror. Hyperesthesia attending inflammation may be re- lieved by sedative troches of slippery elm, althea, lactucarium, or opium. PARESTHESIA OF THE PHARYNX. • 389' The internal administration of from ten to twenty grain doses of po- tassium bromide three or four times daily, and the inhalation from a steam atomizer of a solution of the same, gr. xx.-xxx. ad § i., will also be found beneficial; a five per cent solution of carbolic acid will also> give a good result, and may sometimes be particularly beneficial when ulceration is present. To relieve the hyperesthesia which interferes with laryngoscopic examination, the sucking of ice for fifteen or twenty min- utes will often answer an excellent purpose, but it may usually be ac- complished more speedily by spraying the pharynx five or six times with a ten per cent solution of cocaine. PARESTHESIA OF THE PHARYNX. Paraesthesia of the pharynx, a common affection, is characterized chiefly by the presence of sensations of heat or cold, pricking, or swell- ing; or the patient may imagine he feels in the throat some foreign sub- stance like a hair, bit of straw, bristle, or sliver of toothpick. Etiology. — The affection often follows removal of foreign bodies from the fauces, but not infrequently it occurs in hysterical women with- out definite exciting causes; it is often associated with a varicose condi- tion of the veins or enlargement of glands at the base of the tongue, or with follicular' pharyngitis. It is sometimes kept up by a small ulcer which may have been caused by injury from a foreign body. The principal objective conditions found are, enlargement of the follicles in the phar- ynx or of the glands or veins at the base of the tongue. Prognosis. — The patient should always be assured that it is not a serious disorder, for frequently he is tormented with fears of cancer ; but he must also be told that the condition, in spite of all treatment, may remain for many months, though it is likely eventually to subside. Treatment. — Enlarged follicles upon the pharyngeal wall, or enlarged glands or veins at the base of the tongue, should be destroyed with the galvano-cautery. If this does not relieve the sensations, the application two or three times daily of a spray of morphine, carbolic acid, and tannic acid (Form. 93), and the internal administration of the bromides, with nerve tonics, is likely to be most beneficial. The sensations are fre- quently associated with rheumatism ; under such conditions, anti-rheu- matic remedies should be administered. Neuralgia of the pharynx may be characterized by the same symptoms as paresthesia, but more commonly by actual pain. It is often due to the same conditions as neuralgia in other portions of the body and frequently results from the rheumatic diathesis, when it might properly be termed chronic rheumatic sore throat. The treatment con- sists of applications of sedative, astringent, or stimulating sprays to the throat, combined with the internal administration of potassium bromide and nerve tonics. 390 DISEASES OF THE PHARYNX. SPASM OF THE PHARYNX. Spasm of the pharynx is a rare affection except as associated with acute inflammation of the fauces or hydrophobia, and it is usually of the tonic variety. The affection is sometimes associated with spasm of the oesophagus, and is characterized by sudden ejectment of fluid upon attempted deglutition. Etiology. — Pharyngeal spasm may be due to acute pharyngitis, tetanus, hydrophobia, or certain disorders of the brain. It is occasionally a reflex phenomenon occurring in the course of chronic pharyngitis, and in a mild form may result from swallowing food which is imperfectly masticated. It may be purely a neurosis, asobserved in hysterical persons. Symptomatology. — The spasm is marked by sudden ejectment of food on attempted deglutition. It may occur only at certain times of the day; the patient perhaps being able to eat breakfast and dinner easily, but at supper he may find that he is unable to swallow. Some- times it occurs only after taking certain kinds of food. It may come at the beginning of the meal, or later after considerable food has been taken; it is always a source of great distress to both the patient and his friends. Often, while eating naturally, the patient is suddenly com- pelled to rush from the table, or, without warning, the food is forcibly ejected from his mouth. Diagnosis. — The affection is to be distinguished from stricture or paralysis of the oesophagus and from paralysis of the pharynx. Solid or liquid foods are swallowed with more or less difficulty in stricture of the oesophagus; according to the degree of stenosis, but the bolus is not, as a rule, thrown out forcibly, though sometimes this occurs. In such cases persistent difficulty in the passage of an oesophageal bougie will settle the diagnosis. Dysphagia is present in paralysis of the pharynx or cesophay us, but the food is not suddenly expelled from the mouth. In the spasmodic affection, according to Lennox Browne (Diseases of the Throat, sec- ond edition), an important diagnostic sign in protracted cases is ob- tained by placing the fingers over the masseter and temporal regions during mastication, when it will be found that the muscles are more or less atrophied from want of use, a condition not obtained in the disease under consideration. Prognosis. — The affection may last for weeks or months, and is sometimes so serious a malady as to necessitate the administration of food per rectum. Treatment. — The treatment consists in the administration of tonics and nerve sedatives, such, for example, as quinine, zinc valerianate, arsenious acid, potassium bromide, camphor monobromide, and asafce- tida. If associated with spasm of the oesophagus, the occasional passage of an oesophageal bougie will usually be found most beneficial. PARALYSIS OF THE PHARYNX. 391 PARALYSIS OF THE PHAEIXX. Paralysis of one or more of the constrictor muscles of the pharynx may be unilateral or bilateral, partial or complete. It is characterized by dysphagia and the accumulation of saliva which the patient is unable to swallow and which therefore drips from the mouth. Etiology. — The paralysis may be idiopathic, but the most common cause is disease of the medulla involving the origin of the vagus and glosso-pharyngeal nerves. It may also result from other cerebral dis- eases. It sometimes follows syphilis, cerebro-spinal meningitis, or sun- stroke, or accompanies facial paralysis, or diphtheritic paralysis of the oesophagus. It sometimes occurs in the course of acute febrile diseases, and is then commonly one of the precursors of death. Symptomatology. — Among the most clearly characteristic symptoms is difficulty of swallowing, even of the saliva, which constantly collects and streams from the mouth. Liquids also are often taken with great difficulty on account of running into the trachea and exciting cough and spasm of the glottis. This is caused by associated paralysis of the depressors of the epiglottis. Deglutition is generally accompanied by contortions of the neck and face, from the efforts made to assist the passage of food. In chronic disease of the brain and spinal cord these symptoms sometimes occur long before the fatal termination. In the paralysis associated with facial paralysis, the uvula usually deviates toward the healthy side, and the palate scarcely moves on phonation. Paralysis of the pharynx following diphtheria usually comes on ten or fifteen days after convalescence begins, and is characterized by dysphagia, especially on attempts to swallow fluid, inability to expectorate, and a peculiar nasal timbre of the voice due to paresis of the palate, with non- closure of the passage to the naso-pharynx. The sense of taste is ob- tunded, and the velum is usually relaxed upon one side. Paralysis of the pharynx is frequently associated with paresis of the oesophagus, in which condition solids are swallowed more easily than fluids, and large boluses than small. Paralysis of the pharynx is often one of the early symptoms of pro- gressive bulbar paralysis. In this affection loss of motion is usually first manifested in the tongue, lips, and palate, causing at first indistinctness and slowness of speech, but later, difficulty in mastication and finally dysphagia, with more or less dyspnoea due to spasm of the glottis caused by entrance into the larynx of liquid or solid food. The voice is weak and often aphonic, and there is inability to pronounce the labials b, w, m, p, or the dentals f, d, v, n, and th. Diagnosis. — The diagnosis depends upon the history, symptoms, and signs just described. The continuous character of the paralysis distin- guishes it from spasm of the pharynx. Prognosis. — When due to temporary causes, when following diph- 392 DISEASES OF THE PHARYNX. theria or other acute diseases, or when associated with facial paralysis, recovery may be expected; but cases dependent upon progressive bulbar rjaralysis always end in death. Treatment. — If food cannot be swallowed, it must be administered by means of the oesophageal tube or per rectum. Internally iron, qui- nine, arsenious acid and strychnine, especially the hitter, are indicated in most cases, and sometimes considerable benefit will be obtained by change of air and scene. Here, as in anaesthesia of the pharynx, the most pronounced benefit will usually be obtained from strychnine, in large and gradually increasing doses. SCALDS AND BURNS OF THE PHARYNX. Injuries by heat are not uncommon, especially among children of the poor, in whom they frequently follow inhalation of steam from the teapot. They are sometimes caused in adults, by the inhalation of steam, flame, or hot air, as in burning vessels or buildings. In such cases the tongue, palate, and often the nares and oesophagus are similarly affected. Symptomatology. — There is acute pain and distress in the throat, with quickened pulse and more or less fever. Usually the larynx is in- volved, and swelling and dyspnoea are speedy results. Cohen states that when smoke has been inhaled, the sputum is blackish in color for several days (" Diseases of the Throat "). Dysphagia is always present. If seen early, the affected parts are of a whitish color due to burning of the mucous membrane, and shortly afterward patches of the mem- brane are found to be destroyed, and severe inflammation with marked swelling ensues. Diagnosis. — The diagnosis may be easily made from the history, symptoms, and appearance of the parts. Prognosis. — In many instances the accident is speedily fatal, and in all cases where the burn is at all severe the prognosis is very grave. If the patient lives long enough, sloughing and excessive suppuration occur, and vicious adhesions, together with chronic laryngitis and stenosis of the larynx and trachea, are apt to follow. Treatment. — Cold compresses, with sucking of ice and soothing ap- plications, should be employed, mucilaginous drinks being given if they can be swallowed. Nourishment must be given by enemata, when deglutition is impossible. If dyspnoea supervene, tracheotomy must be promptly performed to prevent suffocation. Unfortunately, how- ever, in these cases the operation does not often prevent a fatal issue. SWALLOWING THE TONGUE. The so called swallowing the tongue is an extremely rare accident. Most of the cases recorded seem to have occurred in children suffering from whooping cough. A case which I reported to the American DISEASES OF THE VALLECULAS AND PYRIFORM SINUSES. 393 Laryngological Society at its annual meeting, 1880, occurred in a lady suffering from hysteria. It was characterized by a spasmodic action of the hyo-glossus and probably also the stylo-glossus muscles, which drew the tongue into the pharynx in such a position as to prevent respiration. There was no cough. The accident may prove speedily fatal. Teeatment. — The tongue should at once be drawn forward to pre- vent suffocation. Subsequently the primary disease should receive ap- propriate treatment. DISEASES OP THE VALLECULA AND PYRIFORM SINUSES. Ulceration of the vallecula? at the base of the tongue, or of the pyri- form sinuses of the larynx, occasionally occurs from injury in swallowing bits of bone or food, and sometimes from inflammation of the glandular structure. Ulcers in either position give rise to pricking sensations and pain upon deglutition, and those in the pyriform sinuses are attended also by cough. Upon inspection with the laryngoscope, the vallecula© are commonly found filled with secretions, which must be wiped away before the cause of the trouble can be discovered, and it is usually nec- essary to anaesthetize the parts thoroughly with cocaine in order to make a complete examination. Teeatment. — If foreign bodies are found, their removal usually gives prompt relief. If ulcers exist, they are generally speedily cured by touching them once or twice with a solution of silver nitrate, gr. lx. ad § i. CHAPTER XXIII. DISEASES OF THE LARYNX. ACUTE LARYNGITIS. Synonyms, — Acute catarrhal laryngitis, cynancke Liryngea, angina laryngea, angina epiglottidea, inilammation of the larynx. Acute laryngitis is a simple catarrhal inflammation of the mucous membrane of the larynx, characterized by pain* dyspnoea* dysphonia or aphonia, stridulous breathing, and cough. Anatomical axd Pathological Charaoj eristics. — In mild cases there is congestion with slight swelling of the mucous membrane, either uniformly or in patches; the latter are more commonly found at the posterior end of the vocal cords, the posterior commissure, or on the ven- tricular band. In more severe cases the mucous membrane is cedema- tous and deeply congested, the epiglottis is thickened and flaccid, the ary-epiglottic folds are swollen into thick, pyriform bodies, and the ven- tricular bands may be so swollen as to overlap and completely hide the cords. Etiology. — Indoor occupation, malnutrition or defective excretion, and excessive use of alcoholic stimulants or tobacco, are among the principal predisposing causes. Certain diseases, as measles, scarlatina, and variola, also favor its occurrence. Among the exciting causes are exposure to irritating vapors or drugs, to wet and cold, or to draughts of air, also violent cough and excessive use of the voice, especially in the open air. It is also frequently due to extension of inflammation from the neighboring mucous membrane. Symptomatology. — The affection usually comes on insidiously, pre- ceded by a mild rhinitis, pharyngitis, or bronchitis, and is finally ushered in by slight rigors or chilly sensations. In severe cases there is some- times a pronounced chill followed by rapid development of the symptoms. Sensations of dryness, roughness, or tickling in the larynx are early ex- perienced, and these may be followed by pain, which is aggravated by coughing or speaking. As the disease progresses, there is a feeling of constriction, the tendency to cough and clear the throat becomes more pronounced, and the swelling may give rise to sensation as of a foreign body. The pain is aggravated by deglutition, and tenderness is usually elicited by palpation. At first respiration is not affected, but as soon as swelling occurs dyspnoea comes on, and in severe cases becomes very ACUTE LARYNGITIS. 395 distressing. The patient cannot lie down, is very restless and makes frantic efforts for breath. At the commencement of the attack, the face is flushed and the eyes are bright, but, as dyspnoea develops, the face becomes livid and anxious, or of an ashy hue, and the eyes protrude as in strangulation. The skin, which is at first hot, particularly in chil- dren, becomes cold and clammy; the pulse, at first full and bounding, grows weak and irregular, and. the temperature rises to 102°, 103°, or 104° F. The voice, in the beginning hoarse and shrill, later may be weak or entirely lost. The cough, at first resonant and clear, becomes convul- sive, brazen or croupy in character, and there is a slight expectoration of tenacious, glairy mucus until toward the end of the disease, when the secre- tions become muco-purulent in character, and profuse when the bronchi are also involved. Children suffering from acute laryngitis are prone to croupy attacks at night, probably due to the collection of secretions about the glottis. The tongue is usually white, furred, and red at the Fig. 98.— Superficial Ulcers op Vocal Cords. Fig. 99.— Superficial Ulceration of Epi- Herpetic ; covered with a thin whitish false glottis. Herpetic ; covered with a thin membrane. whitish false membrane. tip. Upon laryngoscopic examination, the congestion and swelling are readily detected, and occasionally small erosions, particularly at the vocal processes, are observed. In rare instances, superficial ulcerations of an herpetic character are seen, though these are not apt to be associated with much congestion and swelling of the parts (Figs. 98 and 99). As a result of the swelling, there is frequently paresis of the arytenoideus or of the thyro-arytenoid muscles, giving rise to the gaping of the cords (Figs. 182, 183). Occasionally, even before hyperemia occurs, the patient becomes hoarse, and upon examination paresis is found to be present. A mild form of laryngitis frequently attends asthma or hay fever. Diagnosis. — The disease is to be distinguished from laryngismus stridulus, true croup, paralysis of the vocal cords, and foreign bodies in the larynx. The chief features in the diagnosis are hoarseness and dryness and pain in the larynx, with hyperaemia and swelling. It is dis- tinguished from laryngismus stridulus by coming, on more slowly and being attended by chills, fever, congestion, and swelling of the parts. The following are the differential points peculiar to acute laryn- gitis and laryngismus stridulus ; 39b DISEASES OF THE LARYNX. Acute laryngitis. Laryngismus stridulus. Congestion and swelling' of mucous No congestion or swelling of mucous membrane. membrane. Fever. No fever. Generally pain. No pain. Gradual accession, and of several Sudden in its onset and short in days duration. duration. Attack usually at night; may not be repeated. It is distinguished from true croup by the age of the patient and by the greater amount of pain, congestion, and swelling; by the scanty tenacious sputum and absence of false membrane. When occurring in young chil- dren, it is not always possible to make an accurate diagnosis. Acute laryngitis is distinguished from paralysis of the vara! curds, by the pain, congestion, and swelling, which are not present in the latter disease; and by the other points presented in the following table: Acute laryngitis. Paralysis of the vocal cords. Pain, congestion, and swelling. Entire absence of pain, congestion, and swelling. Voice harsh; sometimes aphonia for Aphonia pronounced, especially if a brief period. patient is fatigued; is present through- out course of disease. Short duration. Long duration. It is to be differentiated from foreign bodies in the larynx by the history and by laryngoscopic examination. Prognosis. — Mild cases usually pass off in four or five days, and others in most instances soon yield to suitable remedies; but occasion- ally the swelling and consequent obstruction of the glottis are so great as to cause death. Neglected cases, or those in which the patient again exposes himself before the inflammation has entirely subsided, are liable to end in chronic laryngitis. Treatment. — Cold compresses renewed every half-hour or hour are found most effective in the beginning of the disease. If these fail, seda- tive vapors or inhalations of steam impregnated with opium, belladonna, or lupulin (Form. 55, 56, 57), together with large doses of potassium bromide and warm compresses, will be found more effective. The dis- ease is sometimes aborted by the early administration of ten grain doses of Dover's powder or quinine, or small and frequently repeated doses of the tincture of aconite or opium, one minim every half-hour or hour for ten or twelve hours, or until the physiological effects are obtained, and subsequently less often. Saline cathartics to keep the bowels open are usually desirable unless the affection is aborted within twenty-four hours. In all cases in any degree severe, the patient should remain in the house in a warm, moist atmosphere, and refrain from using the voice. Toward the close of the disease, the application of mild astrin- gent sprays (Form. 88, 90, 94) once or twice daily will be found very SUBACUTE LARYNGITIS. 397 beneficial. Sometimes compressed tablets of potassium chlorate are also useful. If oedema occurs so as seriously to impede the respiration, scar- ification or rupture of the swollen membrane is indicated, though the necessity for it may sometimes be removed by administration of the fluid extract of jaborandi, or its active principle pilocarpine, in sufficient quantity to excite profuse diaphoresis and salivation. Scarification is best practised by means of the guarded laryngeal lancet (Fig. 100). The mucous membrane may sometimes be ruptured by the finger nail, the edge of which has been roughened for the purpose. Severe cases may require intubation or tracheotomy. In children where there is doubt as to the diagnosis, the disease should be managed in the same way as true Fig. 100.— Mackenzie's Laryngeal Lancet (3-5 ordinary size). croup. It is generally best in the beginning to give a free calomel purge and follow this by the treatment suitable for true croup, intuba- tion or tracheotomy being performed as soon as there is serious inter- ference with respiration. SUBACUTE LARYN&ITIS. Subacute laryngitis is a mild form, usually present in what is known as an ordinary cold. It is characterized by dryness or tickling sensa- tions in the larynx, with slight pain, hoarseness, and inclination to cough, with but little or no fever. The cough is laryngeal, hacking, and more or less paroxysmal, and the expectoration usually consists of a small amount of clear, tenacious mucus. The causes are the same as those of acute laryngitis, operating in a milder degree. Upon inspection of the larynx, more or less congestion is observed, but frequently none except along the edges of the vocal cords at their posterior extremities. Prognosis. — The prognosis is favorable, and often the only treat- ment needed is care as to exposure, and confinement to the house for one or two days. Even this precaution is neglected by most patients, yet the great majority recover within five or ten days. Treatment. — Local and internal treatment suitable for mild cases of acute laryngitis are appropriate in the subacute form, and mild astrin- 398 1>LS EASES OF THE LARYNX. gent sprays are especially indicated in the latter portion of the attack if the patient suffers from hoarseness, tickling in the larynx, or a tendency to cough. Unless the patient is careful not again to expose himself, there is great liability to recurrence of the attack, and, if this is repeated a few times, chronic laryngitis is the probable sequel. TRAUMATIC LARYNGITIS. Traumatic laryngitis may result from the irritation caused by foreign bodies, from the inhalation of irritating gases, or from mechanical injury in operations; but most commonly it occurs in children from swallowing boiling liquids, strong acids or alkalies, or inhaling steam, as, for exam- ple, in attempting to drink from a tea-kettle. Symptomatology. — After the accident causing it, the inflammation comes on almost instantaneously, with acute pain, and oedema of the epiglottis and deeper portions of the larynx which causes great dyspnoea. The tongue and throat are red and angry, or white from detachment of the epithelial layer of the mucous membrane or from plastic exudation. The ©edematous epiglottis can often be seen without the aid of the laryngoscope, standing up behind the base of the tongue. It is seldom possible to make a laryngoscopic examination. Diagnosis. — The diagnosis will be easily made from the history, and from the appearance of the mouth and fauces. Prognosis. — The prognosis depends upon the extent of the injury, but is commonly grave, especially when the disease results from scalds or burns. Treatment. — The affection can sometimes be aborted by painting the parts with a strong solution of silver nitrate. However, this appli- cation is not devoid of danger from spasm of the glottis. Full doses of jaborandi may be tried. Constant applications of ice to the neck, and the sucking of ice, should be practised; or, in its stead, hot applications or inhalations of steam. The parts usually become ©edematous in spite of these measures, and then scarification or tracheotomy must be prompt- ly performed. CHRONIC LARYNGITIS. Synoyiyms. — Chronic catarrh of the larynx, laryngitis chronica. The chronic inflammation of the larynx indicated by more or less hoarseness and cough with a frequent inclination to clear the throat is most common in mole adults. Anatomical and Pathological Characteristics. — There is hy- peremia of the parts, which may be general or circumscribed, shading off gradually into the color of the surrounding tissue. Usually there is but little swelling, occasionally small blood vessels upon the epiglottis or the vocal cords are enlarged, and in rare instances nodular excrescences CHRONIC LARYNGITIS. 399 are met with. Xot infrequently slight erosions are noticed, particularly between tbe arytenoid cartilages, but often these consist simply of de- struction of the epithelium and cannot be distinguished except by the absence of the peculiar glistening appearance characteristic of healthy mucous membrane. Exceptionally small ulcers occur upon the vocal cords at the vocal processes (Fig. 101). In unusual instances hypertrophy of the soft tissues exists. Etiology. — The disease is occasionally primary, but more frequently it is the result of repeated attacks of acute or subacute inflammation, and therefore is generally due to like causes. The excessive use of tobacco, chronic alcoholism, and the constant inhalation of irritating dust or particles of metal as observed in metal-grinders, millers, and others, may sometimes be classed as causes. Kot infrequently the dis- ease follows from over-use of the voice, especially in the open air, or when the individual is already suffering from acute or subacute inflam- Fig. 101.— Catarrhal Ulcer of the Vocal Fig. 10?. — Chronic Catarrhal Laryngitis Cord. with Deformity. mation of the organ. The disease sometimes is a sequel of measles, scarlatina or other eruptive fevers, and in rare instances it results from eczema. All long continued affections of the larynx, as cancer, lupus, or poly- poid growths, may finally set up chronic inflammation. Phthisis and syphilis are frequent causes. Symptomatology. — In some cases the symptoms are not marked, and the patient only complains of something wrong in the larynx, with hoarseness and more or less dryness of the throat, especially after expo- sure. These patients often expectorate small pellets of thickened mucus. Sometimes they are suddenly startled in the night or at other times with a sense of suffocation due to spasm of the glottis, and attended by a feeling as though a crumb of bread had dropped upon the vocal cords. In mild cases there are no constitutional symptoms, but in those more severe there may be emaciation, fever, and night sweats, as results of the disturbance caused by the frequent cough. Among the common sensations experienced, are pricking or burning in the throat and a frequent desire to clear it. Varying degrees of hoarseness are observed; in some this symptom is noticed during ordinary conversation, in others only when singing, and in still others the singing voice seems natural, al- 400 DISEASES OF THE LARYNX. though the voice is very hoarse in its ordinary use. In others difficulty is noticed only on attempts at shouting. Sometimes early in the morning the patient is very hoarse, but after two or three hours the voice becomes nearly normal as a result of physiological stimulation of the circulation in the parts. In these cases, the voice usually again becomes hoarse after a few hours. In some instances taking of food greatly clears the voice. In some the cones are clear during quiet conversation, and hoarseness is only experienced after talking or singing for a half-hour or more. In nearly all cases, however, the voice eventually becomes continuously strained. Persons suffering from this disease commonly tire easily on attempting to talk for any length of time, and with the fatigue the voice usually becomes more and more harsh and unnatural. The fatigue resulting from exertion of the parts may be confined to the larynx, or it may be general, so that even strong subjects suffering from laryngitis may become much exhausted after using the voice for half an hour. Eespiration is not affected, barring those instances where- in the laryngeal opening is considerably narrowed by inflammatory changes. The cough usually consists of simple hemming efforts to clear the larynx of small pellets of mucus, but it sometimes becomes frequent and severe, especially during the night. Two kinds of laryngeal cough may occur in this disease : one dry, harsh, and brassy, with little or no expectoration; the other moist, the sputum being brought up with little difficulty. This latter type is usually asso- ciated with chronic bronchitis, in which case the expectoration may be abundant. As a rule, the sputum consists of small masses of mucus, gray- ish in color from being more or less tinged with dust; after a time it may become yellowish or brownish. The tongue is usually thick and coated at its base with a yellowish pasty fur. The mucous membrane of the fauces and pharynx is generally relaxed and more or less congested, and in many instances enlarged follicles may be seen upon the pharyn- geal wall or base of the tongue. The general health is not usually im- paired, the appetite remains good, but constipation is common and oc- casionally there are symptoms of dyspepsia. The mucous membrane of the larynx is more or less red and slightly swollen either uniformly or in patches; the latter condition is more apt to be noticed on the vocal cords and the arytenoids, but may involve the ventricular bands or epiglottis. Sometimes nodular excrescences exist, varying in size from one to five millimetres in diameter; these give the larynx a granular appear- ance. This is especially noticeable upon the vocal cords in the con- dition known as trachoma. In some cases slight erosions may be seen, being more apparent by the loss of that " peculiar sheen " which is seen upon the healthy mucous membrane than by a visible depression. This condition is most likely to occur on the inner surfaces of the ary- tenoid cartilages just above the posterior ends of the vocal cords. The CHRONIC LARYNGITIS. 401 laryngeal mucous membrane is sometimes dry, but, as a rule, the secre- tions are somewhat increased. Often flakes of more or less discolored mucus may be seen adhering to the cords or slightly sticking them to each other, and in other instances a less tenacious and thinner secretion is seen in a very thin layer upon the cords and other portions of the larynx, or stretching between the vocal cords in respiration, but, as be- Fig. 103.— Chronic Catarrhal Laryngitis. Fig. 104.— Catarrhal Laryngitis with De- formity Simulating Cancer. fore mentioned, the secretion is never abundant if only the larynx is involved. In many examples of the disease the tracheal mucous mem- brane is also congested, and often secretions may be seen collected upon its surface. There is as a rule comparatively little thickening of the laryngeal tissues, excepting the vocal cords, which may be swollen to two or three times their normal size — but the epiglottis or one or both arytenoids may be thickened from twenty to fifty per cent. In unusual instances all the soft parts are hypertrophied, and exceptionally the changes are so great as to simulate malignant disease, or aggravated forms of syphilitic laryngitis. It has been stated that the larynx sometimes appears to be dilated, but I have not seen this condition. Subglottic hypertrophy, consisting of a grayish welt just below the vocal cord, is occasionally seen, and it is probable that the same condition Fig. 105.— Slight Subglottic CEdema in a Phthisical Patient. at the outer portion of the under surface of the cord may account for some of those cases of hoarseness where the physical condition of the larynx appears nearly or quite normal. This condition might easily escape observation because of its location beneath the cord. Sluggish movement of the cords or want of proper approximation is not uncom- 26 402 DISEASES OF THE LARYNX monly the result of mechanical interference with contraction of the laryn- geal muscles, or thickening and irregularities of the mucous membrane. The glands at the base of the tongue are quite often enlarged, and some- times they seem to stand in a causative relation to the laryngitis. In some instances a varicose condition of the veins may be noticed in the same locality. The pharyngeal wall may be normal or it may be relaxed and studded with enlarged follicles, while, again, it will be found dry and glazed, or partially coated with secretion. Perhaps the most constant changes which accompany chronic laryngitis are found in the nasal cav- ities, which in the majority of cases are more or less obstructed by exos- tosis or enchondrosis of the septum, or by hypertrophy or swelling of the turbinated bodies. Diagnosis. — The disease may be mistaken for paralysis of the vocal cords, oedema of the larynx, tubercular or syphilitic laryngitis, or for cancer; a definite distinction only being possible after careful laryngo- scopy examination. In chronic catarrhal laryngitis the parts nearly always remain of normal contour, and are but little swollen, though more or less congested; ulceration is rare. Constant hoarseness is caused by paralysis of the vocal cords, and dysphonia is especially pronounced when the patient is fatigued ; there- fore the voice is usually better in the early morning than in the evening. In simple catarrhal inflammation, the hoarseness is generally worse early in the morning. In paralysis, there is no congestion or swelling, but there is marked loss of movement of one or both cords, in which respect it differs from laryngitis. Chronic laryngitis is to be distinguished from paralysis of the vocal cords by the following characteristics : Chronic catarrhal laryngitis. Paralysis of the vocal cords. Parts slightly thickened. More or No swelling or congestion, less congestion. Slight loss of movement of cords. Marked loss of movement of one or both cords. Hoarseness usually most marked in Constant hoarseness; usually less in the morning. the morning. Dysphonia especially pronounced when patient is fatigued. Swelling of the mucous membrane is caused by oedema of the larynx, the parts generally appearing from three to five times as large as normal. The mucous membrane is usually pale and has a semi-transparent ap- pearance. Sometimes it may be considerably congested, but in all cases it appears as though serum would flow out if the membrane were punc- tured. In these respects chronic laryngitis is quite different. From oedema of the larynx, chronic laryngitis is to be distinguished as follows : CHRONIC LARYNGITIS. 403 Chronic catarrhal laryngitis. CEdema of the larynx. Prolonged course; slight swelling of Short duration ; great swelling of parts, with more or less redness of parts, with change of color; membrane membrane. pale, semi-transparent. Respiration normal. Labored respiration. Simple catarrhal inflammation is distinguished from tuberbular laryngitis by the history, by the constitutional symptoms and by the color and contour of the parts. In the early stage of tubercular laryngitis there is frequently anaemia of the organ and sometimes of the soft palate, instead of congestion as in chronic catarrhal inflammation. In some cases, however, the color in the two diseases is not very dissimilar; but in the tubercular affection superficial or occasionally deep ulceration of the vocal cords and ventricular bands or of the posterior commissure, or the epiglottis, are soon discoverable, which are not observed in the simple catarrhal disease. In the later stage of most cases of tubercular laryngitis there is peculiar pyriform swelling of the arytenoids and ary- epiglottic folds, the parts being paler than in health, three or four times their ordinary thickness, and having an appearance of solidity instead of that of oedema. Ulceration is usually associated with this condition, or, if not present at first, it speedily follows. The loss of strength, rapid pulse, fever, emaciation, and night sweats of tubercular laryngitis are very seldom found in the simple catarrhal inflammation. In the tuber- cular affection pain is a common and distressing symptom, but it seldom occurs in the disease under consideration. Again, in the tubercular affection there are generally signs of disease in the apices of the lungs. Simple catarrhal inflammation and syphilitic laryngitis cannot be dis- tinguished in all instances, especially when there is simple redness with slight swelling, although usually the history of the case, the old cica- trices in the pharynx, with scars or deep ulcers in the larynx, and distor- tion and thickening of the organ, which has a peculiarly dense appear- ance as compared with oedema or tuberculosis, are sufficient to enable the physician to make an accurate diagnosis. Between chronic catarrhal laryngitis and syphilitic laryngitis the following are the chief points of difference: Chronic catarrhal laryngitis. Syphilitic laryngitis. No specific history. Syphilitic history. Normal contour of parts. Sometimes distortion of parts by old cicatrices or thickening. No evidences of ulceration, past or Mucous patches, scars, or ulcers gen- present, erally present. We find malignant disease of the larynx usually attended by more or less pain and marked in the beginning by circumscribed congestion which is speedily followed by the development of a neoplasm, that 4(>4 DISEASES OF THE LARYNJT. gradually advances, involving, as a rule, all of the tissues with which it conies in contact, causing distortion of the larynx, and finally undergoing deep ulceration. Catarrhal laryngitis never has this history, though I have seen a few cases in which the swelling and distortion of the parts were strongly suggestive of malignant disease. In such instances noth- ing but continued observation of the case for some time will enable the physician to make an accurate diagnosis. The differential diagnosis of chrouic catarrhal laryngitis and malig- nant disease of the larynx is as follows : Chronic catarrhal laryngitis. Malignant disease of larynx. Moderate uniform congestion and Circumscribed redness and swelling; thickening of parts. contour of parts much changed. No pain. Pronounced pain. Hoarseness, but no dysphagia. Aphonia and dysphagia. No ulceration. Eventually ulceration, with offensive discharge. Prognosis. — The disease usually runs a very protracted course, last- ing for months or years, though there is a strong tendency to improve- ment at times, with subsequent recurrence of the more pronounced symptoms. It very rarely, if ever, terminates fatally; yet there is some reason for believing that very protracted inflammation, after involving the trachea and bronchial tubes in greatly debilitated patients, may eventually terminate in consumption. The disease is not intractable if the exciting causes can be removed and the predisposing tendency cor- rected. Treatment. — In every case of chronic laryngitis it is the first duty of the physician to remove the causes if possible. With this end in view, the excessive use of tobacco and alcoholic stimulants, and some- times even the use of tea and coffee, should be interdicted and the con- dition of the digestive organs must be carefully regulated. The patient must avoid all exposure to damp and cold, or to the vitiated atmosjmere of crowded rooms. He must avoid the inhalation of irritating dust and gases, and must keep the skin and other excretory organs in a healthy condition. The parts involved should be placed, as nearly as possible, at rest, especially during all acute exacerbations of the disease. Singing, shouting, and excessive use of the voice, especially in the open air, must be prohibited; and when there is much irritability of the parts, the patient should converse only in whispers. There are some cases, how- ever, of a chronic low grade of inflammation that seem benefited by moderate use of the voice, which stimulates a flow of blood through the parts, and thus promotes absorption of inflammatory products. Usually prolonged systematic treatment, consisting of repeated ajiplications of stimulating substances, will be necessary before the disease can be cured. The various substances used for this purpose may be applied in the form CHRONIC LARYNGITIS. 405 of ponders, sprays, or pigments according to the tolerance of the patient and the inclination of the physician. As a rule, sprays give the patient less inconvenience and are on the whole preferable, though occasionally powders answer an excellent purpose, and sometimes pigments, espe- cially when applied by means of a cotton probang (Fig. 107), are very effectual. These applications should be made, when possible, every day for one or two weeks, until considerable acute congestion of the parts has been excited; then once in two days for a week or two, and after this less frequently, according to the improvement of the case. It is well Fig. 106. Fig. 107. Fig. 106.— Davidson's Atomizers, Set No. 66, for Office Use (1-3 size). For the specialist, to whom time is an object, it will be found preferable to have these bottles held by an open spring- clip to the edge of a shelf. The facility with which the tips may be changed to throw a spray in any direction makes each of these bottles equivalent to four of the atomizer tubes in common use. They may be used with the hard rubber attachment shown at bottom of cut but more conveniently with the Davidson cut-off. Fig. 107.— Ingals 1 Laryngeal Applicator (copper staff, 2-5 size). The cotton should be wound firmly upon the point, and to prevent the possibility of accident a thread should be tied about it with a slip-knot and wound about the staff up to the handle. also to have the patient at the same time use weaker applications to the larynx by sprays or inhalation each morning and evening. It will be found that different larynges vary exceedingly in sensitiveness, so that an application which will cause no discomfort whatever in one may in another produce extreme pain. It is therefore necessary to try weak medication at first, and always to regulate the strength by the effect, which may be judged quite accurately by the sensations of the patient. Applications which are made by the patient himself should never cause discomfort for more than twenty or thirty minutes. Those made 406 DISEASES OF THE LARYNX. by the physician, if daily, should not cause smarting for more than an hour, and, if every second day, not more than two hours; in either case actual pain should not last more than ten or fifteen minutes. The par- ticular remedy to be employed is, as a rule, a matter of little conse- quence, the object being merely to stimulate the mucous membrane; though it will be found that in some cases one substance will really work better than any other. In most instances a change from time to time will hasten recovery, for where a single agent is used for a long period the parts appear to become so accustomed to it that it has but little effect upon them. The topical remedies commonly employed in this disease consist of zinc sulphate or chloride in solutions varying in strength, from gr. ij. to xxx. ad 3 i. of distilled water; solutions of iron chloride, nj, lx. to cxx. ad 3 i.; iron and ammonium sulphate, gr. v. to xxx. ad 3 i., or copper sulphate, gr. x. to xx. ad 3 i. ; silver nitrate, gr. x. to 5 ij. ad 3 L; tannin, gr. xxx. to 3 i. ad 3 i. Tincture of iodine or turpentine, the fluid extract of thuja occidentalis, and vari- ous other substances are also in common use. The zinc and copper salts have proved most satisfactory in my hands. Usually in the beginning I apply a spray of a solution of zinc sulphate, gr. ij. ad 3 L, and if this causes no discomfort a small quantity of a solution of gr. xxx. ad 3 i. is applied immediately afterward, and should no smarting result, a more thorough appli- cation of it is made, the aim being to produce a reaction which the patient will feel for one BAYIPJ0H RUBBER CC ..,-.. fig. loa-DAYiiMON's atomjzek, °r two hours. At the next visit the solution No. 59, old Style, screw Top, Long may be modified according to the effect which tip (Usize). j ms ^ een obtained, and the time that it has been felt. Other remedies may be employed in the same manner. I usually make these applications in the form of spray with an air pres- sure of thirty or forty pounds to the inch. The swab I seldom use, and the brush not at all. I rarely employ tincture of iodine or silver nitrate, though sometimes they are of great benefit. The strong solutions of the latter recommended by some authors are in most cases objectionable, because of the spasm of the larynx and the great discomfort they cause, while their beneficial effects are seldom greater than those of milder ap- plications. For use at home I give the patient weak solutions of similar astringents (Form. 88, 92, 94). These the patient applies cold with some suitable atomizer. Steam sprays seem to cause relaxation of the parts, which favors sub- sequent inflammation, and therefore they are not recommended. How- ever, they may sometimes be used with more or less benefit at night or when the patient is not going out of doors for one or two hours. Lennox Browne particularly recommends such inhalations as benzoin, CHRONIC LARYNGITIS. 407 phenol, creasote, or camphor. If these are used with warm water, the patient must not go out of doors for some time afterward. They may be employed in some of the lighter oils, as for example, liquid albolene, and applied by means of some of the various nebulizers or atomizers without the danger incident to the use of warm vapors. The substances most commonly used in the larynx in the form of powder are bismuth, boric acid, iodoform, iodol, berberine muriate, gum benzoin, myrrh, alum, zinc sulphate, and silver nitrate. Boric acid and iodol or iodoform in equal parts constitute a very useful stimulant and antiseptic application in some cases. Boric acid alone is slightly more stimulating. Equal parts of gum benzoin, bismuth, and iodol or iodoform make an excellent powder, still more stimulating. Tannin, in the pro- portion of from two to ten per cent, with sugar of milk, is sometimes useful. One part of berberine muriate to two parts of acacia forms an excellent application for certain cases, especially where there is a relaxed condition of the mucous membrane and enlargement of the follicles. Equal parts of alum and sugar of milk answer well when a decided effect is desired. Silver nitrate I never employ in this way, though it is recommended by good authority. With most of these powders it is well to combine about five per cent of pulverized starch to prevent packing, and all of them should be thoroughly triturated. Stimulating or seda- tive troches will often be found beneficial; of the former, troches of am- monium compound, krameria compound, or benzoic acid compound are excellent examples (Forms. 41, 46, 48). Of the sedative troches we have lactucarium, terpin hydrate and cannabis compound (Forms. 29, 33), or morphine, antimony, and ipecac compound (Form. 32) are good examples. When cough is a troublesome feature, sprays of potassium bromide 3 ss. to 3 i.ad | i. will often be found very useful. Irritating cough may sometimes be readily relieved by a few light inhalations of chloroform ; for this purpose a small bottle may be given the patient to carry in his pocket for use as needed. Aside from this local treatment, it will often be found of the greatest importance to cure coexisting disease of the pharynx, base of the tongue, or nasal cav- ities. Enlarged glands at the base of the tongue, or varicose veins, should be reduced by cauterization. Follicular enlargements on the pharyngeal wall must be cut down by the cautery, and hypertrophic rhinitis or exostoses of the septum must be met by proper surgical pro- cedures. Other forms of inflammation or obstruction in the nares or pharynx must also be remedied, for the laryngeal disease can seldom be permanently cured while these affections remain. In some instances it will be found desirable to apply caustics, such as silver nitrate, chromic acid, or the galvano-cautery point to enlarged follicles in the larynx it- self. In such cases the larynx should first be thoroughly anaesthetized by a twenty per cent or twenty five per cent solution of cocaine, and then the application should be made accurately to the parts diseased, and 408 DISEASES OF THE LARYNX. to no other, care being taken that the cauterizations are never extensive or severe. After any of these operations the patient should apply cold compresses to the neck for from twelve to twenty-four hours, to prevent undue reaction. TRACHOMA OF THE VOCAL CORDS. Synonym. — Chorditis tuberosa. Trachoma of the vocal cords is a chronic inflammation of the larynx, characterized by roughness or a granular appearance of the vocal bands, ■with some swelling, and more or less alteration of the voice. It is found most frequently in singers, but may occur in others. I have seen one case in the person of a farmer who used his voice very little in singing. Anatomical and Pathological Characteristics. — The disease appears to consist of hypertrophy of the connective tissue, which results in a nodular or granular thickening of the cord. Fin. 109.— Trachoma op Vocal Cords (extreme). Etiology. — No special causes of the affection are known, aside from repeated over-use of the voice especially when the larynx is congested. Symptomatology. — The symptoms are those of chronic laryngitis, i.e., hoarseness or aphonia, with more or less cough and expectoration. Upon laryngoscopic examination, the cords are found congested and thickened, and presenting a nodular appearance (Fig. 109) of the sur- face, with nnevenness of the edges. Diagnosis. — The diagnosis will be based upon a history of chronic laryngitis, with the physical appearances just mentioned. Prognosis. — The duration may be months or years, but prolonged rest and judicious treatment will usually promote a cure. Treatment. — The treatment consists of the application of mild caustics or mineral astringents in the same manner as recommended for chronic laryngitis. By this course, persistently carried out, a cure may usually be effected. Owing to the obstinacy of this affection, Carlo Labus, of Milan, has recommended flaying of the vocal cords, or, in other words, stripping off of their hypertrophied mucous membrane by means of ordinary laryngeal forceps {Archives of Laryngology, 1880). Charles PHLEBECTASI8 LARYNGEA. 409 E. Sajous, of Philadelphia, has recommended touching small areas of the cord with chromic acid at intervals of several days (Transactions of the American Laryngological Association for 1888). This treatment seems to promise well and should be given a fair trial after the ordinary measures have proven unsuccessful. In applying the chromic acid, a very small portion should be fused on the end of a guarded applicator Fig. 110.— Ingals' Chromic Acid Applicator and Handle (1-3 size). This is a long aluminium wire, properly curved to correspond with the f aucial angle, and guarded at the end by a piece of rubber tubing which protects the parts not to be touched from contact with the agent. The bit of rubber tubing is prevented from slipping off by a silk thread which is tied about it and wound around the stem up to the handle. (Fig. 110) with which the part should be accurately touched, the larynx having first been anaesthetized by cocaine to prevent injury to other parts. PHLEBECTASIS LARYNGEA. Phlebectasis laryngea is a varicose condition of the laryngeal veins, characterized by more or less alteration of the voice and discomfort in the larynx. Anatomical and Pathological Chaeacteristics. — In mild cases fine veins are seen running along the epiglottis and the lower portions of the ventricular bands ; in more severe cases the enlarged veins appear tortuous and extend also over the vocal cords and arytenoid cartilages. <§^> t^^— ■ S^ Fig. 111.— Ingals' Galvano-Cautery Handle (]4, size). In this the circuit is closed by moving the finger from the contact button. Etiology. — There is no known cause of the disease. Symptomatology.— The patients usually complain of uneasy sensa- tions in the larynx, of slight cough, and of more or less hoarseness. Diagnosis. — The diagnosis is made by careful inspection of the larynx, care being taken not to mistake for enlarged veins the blackened mucus which sometimes collects upon the surface. Treatment. — Topical applications of strong astringents may be made, but the most satisfactory treatment consists of destruction of 410 DISEASES OF THE LARYNX. the vein by repeated small cauterizations with the galvano-cautery, a period of from ten days to two weeks intervening between the opera- tions. Intra-laryngeal cauterization should be made with an electrode provided with a small fine platinum tip, which will heat or cool quickly. The best handle for this purpose is one in which the circuit is closed on relieving the pressure from a spring (Fig. Ill) instead of by the usual method of pressure; this allows the circuit to be completed with the least movement of the electrode. CHAPTER XXIY. DISEASES OF THE LARYNX.— Continued. MEMBRANOUS CROUP. Synonyms. — True croup, exudative laryngitis, membranous laryn- gitis. Croup, in the strict sense, is a disease of the laryngeal mucous mem- brane characterized by the exudation of inflammatory lymph, forming false membrane, and attended by more or less muscular spasm of the larynx. Mackenzie and some other authors, together with a large num- ber of the profession, believe it identical in nature with diphtheria, but I am convinced that these are two distinct diseases. Most of the older writers, and not a few of the more recent, agree with Aitken, who says of this affection: " Any one who has seen much of croup in children can have no difficulty in recognizing it as a disease distinct from diphtheria in its attack, its course, and results." I know of no better definition for the disease than that given by Lennox Browne (Diseases of the Throat, second edition), who defines it as a pseudo-membranous inflam- mation of the air passages, non-infectious and non-contagious. The dis- ease occurs most frequently in children between two and seven years of age. It seldom occurs in older children, and is extremely rare in young infants and in adults. Anatomical and Pathological Characteristics. — The inflam- mation is almost entirely confined to that portion of the larynx above the cords. The false membrane, though deposited partially upon the epiglottis and ventricular bands, is mainly found about the glottis itself and upon the vocal cords. The inflammation may extend to the sub- mucous tissues, resulting either in spasm or paralysis of the laryngeal muscles. The false membrane is comparatively thin, only involving the epithelial layer of the mucous membrane, whereas in diphtheria the whole thickness of the mucous membrane is affected. Etiology. — Those who believe in the identity of diphtheria and croup attribute this to a specific contagium, the action of which, how- ever, they admit may be favored by the usually recognized causes of the diseases. In some instances there is undoubtedly a strong hereditary predisposition to the disease, and in a large number of cases its onset is certainly favored by acute laryngitis. The disease is also favored by poor general health. There is little doubt that the majority of cases are 412 DISEASES OF THE LARYNX. directly due to improper clothing or to life in damp, chilly, and ill- ventilated rooms. The disease is peculiarly prevalent in the spring and fall months, when the outdoor temperature is so warm that it is hardly necessary for apartments to be heated, therefore at this time many houses are kept at a temperature of from 60° to 65° F. The adults, who are working about, and who are necessarily in higher strata of air than the children playing upon the floor, do not notice the necessity for more warmth, but the little ones become chilled, a slight catarrhal laryngitis supervenes, and, whether or not this is the direct cause of croup, it cer- tainly favors the development of the false membrane. The disease is not contagious, and it seems to have been satisfactorily demonstrated that it cannot be inoculated from the false membrane, though Mac- kenzie and others hold contrary views. The theory that this disorder is often the direct result of certain ptomaines generated Avithin the patient's own body seems to me reasonable. Symptomatology. — For the sake of convenience in description, the disease may be divided clinically into three stages — a catarrhal, an exu- dative, and a suffocative. The catarrhal stage is usually preceded for about forty-eight hours by a feeling of malaise attended by slight fever and anorexia; later there is considerable fever, cough, hoarseness, and some dyspnoea. In the latter part of this stage the false membrane begins to form. In the exudative stage the false membrane is being gradually or rapidly deposited in the larynx, spasmodic action of the muscles be- comes more frequent, and dyspnoea more and more severe. There is either hoarseness or complete aphonia, and cough may or may not be troublesome. Finally, the membrane becomes so thick as to seriously obstruct the glottis, giving rise to the last stage. In the suffocative stage, dyspnoea is constant, but still more or less aggravated at times by spasm of the laryngeal muscles. As the stage advances, all of the symptoms of gradual suffocation supervene, and finally, in the majority of cases, the patient dies from the effect of im- perfect aeration of the blood. In the first stage the temperature is raised from one to three degrees, and the pulse is quickened from twenty to thirty beats per minute; yet frequently the friends may not notice these symptoms until the child is suddenly wakened at night struggling for breath. This jiaroxysm, which is due to spasm of the laryngeal muscles, continues for a few min- utes, and then may pass off till the following night, or other attacks may occur from time to time during the same night. In the interval be- tween the attacks the child breathes with comparative ease and soon falls into a troubled sleep. It usually plays about the house on the fol- lowing day, but more or less hoarseness is noticed, and at night all of the symptoms become more aggravated. Again, there may be an inter- mission in the symptoms during the day following, and it is not un- MEMBRANOUS CROUP. 413 usual to find the child running about the house after a second night of suffering and unrest from the paroxysms of true croup; but on the succeeding night the suffocative stage generally begins, in which there is constant dyspnoea, with occasional paroxysms which add greatly to the distress. The spasms are less pronounced than in the catarrhal stage, because carbonic acid poisoning renders the muscular action slug- gish. There are some unfortunate cases, however, in which the disease runs rapidly through the three stages and many terminate fatally within a few hours. In the exudative stage, hoarseness is persistent, there is a pe- culiar shrill, harsh cough, which needs to be heard but once to be remem- bered, and occasionally particles of false membrane are cast off. Fever and anorexia are usually present, there is constant dyspnoea, and inspira- tion and expiration are both prolonged, especially the former. The suffo- cative paroxysms now become more frequent and severe. At the onset of one of these, the child suddenly springs up in great alarm, the eyes stand out like those of one in strangulation, the nostrils are dilated, and the respiratory muscles tense with the violent effort at inspiration ; in a few seconds the countenance becomes livid and the child almost ceases its efforts to breathe; but finally the spasm relaxes, air again enters the lungs, lividity disappears, and respiration becomes once more normal, so that excepting for the hoarseness it would hardly be known that the child was ill. One such attack usually lasts two or three minutes, and may be renewed after a short interval of rest. Eecurrence in this man- ner may take place several times; but usually after the first three or four paroxysms the child falls into a restless sleep that may last for sev- eral hours. If the larynx can be examined, we find it congested, with here and there patches of thin, yellowish white membrane upon the surface. In this stage the child is extremely restless, throwing itself about the bed, or every few moments asking to be taken up or laid down in its fruitless search for comfort and the oxygen it needs. The face and general surface are ashy pale, with lividity of the lips and finger nails; the skin, which has been hot in the first and second stages, remains so in the earlier part of this the third stage, but later becomes cold and is bathed in a clammy perspiration. The pulse is quick and small, the voice weak or lost, and the cough feeble or sup- pressed. The tongue usually is coated, and there is much thirst, but no desire for food. In the first stage of the disease the respiration may be accelerated, as in other catarrhal affections of the mucous membrane, but in the later stages the breathing becomes slow and labored, and with each inspira- tion there is sinking in of the soft parts of the chest. This is most marked at the lower end of the sternum and over the false ribs, but it is also noted in the interclavicular notch and just above the clavicles. Diagnosis. — True croup may be mistaken for catarrhal laryn- gitis, laryngismus stridulus, or for diphtheria. The essential points 414 DISEASES OF THE LARYNX. in the diagnosis are: gradually increasing hoarseness, slight consti- tutional symptoms, dyspnoea and the formation of false membrane which is confined to the larynx. In catarrhal laryngitis there is commonly considerable pain in coughing, speaking, or swallowing; there is but little dyspnoea, the cough is short and sharp, there is no expectoration of false membrane, and the respiration seldom becomes slow and labored; all of which symptoms distinguish it from croup. In typical cases there is no diffi- culty in making the diagnosis, but it is difficult or quite impossible, in complicated or obscure instances, and therefore doubtful cases should be treated as croup. From acute laryngitis the disease is to be distinguished by the char- acteristics presented below: Membranous croup. Generally occurs in children. Slight congestion and swelling. Slight pain in coughing, speaking, or swallowing. Cough harsh and stridulous. Marked dyspnoea. Slow, labored respiration. False membrane in larynx. Acute laryngitis. Generally occurs in adults. Marked congestion of parts, and swelling. Marked pain in coughing, speaking, and swallowing. Cough sharp and short. Slight dyspnoea. Respiration nearly normal, or may be increased in frequency. Tenacious, scanty sputum, but no false membrane. Laryngismus stridulus differs from croup in that it comes on sud- denly when the child is apparently well. It is not attended by inflam- mation, or quickening of the pulse, or fever, and the dyspnoea passes off in a few minutes, leaving the child breathing with perfect ease until another paroxysm occurs. Sometimes the paroxysms are not repeated. As soon as the attack is over, the voice becomes normal. From laryngismus stridulus croup is to be distinguished as follows: Membranous croup. Slight congestion and swelling. Fever, rapid pulse. Slow in development. Labored and slow respiration, but with paroxysms of more pronounced dyspnoea. Aphonia and dysphonia constant. Presence of false membrane. Comparatively long duration, usu- ally two or three days. Laryngismus stridulus. No congestion or swelling. No fever, pulse normal except dur- ing paroxysm. Sudden in its onset. Attack may not be repeated ; res- piration and voice normal except dur- ing paroxysm. Voice normal except during brief paroxysms of dyspnoea. No false membrane. Short duration. MEMBRANOUS CROUP. 415 Croup cannot always be distinguished from diphtheria, as there are some cases which at first appear to be simply true croup, but in which diphtheritic membrane is subsequently deposited in the pharynx and eventually paralysis occurs; or other members of the family are at- tacked by diphtheria. But in typical cases the distinguishing symp- toms are well marked. Diphtheria conies on more suddenly, and the constitutional symptoms are more pronounced. There is usually abun- dant false membrane in the fauces, and paralysis is a frequent sequel. The fever in diphtheria is more variable than in croup. The dyspnoea in diphtheria is slowly developed, and there is little, if any, spasm of the glottis. Diphtheria is often very contagious, croup is not at all so. An attack of croup is usually preceded by two or three days of malaise or catarrhal symptoms, and is finally suddenly ushered in during the night by a severe paroxysm of dyspnoea; it is attended by mild but continuous and gradually progressing fever; the constitu- tional symptoms are slight, there is no false membrane in the fauces, and no paralysis following the disease. True croup and diphtheria present the following differential points: Membranous croup. Diphtheria. Malaise or catarrhal symptoms at Constitutional symptoms developed first, but constitutional symptoms com- quickly and very pronounced, paratiyely slight. Fever mild, but continuous and grad- High fever at first, later variable, ually increasing. Severe paroxysm of dyspnoea ushered Dyspnoea developed slowly, no de- in suddenly at night. cided spasm of glottis. No false membrane in fauces. False membrane in fauces. Not contagious. Often contagious. No subsequent paralysis. Frequently paralysis follows. Prognosis. — In unusual cases patients may die with membranous croup within three or four hours after the first indications of the dis- ease, but commonly the affection extends over two or three days, and sometimes it continues for a week. It is probable that not more than twenty per cent of the cases would recover without surgical interfer- ence; and even under the most improved methods, according to Hilton Fagge, sixty or seventy per cent die. It appears, however, that of those upon whom intubation is done by O'Dwyer's method forty to fifty per cent recover. In cases which progress favorably the false membrane gradu- ally disappears, the spasms subside, breathing becomes less and less diffi- cult, the sputum becomes more abundant, the cough easy, and in two or three days the child is out of danger. In fatal cases the dyspnoea steadily increases, the child becomes extremely restless, the cough, which has been severe, loses its loud, croupy sound, and may become almost inaudible; the pulse grows feeble and rapid, the extremities cold, the 416 DISEASES OFTHE LARYNX. skin is bathed in cold perspiration, and the patient finally dies of exhaus- tion, or gradually passes into a comatose condition, in which death en- sues from carbonic acid poisoning. Occasionally life is cut short by a heart clot or by convulsions, and in some instances pulmonary complica- tions are the immediate cause of death. A few cases die from suffoca- tion caused by spasm of the glottis. Treatment. — In the early stage of the disease great benefit may be derived from the external application of either cold or heat; but which- ever is used must be employed continuously, as the alternate use of cold and he.it makes matters worse. Cold may be applied by cloths wrung out of ice water and frequently changed, but, better still, by means of an ice bag. For this purpose a long, narrow rubber bag not more than three inches in width should be obtained and filled about half full of ice cracked into small pieces not larger than a filbert. It should then be wrapped in a handkerchief and tied closely about the neck. The ice will melt in about an hour, and should then be renewed. An excellent method of applying cold is by means of the Leiter coil. This consists of a coil of metallic tubing, which may be fitted accurately to the neck; to each end is attached a rubber hose, one leading from a receptacle of ice water, and the other carrying off the waste. Continu- ous cold for the first twenty-four or forty-eight hours will frequently cut short the attack. Sometimes because of the depression of the patient, and in other instances to meet the wishes of the friends, it is better to use heat. This may be applied by means of cloths wrung out of hot water, by hot water bags, or by the Leiter coil, already re- ferred to. In the early stage of the disease, heat may be made to answer exactly the same purpose as cold, but it is usually more beneficial in the later stages of the attack. The atmosphere of the room should be kept moist and at a tempera- ture of 75° or 80 c F. Moisture may be obtained by means of a basin of water on the register or stove, by the steam atomizer, or by constant slak- ing of lime in the room. Owing to the fact that diphtheritic membrane, when immersed in lime water gradually dissolves, the vapors from lime have been considered especially beneficial in this disease; but it is doubtful whether they are ever inhaled in sufficient quantity or of suffi- cient saturation materially to affect the false membrane. Many physi- cians recommend that a basin of slaking lime be kept constantly in the room or upon the stove, others apply lime water by means of a steam atomizer, but probably the most efficient way of using it is by means of the croup tent, as follows: having placed a pan of hot water close by the head of the bed and dropped into it a handful of unslaked lime, a sheet is thrown over the pan and over the child's head, being held up somewhat from the face: the patient is by this means compelled to breathe the vapors arising from the lime. The application should be continued ten or fifteen minutes and repeated every half-hour when MEMBRANOUS CROUP. 417 practicable. A steam atomizer may be kept constantly running in the room for the purpose of saturating the air with moisture, and the patient should be induced to inhale from it directly two or three times an hour, for five or ten minutes. For inhalation by means of this instru- ment, solutions of sodium bicarbonate gr. v. to x. ad 3 i., the saturated solution of lime water, lactic acid gr. xx. ad 5 i. to dissolve the membrane, or potassium bromide gr. xx. to xxx. ad 3 i., or the aqueous extract of opium or belladonna gr. i. to ij. ad 3 i. may be employed to prevent the paroxysmal dyspnoea. Emetics are employed for the purpose of me- chanically dislodging mucus and false membrane from the larynx, and relaxing the muscular system so as to prevent spasms of the glottis. For this purpose tartarized antimony in the form of the compound syrup of squills is probably the agent most frequently employed. It should be given in doses of ttj, xv. to xxx. repeated every fifteen minutes until vomiting occurs, or until its depressing effects are noticed; but the dose should not subsequently be repeated for several hours. Ipecac in some form is used for the same purpose, and it has the advantage over tartarized antimony of causing no subsequent depression. Zinc sul- phate, alum, and turpeth mineral are also employed ; the latter has been especially recommended by so eminent an authority as Fordyce Barker, who considered it prompt, safe, and efficient in closes of grs. i. to iij. Emesis usually follows its administration, in from five to twenty minutes. Pulverized alum, gr. xx. ad 3 i., mixed with honey is a prompt, safe, and not unpleasant emetic in these cases. Mercurial preparations have been recommended for the purpose of limiting the formation of false mem- brane, and within the last few years mercury bichloride has been much employed in comparatively large and frequent doses. I prefer the mild chloride, which is more easily managed and quite as efficient. Turpeth mineral is also used by some physicians in small and repeated doses for the same purpose. In children one or two years of age, I frequently order one grain of calomel to be given every hour until it acts upon the bowels, and subsequently every two hours for ten or fifteen doses. A healthy child of this age will usually be speedily purged by one grain of calomel, but in croup about twenty grains will generally be taken before the effects of the remedy are noticed upon the bowels, and then it does not act vigorously. Thus, these patients often take from thirty to forty grains of calomel within thirty-six or forty-eight hours, and I have never seen any deleterious effects from its use, but have fre- quently witnessed the most gratifying results in the relief of the laryn- geal symptoms. Unfortunately, however, in the majority of cases, no matter what external applications we employ, or what internal remedies are administered, the disease goes steadily on from bad to worse; the glottis becomes narrower until finally suffocation is imminent, and then we must resort to surgical measures or the child is lost. Mackenzie recommended a croup brush in which the hairs run toward 27 418 DISEASES OF THE LARYNX. the handle, designed to be introduced through the glottis and withdrawn so as to dislodge the false membrane. I do not know how efficient this has proved, but it has not become popular with the profession. In a few instances an ordinary catheter has been passed through the glottis, by which the patient has been enabled to obtain sufficient air to support life. In this extremity we should not temporize, but should resort at once to O'Dwyer's intubation, or to tracheotomy, either of which, if performed early, will save many lives. In children under five years of age intuba- tion seems to offer better chances for recovery than tracheotomy; there- fore it should be advised, and because of the ease of its performance, the readiness with which the consent of parents is obtained, the speedy re- lief afforded, and the avoidance of an anaesthetic, it may be recommended in all cases, for it is no bar to the subsequent performance of trache- otomy if that operation should seem necessary. The best cases for either of these operations are those in which the membrane is confined to a small portion of the larynx and where the carbonic acid poisoning O CDOQo Fig. 112.— O'Dwyer's Ixti/batiox Instruments i>4 size). //, Applicator; A, obturator; B, H. tubes of various sizes; C. C, actual calibre of tubes. is not very pronounced; when the difficulty of respiration has continued for several hours, giving rise to pulmonary atalectasis, or oedema, or to heart failure, little can be hoped from either. When the glottis becomes so obstructed that there is falling in of the soft parts of the chest with each inspiration, and respiration is long and labored, the lips blue and the skin pale, there should be no delay in adopting surgical measures, for every hour then will materially lessen the chances of recovery. Intubation is performed by means of the instrument (Fig. 112) devised by Joseph O'Dwyer, of New York. His set of instruments con- sists of six tubes graduated for children less than ten years of age. It contains a gauge for measuring the tubes to determine the proper size for any given age, an applicator for introducing the tube, an extractor for withdrawing it, and a mouth gag ; the latter, however, is not as satis- factory as some others, because the child is sometimes able to displace it from between the jaws and may bite the operator. But the other in- struments, which were the outcome of long and patient experimenta- tion, are so nearly perfect that it has been difficult in any way to im- MEMBRANOUS CROUP. 419 prove upon them. Henrotin's, Waxham's, or Allingham's gags (Figs. 113, 114, 115) are preferable. In preparing for the operation, the child's age having been ascertained, the proper tube is selected and a strong thread about three feet in length is passed through the eyelet in its head and the ends are tied together; the applicator is then screwed into the obturator, and this passed through the tube ready for the operation. The head of the tube is bevelled so that one side is much shorter than the other, and this short side should be placed toward the handle of the Fig. 113. — Henrotin's Gag (}<$ size). Fig. 114. — Waxham's Gag (% size). instrument, so that when introduced into the larynx it will conform to the position of the epiglottis. The child, wrapped in a blanket or sheet, which is pinned closely about the* neck so that its arms are pinioned, should be held in the arms of the nurse, with its head against her left shoulder. The gag is then inserted between the teeth upon the left side, and intrusted to the assistant who is to hold the head. The opera- tor's forefinger of the left hand should be oiled or smeared with vaseline to prevent inoculation through any abrasions upon the surface in case Fig. 115. — Allingham's Mouth Gag (J£ size). the disease should prove to be diphtheria, and a broad metallic ring or a rubber finger cot the end of which has been cut off, should be slipped over the finger to prevent the patient from biting it in case the gag should become displaced ; or in the absence of these, the finger may be wound with a strip of cloth, which will answer the purpose fairly well. The tube with the applicator, having been dipped into warm water to bring it to blood heat, is ready for introduction. The child's head being thrown slightly backward and held firmly by the assistant, the operator introduces the forefinger of the left hand over the base of the tongue, 420 DISEASES OF THE LARYNX. down behind the epiglottis, until he feels the arytenoid cartilage, upon the upper edge of which the finger is rested. The tube is now guided down along the palmar surface of the finger until it reaches the larynx when, the handle of the applicator being elevated so as to turn the end of the tube farther forward, it is passed into the glottis and crowded down- ward about half an inch. At the same time the end of the finger which is resting on the arytenoid is brought upward and placed upon the upper end of the tube, which is forced downward as far as possible. The slide upon the applicator is then shoved forward, the obturator dis- engaged, and the applicator removed, while with the finger of the left hand the operator crowds the head of the tube fairly into the vestibule of the larynx. Not more than ten seconds should be consumed in this operation : if in this time the operator does not succeed in introducing the tube, it is better to withdraw it and allow the child to breathe for a moment before making another effort. As soon as the tube is intro- duced, the child usually coughs, and the respiration generally has a. peculiar tubular sound, which indicates that the tube has been placed in the air passage; if this sound is not heard, the operator should feel again for the tube to ascertain whether or not it has been passed into Fig. lit;.— O'Dwyer's Extractor (} i size). the oesophagus instead of the larynx. If not in proper position it must be withdrawn by the string and another effort made to introduce it. If in proper position, it should he allowed to remain with the string attached for a few minutes until respiration becomes thoroughly estab- lished and the child has finished coughing. One of the threads should then be cut near the lips, the operator's forefinger carried down to the head of the tube to hold it in position and the string withdrawn. The tube is left in the larynx, where it should remain for from two to six days, unless it should become partially stopped by dried mucus, as indicated by difficult breathing, or unless subsidence of the symp- toms leads us to believe that the swelling has gone down and the false membrane disappeared. In many cases the tube will be coughed out as soon as the necessity for its further use ceases. When it becomes nec- essary to remove it, the child is placed in the same position as for its introduction, and with the index finger of the left hand the operator guides the extractor down to the larynx, where it may be felt to strike against the end of the tube. It is then moved about gently, no force being used, until it drops into the opening of the tube : the blades should then be separated and firmly held while the instrument and the tube are being withdrawn, especial care being observed not to MEMBRANOUS CROUP. 421 Telax the pressure just as the tube is being turned out of the pharynx, for, if this is done, the instrument will slip, and the tube may either fall back into the larynx or be swallowed. It is well to have at hand a pair of forceps for the purpose of seizing the tube in case the instrument should slip at this stage of its withdrawal. Special care should be taken that no pressure is made upon the head of the tube in attempting to introduce the extractor, for the tube might possibly be pushed below the vocal cords, an accident which has happened in a few cases. After intubation, mercurials should be given freely for twenty-four or forty- eight hours, as already advised, and care should be taken that when the patient takes fluid none of it passes into the trachea, an accident liable to set up pneumonia, and one which is probably responsible for many of the deaths which occurred in the early days of intubation. When fluid of any kind is taken while the child is in a sitting position, a cough almost immediately follows, indicating that some of it has passed into the air passages. To avoid this, the most effec- tive plan is that recommended by Frank Gary, of Chicago, and in- troduced by "Wm. E. Casselberry, which consists of placing the pa- tient supine with the head much lower than the body, and feeding it from a nursing-bottle or through a tube. In this position fluid can- not run into the trachea, but will be forced up the oesophagus into the stomach. Soft solids may be given with the child in any position, and some children will speedily learn to swallow even fluids in the erect position; but the friends must be cautioned not to try this experiment. The child may suck small pieces of ice if it wishes, to quench thirst, or it may be given ten or fifteen drops of water without danger, even in the erect posture, but the safer way is the better. Occasionally on in- troducing the tube some portion of the false membrane is forced below it in the trachea, and suffocation becomes imminent. If this occurs, the tube should be at once withdrawn, when it usually either brings the membrane with it or the latter will be speedily coughed out. If this should not occur, tracheotomy should be done at once. Because of the liability to this accident, the operator should always have his tracheotomy instruments at hand when performing intubation. I consider the opera- tion of intubation preferable to tracheotomy in croup occurring in chil- dren under five years of age, and in those older than this it will usually be satisfactory; but there are, all told, many cases among these older patients, especially in diphtheritic laryngitis, where tracheotomy would be advisable. Tracheotomy is so thoroughly described in all works on general sur- gery that I need only mention the essential points as they have im- pressed themselves upon me. The instruments which are liable to be needed are: a sharp pointed bistoury, a scalpel the handle of which should be flat and thin so that it may be used in tearing through the connective tissue, a blunt pointed scalpel which may be used in enlarg- 422 DISEASES OF THE LARYNX. ing the opening in the trachea, three tenacula, a strong grooved director, an aneurism needle, several artery forceps and sponge holders, several large curved needles, and a suitable double tracheotomy canula, which should have no fenestra in it, for such an opening favors the forma- tion of granulation tissue at the upper end of the incision in the trachea, and is not needed. Two retractors are also needed for holding apart the edges of the wound, and I like very much a pair of rat-toothed artery forceps for taking up and tearing through the connective tissue. The patient should be placed upon a table before a good light, and, when anaesthetized, a rolling pin wrapped about with a towel (or some other firm roll) should be placed under the shoulders and neck, in order to throw the head backward and raise into j^'ominence the anterior superior tracheal region, and give a good field for the operation. Ether or chloroform may be used as a general anaesthetic for this operation; but the latter is generally preferred especially for children. In adults the parts may be sufficiently anaesthetized by the hypodermic injection of a few drops of a four per cent solution of cocaine along the line of incision three or four minutes before the operation (Form. 140). The operator stands at the patient's right, with his right hand toward the patient as he faces the head, the patient being between him and the light. The first cut is made by pinching up a transverse fold of the skin over the trachea, transfixing it with the sharp pointed bistoury and cutting out so as to make an incision about two inches in length, ex- tending from a little above the inter-clavicular notch to the cricoid car- tilage. By this the superficial fascia and adipose tissue are exposed, which should be worked through with the back of the scalpel or with the aid of the rat-toothed forceps and grooved director, accompanied by as little cutting as possible. ^Te then come down iipon the dense fascia covering the muscles and important blood vessels. At this stage of the operation I have derived great benefit from the rat-toothed forceps, with which I grasp the fascia and twist out a small piece, thus making a hole into which the director can be inserted. With the director, and handle of the scalpel, the fascia can mostly be torn through, but sometimes portions of it will have to be cut upon the grooved director, in doing which great care should be taken not to incise a blood vessel which it may be difficult to detect when stretched over the director. Thus working through the fascia we come upon the muscles and engorged blood vessels, which must be separated, by the handle of the scalpel, the director, and the finger, and pushed aside, where the assistant should hold them by means of the retractors. A thin layer of fascia covering the trachea is thus exposed; this should be carefully divided with the back of the scalpel before the windpipe is opened. During the operation blood should be carefully mopped away, and if veins or arteries are accidentally cut they should be caught by the artery forceps and turned aside. In working our way through the soft MEMBRANOUS CROUP. 423 tissues down to the trachea, we come upon the isthmus of the thyroid,, sometimes found considerably enlarged. This may be crowded out of the way upward or downward, in either direction that is most conven- ient, though upward is usually best. Sometimes it is so much in the way that it is necessary to pass a double ligature, tie upon each side, and cut between. The ligature may be easily passed with the aneurism needle. If we succeed in reaching the trachea without much bleeding, it will be seen as a round, yellowish tube at the bottom of the wound, and may also be readily felt by the finger. About this time the patient is liable to cease breathing, apparently from the effect of the atmosphere on the pneumogastric nerves, and it frequently becomes necessary to complete the operation at once. However, if time is allowed, the wound should be sponged out and all bleeding checked before the trachea is opened. From the efforts at respiration, the trachea often moves up and down convulsively, and it must be seized and held firmly before an incision can be made. The best way to accomplish this is to pass a tenaculum just below the cricoid cartilage, or first ring of the trachea, and draw it upward and forward. The point of a scalpel should then be passed between the rings of the trachea at the lower portion of the wound, and a cut made upward, dividing three or four rings. I prefer to divide the third, fourth, and fifth rings of the trachea rather than to make either the high or the very low operation, as the high incision comes too near the larynx, and the very low is more difficult because of the deep situation of the trachea. Care should be taken that the point of the scalpel does not pass far enough through to injure the posterior wall of the trachea. As soon as the cut has been made, air will be heard hissing in and out of the trachea, and the knife should be turned sideways to separate the edges, and held a few seconds until the patient obtains a little air; but as soon as possible the cut edges of the trachea should be caught with tenacula and the wound drawn open. The patient then usually has a paroxysm of coughing that throws out blood, mucus, and false membrane, which should be quickly wiped off so as not to be drawn back into the opening. As soon as the patient becomes quiet, the large bent needles, which have been previously threaded with strong ligatures, are passed, one through each side of the edges of the trachea, the needle is removed, and the threads are tied together so as to form two loops by which the trachea may be held open. These are often found exceedingly useful during the next two or three days, providing- the tube happens to be displaced, for they relieve us from the necessity of holding the trachea open, with tenacula or with special instruments devised for the purpose, during the reintroduction of the tube; further- more, if at any time the tube should be accidentally displaced, the nurse r by drawing upon these strings, may open the wound so that breathing can be readily carried on. The tracheal tube, which should always be as large as can be conveniently worn by the patient, never less than 424 DISEASES OF THE LARYNX. a quarter of an inch in diameter, may now be introduced, it having first l>een dipped into warm water to bring it to the temperature of the body. This is a part of the operation frequently found difficult, apparently either from the surgeon's having imperfect means of holding the tra- cheal wound open, or from having only cut two rings where an opening through three is necessary. I have never experienced any difficulty in introducing the tube, a good fortune which I attribute to the use of the ligatures for holding the cut edges of the trachea apart and to making a sufficiently large opening. Before the operation is begun, tapes about eighteen inches in length should be sewed to the tracheal tube; when it has been placed in the trachea, these are passed about the neck and tied upon one side so as to hold it firmly in place. In case the wound is too small, it will not do to try to crowd the tube into the trachea, a procedure very apt to force it into the cellular tissue in front; but the soft tissues should be drawn away from the lower end of the wound and another ring cut, if necessary, to introduce the tube easily. A probe-pointed scalpel is generally used for enlarging the wound and may be employed for making the main cut after a slight puncture with an ordinary scalpel; in this way all danger of cutting the pos- terior wall and opening through into the oesophagus may be avoided. If the false membrane has extended below the opening, before the tube is inserted an effort should be made to remove all of it that is possible with Trousseau's tracheal forceps, or by passing down into the trachea a feather', or with the forceps a strip of linen one end of which is held by the hand, thus causing the patient to cough and remove the blood and false membrane. The tube having been inserted, the wound above and below it may be drawn together by one or two stitches and covered with a strip of antiseptic gauze drawn under the rim of the collar of the tube to prevent it from irritating the neck. A strij) of cloth may then be tied loosely about the neck and a large piece of gauze folded over it and allowed to fall down over the opening of the tube, thus pre« venting the patient from coughing out blood or mucus upon the bed- ding and attendants. After the operation is completed, the inner of the two tracheal tubes should be removed and carefully cleaned every half-hour, for the first twenty four hours, in order to prevent it from filling with inspissated mucus. Subsequently it may be cleaned less frequently, but it should always be borne in mind that it must be. kept free. After the operation, the temperature of the room should be kept at about 80° F. and the air moist. If the secretions show a tendency to dry, the patient may inhale from time to time steam impregnated with lime, soda, or the various other remedies already mentioned. In- ternal administration of medicine calculated to prevent extension of the false membrane should be continued as before. The patients, even when the operation has been done for diphtheria, usually do exceedingly MEMBRANOUS CROUP. 425 well for twenty-four or thirty-six hours, and breathe so easily and rest so comfortably that the friends think a cure has been effected; but at the end of this time the development of bronchitis or pneumonia or the extension of false membrane will often evince itself to the physician by increased fever, quickened respiration, and renewed signs of imperfect aeration of the blood. When these symptoms occur, the disease usually goes on from bad to worse until death comes at the end of fifty to seventy hours after the operation. If the case progresses favorably, it will usually be found in from five to eight days that the patient breathes easily "with the tube stopped by the finger, or a cork which should be worn some hours before an attempt is made to remove the canula. When this is removed, the sides of the wound, as a rule, readily fall to- gether, and within a few hours no air will pass through the opening. If the wound does not speedily close, all that is usually necessary is to touch it a few times with the solid silver nitrate. Sometimes, after the tracheal canula has been worn for months, it is found on attempting its removal that the patient cannot breathe, by reason of spasm of the glottis or an obstruction from new growths at the upper part of the wound. If granulation tissue is found in the trachea, it must be removed before a cure can be effected, but to overcome the tendency to spasm, no method has yet been found so satisfactory as the introduction of an O'Dwyer tube, which will generally be coughed out, or may be removed within forty-eight hours, and may not be needed afterward.. When a tracheal canula has been worn long, it often becomes necessary, especially in a thin subject, to make a plastic operation in order to cover the tracheal wound. This may be best done by paring the edges of the tracheal wound, loosening up the soft coverings freely on each side, then drawing them forward and stitching the edges together. In performing tracheotomy, chloroform is preferable to ether as an anaesthetic, because of the profuse secretion excited by the latter, and it is probable that in these cases it is quite as safe. W'hen carbonic acid poisoning is pro- nounced, no anaesthetic is needed, but at other times anaesthesia is im- portant, not alone for prevention of pain, but to keep the patient quiet. In adults who are not timid, and in some children, local anaesthesia, quite sufficient, may be obtained by injecting under the skin along the line of incision a few drops of a weak solution of cocaine (Form. 140). Eapid Tracheotomy. — In extreme cases it sometimes becomes im- perative to open the trachea at once; for this purpose various instru- ments have been devised. Some surgeons recommend that the child be placed upon its face at the side of the table, the trachea steadied with the thumb and finger of the left hand, and the skin, fascia, muscles, blood vessels, and tracheal walls divided with a single cut. This proced- ure has also been recommended for ordinary cases in place of the care- ful dissection generally practised, but the danger of hemorrhage renders it extremely objectionable except in those very rare cases where not a *"26 DISEASES OF THE LARYNX. second can be lost, and an intubation set is not at hand. Hook-like traclieotomes consisting of blades that may be opened after the trachea has been perforated, and which will Mms cut a sufficiently large opening to introduce the tracheal tube, have also been recommended, but they do not meet with favor among surgeons. An ingenious trocar which enables the operator to leave the canula in the trachea has been devised, but the canula is too small, and I consider it a dangerous instrument, which is likely to cause the loss of valuable time, if not of the patient's life. By most experienced surgeons, tracheotomy is considered a very dangerous operation, because, with the greatest care, serious hemorrhage will sometimes be encountered, and unavoidable accidents may so delay the operation that breathing ceases before it is completed, and it may become necessary to open the trachea hastily before the superficial tis- sues have been cleared away. For the avoidance of hemorrhage, great care should be exercised in tearing instead of cutting through the super- ficial tissues, and if by accident a blood vessel is opened it should be caught immediately with artery forceps, and if large it should subse- quently be tied and the ligature cut short; if small, it may be twisted sufficiently to prevent hemorrhage. If during the operation the patient stops breathing, at least five or ten seconds may be safely consumed in opening the trachea, providing artificial respiration is then established ; therefore the surgeon should not be precipitate in his incision. In these cases the surgeon will sometimes be able, by keeping up artificial respi- ration, to restore a child apparently dead for fifteen or twenty minutes. There is danger from gradual oozing of blood into the tracheal wound after the tube has been introduced, but usually this is stopped by the introduction of a tracheal canula. Secondary hemorrhage some- times occurs; if it takes place, the canula must be removed and the bleeding vessels tied or twisted. The danger from the extension of the disease to the lower air passages, and the development of bronchitis or pneumonitis, cannot always be anticipated, but it is best guarded against by care to prevent the entrance of blood or other foreign substance into the air passages, by keeping the atmosphere of the room warm and moist and by the judicious administration of internal remedies. The tracheal canula is not infrequently coughed out; this is best prevented by having a long tube which will pass into the trachea three-quarters of an inch beyond the cut. Many patients have been lost because of secre- tions collecting and drying in the tube; this can only be obviated by carefully and frequently cleansing the inner tube. A tracheotomized patient must be left in the care of the best possible nurse, and every detail should be carefully watched by the physician until all danger is passed. The prognosis should always be guarded until convalescence is fully established. CHAPTER XXY. DISEASES OF THE LAEYNX.— Continued. PHLEGMONOUS LARYNGITIS. Synonyms. — Submucous laryngitis, diffuse abscess of the larynx, laryngitis phlegrnonosa, laryngitis submucosa purulenta, laryngitis sero-purulenta. Phlegmonous laryngitis is a rare affection, in which inflammation attacks the submucous tissues, causing suppuration and necrosis, with the formation of diffused or circumscribed abscesses which are generally located in the upper portion of the larynx at the base of the epiglottis, or in the aryteno-epiglottidean folds. The affection sometimes involves the ventricular bands, and rarely the vocal cords. Etiology.- — -The disease may either originate in the larynx or extend to it from the surrounding parts, especially from the pharynx, in which case it is nearly always due to blood poisoning. In many instances the inflammation begins in the cartilages or perichondrium, usually result- ing in such cases from typhoid fever or syphilis, or occasionally from other diseases. Symptomatology. — At first the patient often complains of a sensa- tion as of some foreign substance in the part, soon followed by actual pain, especially upon deglutition. The voice becomes weak or hoarse and may finally be lost, and, as the swelling advances, dyspnoea occurs, which in severe cases gradually increases, causing stridulous respiration, or orthopncea, cyanosis, and all the symptoms of strangulation. There are frequent violent efforts to clear the throat, but usually no cough. Dys- phagia is more or less prominent in proportion to the swelling of the epiglottis which may often be detected by palpation, but this should be practised carefully as there is danger of exciting suffocative spasm of the cords. Upon inspection, the parts are found deeply congested aud much swollen, and often the tracheal mucous membrane is involved. In some cases swelling and fluctuation are present. Diagnosis. — In adults this may be easy from the history of ante- cedent disease, with gradually increasing dyspnoea, and from the appear- ance of the parts on laryngoscopic examination. But in children when the larynx cannot be inspected there is some danger of confounding it with laryngismus stridulus, laryngeal polypus, retro-pharyngeal abscess, foreign bodies in the larynx, or diphtheritic laryngitis. We may exclude 428 DISEASES OF THE LARYNX. retro-pharyngeal abscess by inspecting the fauces and by lifting the larynx, which will relieve the dyspnoea in most cases of abscess of the pharynx, but not in phlegmonous laryngitis. A history of their entrance and absence of antecedent disease may readily distinguish foreign bodies. Compared with phlegmonous laryn- gitis, polypus develops much more slowly, and laryngismus stridulus much more cpiickly, and neither of them is attended by the symptoms of inflammation. Prognosis. — The disease usually runs a rapid course and terminates fatally in about seventy-five j:>er cent of the cases, from either suffoca- tion or exhaustion. Treatment. — Early in the disease the best remedies are leeches and warm applications to the neck, with steam inhalations, or, instead of these, constant sucking of bits of ice. As soon as there is oedema or a collection of pus, scarification should be employed. Quinine and strych- nine in medium doses and potassium chlorate in full doses are indicated, together with nourishing diet and the free use of stimulants. Remedies and food should be given by enema if the patient cannot swallow. Urgent dyspnoea demands intubation or tracheotomy, the latter gener- ally being most efficient in this disease. ERYSIPELATOUS LARYNGITIS. Erysipelatous laryngitis is an inflammation of the larynx, usually associated with erysipelas of the tongue and palate. Most cases are either endemic or epidemic. It sometimes results from metastasis of cutaneous erysipelas, or from its extension along the mucous membrane of the nose, mouth, or ear. The inflammation soon terminates in ex- tensive suppuration and sloughing of the intra-laryngeal or perilaryn- geal tissues. Etiology. — The pharynx is usually first involved, the disease sub- sequently extending into the larynx. Symptomatology. — The symptoms are fever, local pain and swell- ing, with difficulty in speaking, dyspnoea, and great prostration. In severe cases these symptoms are usually succeeded by vomiting and finally by delirium. Early in the disease the laryngoscopic appearances are simply those of laryngitis; subsecjuently sloughs or extensive ulcers will be observed. Diagnosis. — The diagnosis must be bused upon the symptoms and the evidence of inflammation of the same type affecting the skin or the mucous membrane of the mouth. Prognosis. — The disease usually runs a rapid course, terminating fatally in the majority of cases. According to Cornil {Archives generales de Medicine, Paris, 1S62) about one-fourth of those cases die in which the inflammation first begins in the larynx, whereas of those in which ABSCESS OF THE LARYNX. 429 the inflammation extends from the pharynx to the larynx about three- fourths die. This result is apparently due to an increase in the consti- tutional disease marked by extension of the inflammation from the pharynx downward. Treatment. — The general treatment should be the same as for ery- sipelas of other localities. Quinine and tincture of iron are most useful medicines. Xourishing diet is essential, and stimulants are indicated early. In view of the more recent bacteriological knowledge concern- ing the materies morbi of erysipelas, agents opposing the development of micro-organisms are indicated; therefore a saturated boric acid spray, and salol and naphthalin internally, are recommended. Shoe- maker, in his late work, praises pilocarpine highly, regarding it as almost a specific in the cutaneous erysipelas. In hopes of aborting the attack, ice may be sucked constantly for the first few hours. Gibb reports a case in which applications of a strong solution of silver nitrate, gr. lxxx. ad 3 i., every six hours cut short the disease. Steam inhalations and anodynes will be useful in relieving pain. Tracheotomy will naturally suggest itself, but it is of doubtful value. Intubation mav be tried. ABSCESS OF THE LARYZnX. Abscess of the larynx consists of a circumscribed collection of pus in the soft tissues. It is very rarely a primary affection, but occurs not infrequently as the result of inflammation of the cartilages or peri- I Fig. 117. — Perichondritis and Abscess of T,at?vvt, chondrium following typhoid fever or pyaemia, or dependent upon tuberculosis, syphilis, or local injuries. Abscesses occurring as the re- sult of typhoid fever are generally found during the second or third week of the fever. The smaller of these appear just beneath the mucous membrane, and the larger ones beneath the perichondrium. Symptomatology. — The symptoms of abscess of the larynx are: pain which is aggravated by pressure, cough, dysphonia or aphonia, difficulty in swallowing, and dyspnoea. Upon laryngoscopic examina- tion, the abscess appears as a glistening swelling, red at its base, and either red or yellowish at its apex. It is usually located on the inner 430 DISEASES OF THE LARYNX. surface of the larynx, either at the base of the epiglottis, upon the aryt- enoid or supra-arytenoid cartilages, or in the aryteno-epiglottidean folds. Diagnosis. — In children the disease may be mistaken for croup or retro-pharyngeal abscess, and the diagnosis is sometimes attended with great difficulty. In adults the luryngoscopic appearances are character- istic if the abscess points; otherwise it is not always possible to distin- guish it from simple inflammatory swelling. It is distinguished from croup by the history, pain, and difficulty in deglutition; from retro-pliaryngeal abscess by inspection and palpation of the pharynx; from acute catarrhal inflammation by the history, local- ized inflammation and swelling; from oedema by the history, symptoms, and signs; oedema follows renal or cardiac disease instead of inflamma- tion of the cartilages and perichondrium, and it is characterized by a pale, translucent color, and the absence of pain and dysphagia. Prognosis. — The affection usually terminates in from three days to two weeks and if seen in time and properly treated, most cases recover. Fig. 118.— Infra-glottic Abscess of Larynx, Fig. 119.— The Same as Fig. 118, Twelve Hours due to Syphilis. Great dyspnoea. after Opening of Abscess. Sometimes fistulous openings remain after opening of the abscess into the oesophagus or externally; and in the former case liquids or soft food are apt to pass into the larynx during deglutition, causing dangerous spasms or pneumonia. In some cases subcutaneous emphysema has resulted. When the affection proves fatal, death may occur from suffo- cation or the exhaustion attending prolonged suppuration. Treatment. — When the abscess can be reached, the pus should be evacuated by means of the laryngeal lancet. When this cannot be ac- complished, the patient must be carefully watched, and if dyspnoea threatens, tracheotomy must be performed. Subsequently, with the trachea completely stopped by a large canula, renewed efforts should be made to open the abscess. (EDEMA OF THE LARYNX. Synonyms. — (Edematous laryngitis, sub-mucous laryngitis, supra- glottic or infra-glottic dropsy, oedema glottidis. (Edema of the larynx consists of a serous or sero-sanguinolent infil- tration into the areolar tissue beneath the mucous membrane, which, owing to the formation of the parts, at once diminishes the size of the (EDEMA OF THE LARYNX. 431 air tube, causing dyspnoea, and unless the process is checked or promptly relieved, speedily inducing suffocation. When the infiltration is of a sero-purulent character, the affection would more properly come under the head of phlegmonous laryngitis. A spasmodic element frequently coexists with the mechanical inter- ference to respiration, and thus adds greatly to the gravity of the case. Etiology. — The trouble may result from simple acute catarrhal in- flammation, but most frequently from tuberculosis, syphilis, or Bright's disease. It is sometimes induced by exposure to impure atmosphere, sewer gas, and the like, or by inhalation of extremely cold air; it may follow injuries from foreign bodies and operative procedures or scalds and burns. It occasionally follows small-pox, typhoid fever, and scarla- tina, or results from submucous hemorrhage, from erysipelas, or from chronic inflammation of the cervical tissues, and sometimes from the pressure of aneurisms of the larger arteries. Symptomatology. — There is usually a history of extreme fatigue, exposure to excessive heat or cold, an injury to the larynx, or of some of the diseases already mentioned. The acute attack not infrequently comes on suddenly during the night, the patient awaking with a sense of discomfort in the throat, or choking. The symptoms increase in se- verity with great rapidity, giving rise to frequent suffocative attacks, with intervals of less impeded respiration. These intervals grow shorter and shorter until relief is obtained or death occurs. When oedema fol- lows chronic diseases, the progress of the case is more gradual. At first, symptoms due to slight obstruction present themselves. These gradu- ally increase in severity, until finally a suffocative paroxysm occurs, which usually subsides after a short time, to recur after a few hours and again and again at shorter intervals, until it proves fatal. The symp- toms referable to the larynx are slight local tenderness, with a sense of dryness, heat, and constriction in the throat, hoarseness, aphonia, dysp- noea with labored and sometimes stridulous respiration, and more or less difficulty in swallowing. The inspiratory act is chiefly obstructed, expiration being comparatively free; this is an important point in the diagnosis. Upon inspection, the fauces are sometimes, found to be oedematous; and by the aid of the laryngoscope the epiglottis, or aryteno- epiglottidean folds, or both, are seen to be greatly swollen, and occasion- ally the ventricular bands or vocal cords are also affected. The affected parts are translucent, of a pinkish or yellowish color, and closely resem- ble, in their general appearance, an oedematous eyelid or prepuce. The epiglottis has the appearance of a roll or ridge, and the aryteno-epiglot- tidean folds are globular or irregular in form, and usually project upon both sides; though occasionally only one side is involved, and at other times the swelling is greater on one side than on the other. When oedema results from catarrhal inflammation, the vocal cords are always 432 DISEASES <>F THE LARYNX. of a bright red color, and the other parts even more congested, some- times showing distended veins upon the surface. When resulting from renal, hepatic, or cardiac disease, the membrane is pale and translucent. In hemorrhagic effusion there is localized swelling of a deep red color. When occurring during scarlet fever, the mucous membrane is apt to be congested in patches of varying shades. In typhus fever the (Edema- tous larynx is usually of a dusky red hue. When inflammation has been excited by irritant poisons, excoriations of the epiglottis can frequently be detected; when caused by scalds, patches of thin false membrane are observed: and when by other traumatic causes intense congestion be- ginning at the seat of injury is generally present. Prognosis. — "Most cases terminate within five or ten days, but some are more prolonged. About fifty per cent of all these cases prove fatal. Fm. liO. — (Edema of Larynx (Cohen). (Edema caused by pharyngeal inflammation usually terminates favora- bly, but when resulting from inflammation of the cervical tissues it is generally fatal. In oedema of the larynx resulting from syphilis, the prognosis is fairly favorable if proper treatment is adopted. Tuber- cular cases ultimately end in death, and those due to blood poisoning are nearly always fatal. Treatment. — Prompt and complete relief is sometimes given by the administration of pilocarpine hydrochlorate which may be used hypo- dermically in doses of gr. £. It will cause profuse salivation or dia- phoresis, or both, in about twenty minutes. Larger doses cause a pro- fuse and prostrating diaphoresis. Its depressant effect upon the cardiac muscle should always be borne in mind: and when oedema of the larynx attends heart disease, or when the heart is weakened from other causes, this remedy should be exhibited with much care. It often causes vomit- ing after two or three hours, but this action is also favorable in (edema of the larynx. If we fail with the remedy, scarification of the larynx is the best treatment: when this does not afford relief, tracheotomy or in- tubation must be performi CHONDRITIS AND PERICHONDRITIS. 433 Chronic 03d ema of the larynx should be treated by scarification, fol- lowed by the stronger stimulating or astringent pigments, as zinc chlor- ide or silver nitrate. When the oedema is located below the vocal cords, very little can be accomplished by topical applications. Schlatter's method of dilating the larynx by means of hard rubber tubes of gradu- ally increasing size, which are introduced every day or second day, and kept in positiou several seconds or as much longer as the patient can tolerate them, has been successfully employed in cases of this kind; but from the limited experience of the past few years, dilatation by O'Dwyer's laryngeal tubes seems the most satisfactory for the majority of cases. If dyspnoea cannot be relieved by these methods tracheotomy must be performed. CHONDRITIS AND PERICHONDRITIS OF THE LARYNGEAL CARTILAGES. An inflammation of the laryngeal cartilages or perichondrium seldom occurs as a primary affection. The acute disease is seldom found except in persons of advanced life. The inflammation soon results in more or less caries of the cartilages and thickening of the remaining portions. In severe cases the whole cartilage may be destroyed and thrown off. Etiology. — The disease, sometimes primary, is usually the result of tuberculosis, syphilis, typhoid fever, or of trauma. It has been produced by injury done in laryngeal operations, by external wounds, and in rare instances when the cricoid cartilage is ossified, by introduction of the oesophageal sound. Symptomatology. — Excepting in traumatic cases, the patient usu- ally first complains of tenderness and pain in the larynx, soon followed by hoarseness and more or less dyspnoea and difficulty in swallowing. The crico-arytenoid articulations are early affected, and as a result there is partial or complete immobility of the vocal cords. Finally, especially after typhoid fever, the consolidation and contraction of the inflamma- tory lymph may cause permanent anchylosis of this joint. Occasionally a grating or crepitating sensation may be detected on palpation. Until an abscess forms, laryngoscopic examination will often reveal nothing except slight hyperaemia, with very trifling swelling of the parts. inflammation of the thyroid cartilage causes some tumefaction of the ventricular bands and of the arytenoid or crico-arytenoid articulations, impairment of the movement of the vocal cords and occasionally subglottic swelling. Inflammation of the cricoid cartilage causes swelling below the vocal cords, which may not be detected at first, but as the disease goes on to suppuration the tumefaction becomes more prominent and sometimes a yellowish spot may be seen as the abscess is about to open. Abscesses of the arytenoids present above and those of the cricoid just below the glottis. Abscesses of the thyroid cartilage usually point below 28 4:J4: DISEASES OF THE LARYNX. the glottis, but sometimes externally. When the affection is secondary, ulceration of the mucous membrane may sometimes be first detected, extension of which finally causes inflammation of the cartilage or peri- chondrium. Diagnosis. — Primary perichondritis may be suspected when the pa- tient complains of dull aching or boring pain, and laryngoscopy exam- ination reveals enlargement of some of the cartilages without much congestion of the parts. Secondary perichondritis may escape notice owing to swelling of the parts. Late in the affection abscesses are formed, the movements of the vocal cords become impaired, distortion of the larynx may occur without the presence of cicatricial tissue, and often a fetid discharge takes place. From a consideration of these con- ditions and the history, the affection can generally be easily distin- guished from other laryngeal diseases. Prognosis. — The majority of cases prove fatal. Cases have occurred, however, in which the whole arytenoid or even cricoid cartilages have been thrown off, and recovery has taken place. Usually gradual exten- sion of the disease produces progressive dyspnoea, or the rapid formation of an abscess ma}' cause sudden suffocation unless tracheotomy is per- formed. When an abscess ruptures, pus may escape externally or into the oesophagus or larynx, and the continued discharge may finally ex- haust the patient's strength. Tracheotomy may be performed to avert suffocation; but if recovery takes place, it is probable that the patient will have to wear the tracheal canula during the remainder of life. Even after tracheotomy there are but few who live longer than twelve or eighteen months, but those in whom the disease is not of specific or tubercular origin may live many years. Treatment. — When the disease is slowly progressing, the patient's general condition demands our first attention. In specific cases the iodides in large doses are of the most importance, and in all cases tonics and nutritious diet are usually necessary. Tracheotomy must be per- formed when dyspnoea becomes marked, and the lower operation will be most likely to prolong life. If the patient recovers, subsequent attempts at dilatation of the larynx, either by Schrotter's dilators or by O'Dwyer's tubes, should be made, and will sometimes be successful. A fistulous communication between the larynx and the oesophagus demands feeding by the oesophageal tube. Occasionally nutritive enemata must be em- ployed. TUBERCULAR LARYNGITIS. Synonyms. — Laryngeal phthisis, throat consumption, helcosis laryn- gis, laryngeal tuberculosis. Tubercular laryngitis is a chronic affection of the throat attended by dyspnoea, dysphagia, emaciation, and hectic fever. It is characterized by moderate congestion and swelling of various portions of the larynx TUBERCULAR LARYNGITIS. 435 followed by ulceration and severe pain on attempts at swallowing, and usually by a peculiar pyriform swelling of one or both arytenoids or ary-epiglottic folds; which is often pathognomonic. Anatomical and Pathological Chaeacteristics. — The charac- teristics vary considerably in different cases and at different times in the same case. Early in the attack there is sometimes simple conges- tion, but more frequently anasmia. Ere long in most cases swelling of Fig. 121.— Tubercular Laryngitis. Fig. 122. — Tubercular Laryngitis, showing Pyriform Swelling of Left Ary-Epiglottic Fold and Paresis of Left Vocal Cord. the soft tissues over the arytenoids from tubercular infiltration gives rise to the pyriform appearance. This swelling may occur on one or both sides, and the epiglottis may also be much swollen or, in rare in- stances, it may be thickened while the arytenoids remain normal. Shortly afterward, at about the time this swelling takes place, ulcers usually occur on the cords or the ventricular bands, and they may subsequently be found in the upper portions of the larynx. Ulcera- tion in this disease nearly always begins in the lower part of the TTMnW^THTTlUmT,,^ Fig. 123. — Tubercular Laryngitis, showing Pyriform Swelling of Both Ary-Epiglottic Folds and Thickening of Epiglottis. Fig. 124.— Tubercular Laryngitis. larynx, subsequently extending upward to involve the arytenoids, the posterior commissure and the epiglottis. The ulcers are superficial and at first small; later these may coalesce, forming large, irregular patches, and they may attain considerable depth when the cartilages are involved. Occasionally the tubercular deposit may be detected before ulceration has taken place ; these macroscopic deposits consist of small, yellowish or grayish granules not larger than a millet seed or a pin's head. Not more than two or three of these are likely to be detected, but they are sometimes found in groups. It is probable that in most cases these immediately precede the ulceration. Warty growths are sometimes found about the edges of the ulcer or upon its surface; these are soft, 436 DISEASES OF THE LARYNX easily broken down, and have somewhat the appearance of papillo- mata (Figs. 125, 12G). Bosworth describes as one of the phases of the the disease an acute follicular inflammation of the epiglottis which may extend to other portions of the larynx. This is characterized by con- gestion and swelling of the mucous membrane, with numerous pearly white or gray granulations upon its surface, which at first appear like the follicles in follicular tonsillitis, except that they are smaller. After a short time they rupture, coalesce, and form superficial ulcers. In this way the entire epiglottis may become implicated. In such cases the patient is almost unable to swallow on account of the severe pain, and as a result he declines rapidly, and may die within two or three weeks. Tubercular deposit and ulceration frequently affect the perichondrium or the cartilages. If the latter are affected, necrosis and extensive sup- puration are liable to ensue. Paresis of the laryngeal muscles is common, due to atrophy of the fibres or pressure upon the nerve trunks. This 1 -\* ^■' ; Fig. 125.— Incipient Tcbercular Laryngitis. Fig. 126.— Tubercular Laryngitis. Granu- lating tissue resembling papillary tumor. may occur early in the disease when it is indicated only by weakness of the voice and loss of tonicity of the vocal cords. Etiology. — The causes of this disease are the same as those of pul- monary tuberculosis, which generally precedes the throat affection. Symptomatology. — The patient usually complains of first having taken a cold, which lasted for some time and was followed by a hacking- cough, that may have continued for several months, or in exceptional cases for two or three years. As soon as the disease has made much progress, nutrition is disturbed, and there is gradual emaciation with fever and night sweats. The patient gradually loses strength, the voice is weak, and later when ulceration takes place, and sometimes even before this, deglutition becomes difficult, and even phonation may be painful. The pain on swallowing is liable to grow steadily worse, and finally to become exceedingly distressing. Indeed, I know of no disease in which the patient suffers more than in the later stage of laryngeal tuberculosis, though in the beginning he may notice only pricking or tickling sensations in the larynx. "When the disease is fairly established, the patient has the appearance of one with pulmonary tuberculosis. The skin is sallow, hot, and dry or bathed with profuse sweat, fever of three or four degrees occurs at some part of TUBERCULAR LARYNGITIS. 437 the da}*, and the pulse, which is soft and small, ranges from 100° to 120° F., or higher. Hoarseness is present in about nine-tenths of the cases, and in some there is complete aphonia. Most cases soon exhibit more or less dyspnoea, especially upon exertion, clue partly to weakness and partly to obstructed respiration. It is said that laryngeal obstruction occurs in about two and two-tenths per cent of all cases of tuberculosis and becomes so grave as to demand tracheotomy in nearly a third of these. Cough may not annoy the patient much, but usually it is very troublesome. The amount of expectoration is not very great unless the bronchial tubes or pulmonary parenchyma are also involved, but in the latter part of the disease the thick secretions which cover the mucous membrane of the larynx are very difficult to remove and cause the patient much distress. The tongue is coated and often, as in pulmo- nary tuberculosis, shows smooth, red, oval patches from which the epithe- lium has been entirely removed. The difficulty in swallowing, varying much in different patients, depends upon the extent and location of Fig. 127.— Tubercular Laryngitis. Fig. 128. — Tubercular Laryngitis. the ulceration; in some cases there may be considerable ulceration with- out difficulty in swallowing; in others a small ulcer will give great pain and prevent taking of food. "When the epiglottis or ary-epiglottic folds are so swollen that the orifice of the larynx cannot be properly closed, fluids find their way into the trachea and excite spasms of cough attended by such distress that the patient prefers to suffer from thirst and hunger rather than to swal- low. Anorexia is generally but not always present. Upon examination of the parts very early, there is sometimes simple congestion, but in the majority of cases the mucous membrane is anaemic. Where congestion is observed first, the progress of the case is likely to be slow, but cases where anaemia is pronounced generally advance rapidly. The peculiar pyriform swelling (Figs. 121, 122, 123) of the ary-epiglottic folds is present in a large number of cases; it may be confined to one side or may be found on both, and the epiglottis may or may not be involved. Ulceration of the cords (Figs. 127, 128) or ventricular bands (Figs. 129, 130) is common early in the disease. The vocal cords act slug- gishly (Fig. 131) in many cases even before swelling or ulceration, and their movements afterward are often very much restricted. Diagnosis. — The affection is to be distinguished from anaemia, 438 DISEASES OF THE LARYNX. oedema of the larynx, catarrhal laryngitis, and from syphilis. The essential points in the diagnosis are the pain, the peculiar swelling, the character of the ulceration, and the physical signs which may be found by examining the lungs. Tubercular laryngitis is distinguished from chronic catarrhal laryn- gitis by the history and by the physical appearance. In simple chronic laryngitis there is usually diffused congestion with but little swelling. Fig. 139.— Tubercular Laryngitis. Ulceration of ventricular bands. Fig. 130. — Tubercular Laryngitis. Ulceration of ventricular bands and vocal cords. In the tubercular disease, while there may be congestion, more com- monly the parts are anaemic, and sooner or later there is the peculiar pyriform swelling (Figs. 121, 122, 123). In the early stage of laryn- geal tuberculosis when attended by congestion instead of anaemia, the appearance of the parts may not enable us to make a diagnosis; then we must rely upon the pulmonary signs and the discovery of tuber- cle bacilli in the sputum. Ulceration is uncommon in catarrhal, but is the rule in tubercular, laryngitis; yet there are rare cases of laryngitis with ulceration, in which it is difficult to determine whether the pa- tient has tuberculosis or not; and in such instances, should we find but Fig. 131.— Tubercular Laryngitis. Paresis of muscles preceding redema and ulceration. little change in the physical signs over the apex of one lung, it will be especially difficult to determine whether we have an instance of laryn- geal tuberculosis or one of catarrhal laryngitis. I recall two or three obstinate laryngeal cases in which the condition of the apex of one lung aroused my suspicions, though I could not be certain of a deposit, and in whom the ulceration finally completely healed, and the patients remained well for a number of years; apparently indicating that there was no pulmonary tuberculosis. If ulceration occur upon the vocal TUBERCULAR LARYNGITIS. 439 cords in front of the vocal process, or upon the ventricular bands, we may generally safely conclude that it is not a case of catarrhal laryngitis; and if the ulceration extends to the upper part of the larynx (Fig. 132), and there is a peculiar pallid or light pink appearance of the tissues, with more or less swelling, Ave are then certain of our diagnosis. The disease can be differentiated from chronic catarrhal laryngitis by the following characteristics : Laryngeal tuberculosis. Chronic catarrhal laryngitis. Usually very slight congestion. Congestion of membrane. Usually Parts generally pale, change of contour normal contour of parts. Rarely ul- by pyriform swelling or ulceration. ceration. No pain, no fever. Pain, he,ctic, rapid pulse, sallow skin. Emaciation. No emaciation. Aphonia and dysphagia. Hoarseness, but no dysphagia. Sometimes anorexia No anorexia. Short duration. Long duration. Usually tubercles elsewhere. No pulmonary complication. The essential points in oedema of the larynx are : semi-transparency of the swollen tissues, and the absence of ulceration and pain. The distinguishing features are indicated in the following table : Laryngeal tuberculosis. (Edema of the larynx. May be slight congestion of parts. Usually no congestion of parts. Early change of contour slight. Great change of contour by marked swelling, with parts pale and semi- transparent. Pain, fever. Absence of pain and fever. Emaciation. No emaciation. Respiration commonly normal. Labored respiration. Long duration. Short duration. We may be able to distinguish laryngeal tuberculosis from syphilis of the larynx, in the first place, by the history, though it is frequently difficult to obtain this satisfactorily. The majority of people who have had syphilis flatly deny it, no matter how much it affects the condition under which they are laboring. In syphilis the larynx is occasionally involved early but usually not until the tertiary stage; although ulceration may occur at the upper part of the larynx in the secondary stage. The margin of a syphilitic ulcer is sharply defined and has an areola of reddened and slightly thickened tissue about it. On the other hand, the tubercular ulcer has a grayish, worm eaten appearance, the border is not regular and well defined, but here and there runs into the sound tissue, and commonly numerous small ulcers are visible about the larger one. In syphilis, ulceration is apt to occur first upon the epiglottis; in tuber- culosis, on the vocal cords or ventricular bands. This is not an absolute rule, but holds in a large number of cases. The ulcer in tertiary syph- DISEASES OF THE LARYNJT. ilis is deep, and its sharply cut edge is frequently undermined; in tuber- culosis the ulcer is shallow except in rare cases where the process has existed for a long time, but these have not the sharp cut, undermined edges of the syphilitic ulcer. Very often in the latter affection cica- trices may be seen in the upper part of the pharynx or about the fauces and on the soft palate, significant of former ulceration. In the syph- ilitic affection the pain is not nearly as marked as in the tubercular; many cases of jn'onounced syphilitic ulceration of the throat occur in which there is no pain, and in others it is slight: while the tubercular ulcer is attended by severe pain, especially on attempts at deglutition. There are, unfortunately, not a few cases in which the tubercular infec- tion has occurred in syphilitic subjects (Fig. 133); giving rise to an atypic ulceration. General evidence of tuberculosis and marked laryn- geal pain may be associated with an ulcer of the syphilitic type, and in such cases particularly, the results of treatment must often clear up the \ Fig. 132.— Tcbercclar Laryngitis. Superfi- Fig. 133.— Ti-bercu-ar L»Ri>gitis Occurring cial ulcers and fungus granulations. in Patient with Specific History. Ulceration continued tor eighteen months. doubtful points of a diagnosis. If upon the free administration of antisyphilitic remedies such as potassium or sodium iodide the ulcera- tion begins to heal and the patient to improve, we may be at once sat- isfied of the character of the disease. There are some cases, however, in which there is undoubted evidence of syphilis, where the patient will not improve quickly, but only recovers after prolonged use of antisyph- ilitic remedies; therefore, exceptionally, a diagnosis cannot be made un- til the course of the disease has been watched for some weeks. Between laryngeal tuberculosis and syphilitic laryngitis the following are the chief points of difference : Laryngeal tuberculosis. Syphilitic laryngitis. Syphilitic history. Generally in adults. Sometimes seen in children, if hered- itary. Ulceration usually superficial, with Ulcer sharp cut with indurated and grayish worm-eaten appearance ; usu- congested border, sometimes under- ally steadily progresses for three or mined. May attain a large size within four months to a fatal issue. two or three weeks, but is apt to pro- gress but slowly afterward or may be checked or completely healed. Comparatively short duration. Long duration. TUBERCULAR LARYNGITIS. 441 Prognosis. — Tubercular laryngitis usually runs a rapid course, many cases terminating within six months. It is claimed that sixty-six per cent die within from six to twenty-four months. In most instances the earlier stages run on gradually, and it is some time before ulceration takes place; when this occurs and is accompanied by difficulty in swal- lowing, we may expect the disease to run a rapid course, mainly because of deficient nutriment. When extensive ulceration of the larynx is found, we may safely predict that the patient will not live more than eight or twelve weeks. A few cases die within six Aveeks of the begin- ning of the disease. It is not now the belief, as formerly, that all of these cases are fatal, for there is ample proof that a few recover. We nearly al- ways find accompanying pulmonary tuberculosis; and it is probably safe to say that where laryngeal tuberculosis is so complicated, nine-tenths of the patients die. Finally, while the local reparative process depends largely upon the ability to better the general nutrition, the hope of cure, as well suggested by Jarvis, should be also based upon the extent of ulceration (Transactions American Laryngological Association, 1883). Treatment. — Constitutional treatment is of the first importance, and should be similar to that for pulmonary tuberculosis. Local sooth- ing applications, in the form of inhalations, sprays,- and powders are of more or less benefit. The principal inhalations which are recom- mended are : the compound tincture of benzoin, camphorated tincture of opium, or solutions of opium or belladonna with or without carbolic acid, or eucalyptol (Forms. 56 to 59). These give some relief, but are not of great importance, for they do not appear to check the disease. Sooth- ing sprays which may be applied cold by the atomizer are preferable when the patient is able to be out of doors, as the warm inhalations pre- dispose to acute colds. Early, before much swelling has taken place, mild astringents such as carbolic acid gr. ij., and zinc sulphate gr. ij., ad 3 i., or similar preparations are often helpful. These should be ap- plied by the physician every second day when convenient, in sufficient strength to cause smarting for about half an hour, or by the patient twice daily of a strength that will cause some discomfort for only five or ten minutes. Menthol has also been highly recommended as a spray or inhalation in the strength of a drachm to the ounce of liquid albolene. Wm. T. Belfield has recently communicated to the New York Medi- cal Record a preliminary paper on the use of iodine trichloride in sur- gery; from which I am led to hope for good effects in the local treat- ment of tubercular laryngitis; and also in the general treatment of pulmonary phthisis. The demonstrations by W. S. Haines, revealed to him that when brought in contact with saliva, blood, pus, and other animal matter, iodine trichloride is quickly decomposed; setting free iodine and chlorine in the nascent state, most potent for destruction of disease germs. I have used this remedy in many cases of laryngeal tuberculosis applied 44"> DISEASES OF THE LARYNX by spray in a solution in distilled water gr. ss. to gr. iiss. ad f i., and have used it hypodermically in the manner recommended when speaking of pulmonary tuberculosis for Shurly's solution of iodine. Hy- podermically it may be used in solution in distilled water; gr. i. to gr. iiss. ad 3 i. aud iT| x. to TT[ xx. may be administered. The results have been favorable, and justify its extended trial in all forms of tuberculosis of the air passages and pleura. Powders are often better than sprays, because patients generally apply them to the throat more easily. The most serviceable powders are: iodo- form, morphine, bismuth, tannin, iodol, and gum benzoin, in various com- binations with each other and sugar of milk, starch or acacia (Form. 163-165, 172, 177); an excellent soothing powder is composed of equal parts of gum benzoin and bismuth, with two parts of iodoform. The latter, however, is so exceedingly unpleasant to many patients that it is better to substitute iodol, which has nearly, if not quite, as good effect and has but slight odor. When there is much pain, unless con- tra-indicated by idiosyncrasy, morphine may be advantageously combined with any of these powders in the proportion of about five per cent, so that the patient will receive one-tenth of a grain with each insufflation. For the same purpose cocaine has been highly recommended, but I have found that it affords the patient very little relief and often proves to be exceedingly uncomfortable. Morphine, iodol, and bismuth, in proper proportions (Form. 165), give more relief than other combinations, in my experience; though a small amount of tannin or gum benzoin may be advantageously added, if not too irritating. If the epiglottis be- comes destroyed by ulceration, the patient may need to be fed with an oesophageal tube, which if of small size may be passed with- out much discomfort. The patients sometimes swallow more easily with the head low in the manner recommended for patients who are wearing the laryngeal tube. They often suffer greatly from thirst and hunger, rather than endure the agony caused by swallowing. For miti- gating the torture under these circumstances, I have had great satisfac- tion from the use, by swab or atomizer, of a pigment of morphine, carbolic acid, and tannic acid with glycerin and water (Form. 139). This applied to the larynx in full strength usually causes intense smarting for a few moments and subsequently so benumbs the parts that the patient may swallow readily, the anaesthesia continuing for some hours. In one case where I frequently used it, anaesthesia would often continue for thirty-six hours. I often give this preparation diluted with an equal quantity of water, for the patient to use by the atomizer two or three times daily. There is now and then a case, in which it only causes suffering. F. D. Owsley, of Chicago, informs me that he has been able to give great relief in these cases by having the patient spray into the larynx, before eating, a saturated solution of oil of cloves (f of one per cent) in water. Tracheotomy has been recommended in these cases, not only to prevent dyspnoea, but also to give the larynx rest. With the SYPHILITIC LARYNGITIS. 443 latter end in view, it lias been advised comparatively early in tubercu- lar laryngitis, but there is no proof that it improves the patient's chances for recovery, and I think it unjustifiable, excepting, of course, when there is marked obstruction of the glottis, in which case it may be the means of prolonging life for several months. The question of artificial feeding in these cases is ably discussed in a paper by Beverley Robinson, to be found in the Transactions of the American Laryngo- logical Association, 1883. SYPHILITIC LARYNGITIS. The local laryngeal phenomena of syphilis vary at different stages of the disease. Syphilitic laryngitis, although frequent, is present in only a comparatively small portion of cases of all varieties of throat disease. Primary syphilitic laryngitis is extremely rare. The symp- toms of secondary syphilitic laryngitis make their appearance with- in from six to twenty-four months after infection, and are charac- terized by hypersemia with alteration of the voice and frequently condy- lomatous formations. The tertiary manifestations do not usually appear until three or four years or much longer after the primary affection, and it is not uncommon to observe cases in which they are delayed fif- teen or twenty years. This stage is indicated by gummatous tumors, deep ulcerations, and vicious cicatrices, with consequent dyspnoea and altera- tion of the voice. Syphilitic patients are more subject than others to acute inflammations of the larynx, which are usually slow to recover. The disease is more frequent in men than in women, and the tertiary symptoms are about twice as frequent as the secondary. In secondary syphilis of the larynx, chronic hyperaemia and superficial ulcers are found, but Mackenzie thinks that smooth, yellow, round or oval condy- lomata are most characteristic (Diseases of the Throat and Nose, Vol. I, j). 355). These are from five to ten millimetres in diameter, but may be twice as large, and are most frequently found upon the epiglottis or posterior commissure. Lennox Browne states that he has seen several cases in which these formations were essentially like warty growths (Diseases of the Throat, second edition). There is usually nothing characteristic about the persistent hyperaamia, but, as Browne observes, in many cases there is a well defined, mottled discoloration, apparently less superficial, and not so vivid in color as in simple chronic inflammation. This is most distinct on the vocal cords. Small superficial ulcers or mucous patches are occasionally seen on the ventricular bands, edge of the epiglottis or posterior part of the larynx. These are described by Gottstein as round or elongated, grayish white spots of thickened epithelium, slightly raised above the congested tissue which surrounds them, and either gradually shading off into it or sharply defined. In tertiary syphilis of the larynx, gummata, deep ulceration, cicatrices, or chronic thickening (Fig. 137) are characteristic. The gummata may occur singly or in 444 DISEASES "F THE LARYNX. groups, and are most frequent upon the posterior commissure or aryt- enoid cartilages. They are usually observed as round, smooth eleva- tions of the same color as the surrounding tissue, or of a slightly yellow- ish tint; but as breaking down occurs they usually become yellowish at the centre. The ulceration may he superficial at first, but ere long it becomes deep and destructive. It may occur in any portion of the larynx, but the epiglottis is the most vulnerable point, and frequently Fig. V j A. — Condyloma on the Upper Surface of the Epiglottis (Mackenzie;. Fig. 135. — Gumma i Mackenzie). it is destroyed by the progress of the disease. When the ulcers heal, resulting cicatrices may seriously interfere with swallowing or respiration. These ulcers are often, though not always, the result of softening of tin- gummatous tumors. Chronic thickening of the walls of the larynx or of the vocal cords, with anchylosis of the cartilaginous articulations, are among the common results of the disease. Etiology. — The affection is due to constitutional syphilis, either in- herited or acquired. It sometimes gradually extends from the pharynx, but more frequentlv occurs after it has disappeared from that locality. Symptomatology. — By careful inquiry, a history of some of the manifestations of hereditary or acquired syphilis may generally be ob- Fig. 136.— Multiple Gummata atient is greatly debilitated, it is sometimes impossible to arrive at an accurate conclusion. Usually there is no fever, no excitation of the pulse, and no emaciation in the syphilitic affection, while all of these are present in the tubercular disease. In the early stages of both there may be simple hyperemia of the parts, but very soon there is a peculiar, pale red swelling in tuberculosis, having a semi- solid appearance much like oedema, instead of the darker red color and dense appearance of syphilitic swelling. The ulcers in tuberculosis are usu- ally comparatively numerous; they are superficial with irregular, poorly defined borders ; and are attended by much pain. This is not the case in syphilis. The ulceration is usually rapid in syphilitic laryngitis, slow in tubercular. It is more apt to begin at the upper }3art of the larynx in the former, and at the lower in the latter. In syphilitic laryngitis, adminis- tration of the iodides usually causes speedy improvement, whereas in tu- berculosis it is likely to work an injury to the patient, and the symptoms grow worse. Tubercular laryngitis is nearly always attended by distinct signs of pulmonary phthisis. The rapid growth of condylomata, their location, and, under appro- priate treatment, their speedy disappearance, together with other evi- dences of specific disease, will usually enable us to easily distinguish them from papillomata or other laryngeal tumors. The gummata are not likely to be mistaken for any other growths in the larynx. The fungous growths which sometimes occur about the edges of syphilitic ulcers are not likely to be mistaken for any of the benign tumors of the larynx, but are not unlike those which may be observed in some cases of tuberculosis, and can only be distinguished from the latter by a care- ful consideration of other symptoms and signs. In the early stages, while there is simple congestion of the larynx, it may be impossible to distinguish cancer from syphilitic laryngitis, but congestion in the malignant disease is usually confined to one side or to a limited portion of the larynx, whereas that of the specific affection is more apt to be uniformly distributed. In cancer the growth precedes the ulceration, whereas in syphilis the ulceration is often first. In syphilis the ulceration is more rapid, though there is less inflammation about it, and the ulcers are usually smaller and more apt to be multiple. In the later stages of cancer, when a large, irregular tumor has been formed there can be but little difficulty in making the diagnosis. In 448 DISEASES OF THE LARYNX. rare cases where there has been much thickening of the larynx, with ulceration and cicatrization so that portions of the organ are much dis- torted, it is sometimes impossible at first to tell with which disease we are dealing. In these cases, as suggested by Lennox Browne, much reliance may be placed upon the evidence obtained by frequently weigh- ing the patient while he is taking the iodides. Although under antisyph- iiitic treatment, persons suffering from cancer of the larynx sometimes do well for a short time; improvement soon ceases, and they lose weight; whereas in the syphilitic disease there is generally steady increase in weight for a considerable time while this treatment is pursued. Prognosis. — In the secondary stage of the disease 'appropriate treat- ment usually effects a speedy cure, though the singing voice may be permanently lost. However, there is a peculiar predisposition to re- lapses under exposure to the causes of catarrhal inflammation. In the tertian* variety a favorable prognosis may be given where the case comes under observation sufficiently early; but if the perichondrium or the cartilages are extensively involved, there is great danger to life. In either case restoration to the larynx of its perfect functions is impossible, though improvement may be expected under appropriate treatment. The ulcerations will usually heal within two or three weeks, but the thickening or cicatrices remaining may interfere with deglutition, res- piration, or phonation. Death may result from acute oedema, and has occurred from hemorrhage though this is not a likely termina- tion. Chronic thickening or distortion of the larynx is liable to remain permanent in all cases where there has been extensile ulceration: and gradual exhaustion due to stenosis of the larynx may finally wear the patient out if tracheotomy is not performed. Destruction of the epi- glottis may for a short time interfere with deglutition, but the patient soon learns to swallow without this valve. Tkeatmext. — In the secondary disease, local stimulating applica- tions, similar to those recommended for simple chronic laryngitis, are indicated and are peculiarly beneficial. For this purpose solutions of zinc chloride or copper sulphate have been found most useful. A mild mercurial course is also indicated; and whenever condylomata or ulcerations appear, potassium or sodium iodide should be given. Bitter and ferruginous tonics are indicated if the appetite is fitful. The use of tobacco in any form should be interdicted, and alcoholic stimulants are generally hurtful. In the tertiary form of the disease the greatest reliance is placed upon the internal administration of potassium or sodium iodide. If for any reason these cannot be borne, the patient may be given a mercurial course; gold and sodium chloride sometimes acts equally well. It is sometimes found necessary to use the iodides in very large doses; for example, I have seen a patient in whom twenty grains of potassium iodide taken four times daily had no effect ; whereas, when he was siven much larger doses the condition of the larynx im- SYPHILITIC LARYNGITIS IN INFANTS. 449 mediately improved. The remedy should always be given freely diluted with water, and it is best to begin with small doses, which can be steadily increased. I usually begin with seven and one-half grains after each meal and at bedtime, and the dose is increased each day two and a half grains until fifteen or twenty grains are taken at a close. If with this treatment the patient does not improve, and the symptoms of iodidism do not occur, the dose is increased each clay five grains until thirty, forty, or sixty grains, and in extreme cases even one hundred and twenty grains are taken at a dose four times daily. The maxi- mum dose having been reached, it is continued for two or three days, and then the patient again begins with the minimum dose and increases the quantity daily as in the first instance. This plan has seemed to me much more satisfactory than the continued administration of large doses. Usually it is well to direct the patient to drink nearly half a pint of water with each dose of the medicine. Locally, Lennox Browne (Diseases of the Throat, third edition), especially recommends the solid silver nitrate, or, when the epiglottis is ulcerated, the galvano-cautery. I prefer at first the tincture of iodine full strength, thoroughly and accurately applied to ths ulcers daily for five or six days, and subse- quently less often until healing has occurred. In case the tincture of iodine fails, I resort to co]3per sulphate in solution of from gr. x. to xx. ad 5 i., or to zinc chloride in solutions of from gr. xv. to xxx. ad \ i. Under this course, even large ulcers will usually heal within two or three weeks. After cicatrization of the ulcers has taken place, if sten- osis of the larynx occurs, it must be dilated by means of Schrotter's bougies or O'Dwyer's laryngeal tubes, as described in the treating of sten- osis of the larynx. At times the specific medication should be discon- tinued and tonics substituted. Where the patient is much run down, it is best to administer nux vomica and quinine while the specific course is continued. SYPHILITIC LARYNGITIS IN" INFANTS. The attention of the profession was first directed to congenital syph- ilis of the larynx by John N. Mackenzie, of Baltimore, according to whom it is not very infrequent, and occurs mostly within the first year of life {American Journal of Medical Sciences, 1880). It is character- ized by cough, dysphonia, dysphagia, dyspnoea, and deep, destructive ulceration. The voice of the child may pass through all stages from slight huskiness to aphonia. Paroxysmal cough is frequent, and res- piration is more or less embarrassed according to the condition of the part. Laryngismus stridulus is also spoken of by John N. Mackenzie as a not infrequent symptom in these cases. Deglutition is often diffi- cult, and cutaneous eruptions may be present. Diagnosis. — The diagnosis must be made from the symptoms, and personal and hereditary history ; from the signs as manifested upon 29 450 DISEASES OF THE LARYNX. the skin or the fauces; and from the appearance of the larynx, when laryngoscopic inspection is possible. Prognosis. — The prognosis is always unfavorable. The younger the child, the more rapid will be the course and the greater the certainty of a fatal termination. Some cases recover under proper treatment, but there is a strong predisposition to recurrence. Treatment. — The treatment is essentially the same as for the ac- quired disease; but when difficulty in respiration occurs, prompt intuba- tion or tracheotomy should be performed. The former is to be espe- cially recommended, as it will generally insure sufficient breathing space and give time for the administration of medicine adapted to promote healing of the parts. If stenosis of the larynx occurs, so that it is nec- essary to wear an instrument permanently, tracheotomy is preferable; but the good results obtained from intubation in chronic stenosis of the larynx would lead me to recommend first a persistent trial of O'Dwyers method. CHAPTER XXVI. DISEASES OF THE LAKYNX.— Continued. LUPUS OF THE LARYNX. Lupus of the larynx is a rare affection said to occur with about eight per cent of all cases of lupus in other parts of the body. It is usually secondary to lupus of the face, is more frequent in women than in men, and is most common in the lower classes of society. For a history of this disease we are indebted largely to G. M. Lefferts, of New York {American Journal of the Medical Sciences, April, 1878). The literature has been much enriched by Chiari and Eiehl (Lupus vulgaris Laryngis, Vierteljaliresschrift fur Derm, und Syph., 1882) ; Morris Asch, of New York ; F. I. Knight, of Boston (Archives of Fig. 141.— Lupus of Larynx (Ziemssen). Fig. 142.— Lupus of Larynx (Turck). a. b. Epiglottis. Laryngology, 1881), and by numerous other writers. Although the vari- ous investigators have observed numerous cases, it is not yet possible to point out any diagnostic characteristics of the disease. ■ Axatomical autd Pathological Characteristics. — According to Lefferts, the essential pathological characteristic is hypertrophy of tissue. This is followed by slow but very destructive ulceration, and when heal- ing occurs the cicatricial tissue is very 'hard and of low vitality. About these scars congested nodules are usually seen. Etiology. — The causes of the disease are not known. It has gener- ally been considered as an evidence of a scrofulous taint. By some it is believed to be tubercular. The experiments of Koch, in discovering tubercle bacilli in the lupus nodules, and from them obtaining pure cul- tures, while not furnishing conclusive evidence of the tubercular charac- 452 DISEASES OF THE LARYNX. ter of the disease, make this the most plausible hypothesis, though the difference in the clinical aspect of the two affections has not as yet been satisfactorily explained. Whatever the ultimate cause of the dis- ease, it is evidently the same as that which causes lupus on other por- tions of the body. According to Harries and Campbell, the disease requires for its development a suitable soil (" Lupus," etc., London, 1886) — possibly allied to tuberculosis and scrofula; a predisposing cause, particularly traumatism; and an exciting cause, probably a micro- organism. Symptomatology. — At first the patient may complain of mild sore throat, but the symptoms are not marked and are entirely out of propor- tion to the physical signs. There is often neither pain nor discomfort, and the patient is usually ignorant of laryngeal disturbance; but as the disease progresses, the voice is often affected and in many cases dyspnoea is developed. In some there is distressing cough and a sense of obstruc- tion in the throat, and occasionally there is complaint of dysphagia. No characteristic physical appearances are observed upon laryngoscopy examination, but in many cases congested nodules will be seen on the epiglottis or anterior surface of the arytenoids. These nodules are irregular or may be almost spherical. Ulcers or cicatrices may also be seen, similar to those observed when the disease affects the face. Ramon de la Sota speaks of marked absence of bleeding from the ulcers (Trans- actions of the American Laryngological Association, 1886). Diagnosis. — The disease is to be distinguished from tuberculosis, syphilis, or cancer of the larynx. The most important points in the differentiation are the history and the presence of lupus externally. When the latter exists the diagnosis is not usually difficult, and in young subjects lupus can scarcely be confounded with any disease excepting hereditary syphilis. In cases where the disease is confined to the larynx a diagnosis can only be reached by a careful exclusion of other diseases. Lupus is to be distinguished from tubercular laryngitis by the char- acteristics presented in the following table: Lupus of the larynx. Tubercular laryngitis. Generally in young- adults. Commonly in middle-aged persons. Usually associated with disease of Nearly always signs of pulmonary the face, and no signs of pulmonary dis- disease, ease. Absence of constitutional disturb- Marked constitutional disturbance, ance. Little, if any, pain. Severe local pain. Progress slow and may be arrested. Progress rapid and seldom arrested. Ulcers deeply destructive. Ulcer generally superficial. Lupus of the larynx is to be distinguished from syphilis as follows: LUPUS OF THE LARYNX. 453 Lupus of the .larynx. Most apt to occur in young adults. No syphilitic history. No constitutional symptoms; absence of pain. Progress slow; aggravated by anti- syphilitic treatment. (Brown, in the third edition of his work, p. 429, re- marks that mercurial treatment does not aggravate true lupus, but he ap- pears to contradict this statement on p. 437 of the same.) Syphilitic laryngitis. If of hereditary origin, it may occur in children; otherwise it is most apt to occur in middle life, five or ten years later than the advent of lupus. Syphilitic history. May be marked constitutional symp- toms. Frequently no pain, but this symptom may be severe. Progress may be rapid, but benefit or cure follows anti-syphilitic treat- ment. . Between lupus and cancer of the larynx the following are the chief j)oints of difference : Lupus of the larynx. Presence of the disease or the scai-s which follow it upon the face. Usually occurs in early life. Slow progress, and may be arrested. Apt to extend over several years. But slight pain. Slight constitutional disturbance. Cancer of the larynx. No lesions upon the face. Appears visually after the age of forty. Comparatively rapid progress, sel- dom or never arrested, and visually ter- minates fatally within from twelve to eighteen months, but sometimes ex- tends over four or five years. Frequently severe pain. Marked cachexia, rapid emaciation and exhaustion. Prognosis. — The disease progresses very slowly and may last indefi- nitely, without materially shortening the patient's existence. It is certainly not dangerous to life, but sometimes new formations so ob- struct respiration as to demand tracheotomy. Any interference with cicatrices by incision is liable to result in renewed ulceration. The dis- ease may sometimes be arrested. Treatment. — Ferruginous and bitter tonics and cod-liver oil are recommended internally, though their effects are not very apparent. Chemical caustics, of which the solid silver nitrate is preferable, have been used, but not very satisfactorily. The galvano-cautery is recom- mended by Lennox Browne as the best means of destroying the diseased tissue and promoting a healthy condition of the parts. Thorough scraping and the application of lactic acid, as specially recommended by Ramon de la Sota (loc. tit.) are worthy of fair trial. This author also lays stress upon strict hygienic and tonic treatment, arsenious acid giving especially good results. Koch's tuber culine has not been found 454 DISEASES OF THE LARYNA. more valuable than other remedies, and its use is not infrequently followed by disastrous consequences. LEPRA OF THE LARYNX. Lepra of the larynx is an affection which attends some cases of gen- eral leprosy or elephantiasis, and is characterized by inflammation and the formation of nodular masses similar to those seen upon the skin. These usually ulcerate and are a cause often of dyspnoea or hoarseness. Anatomical and Pathological Characteristics. — The disease is attended by congestion of the mucous membrane, with uniform or nodular swelling, and considerable deformity. In advanced cases ex- tensive ulceration may have occurred. In some cases the vocal cords have been found thickened and of a yellowish red color, while the mucous membrane of the ary-epiglottic folds and ventricular bands has been much congested, and has the appearance in some cases of having been loosened from the tissue beneath. In the only case which has come under my observation, the mucous membrane was of a reddish yellow color, the vocal cords had a grayish appearance, and the epiglottis and supra-arytenoid cartilages were thickened, and several nodules appeared on the ventricular bands, epiglottis, and vocal cords. There is a tendency of these nodules to ulceration, but, owing to the slow progress of the disease, this stage in many cases is not reached. In some instances great thickening occurs, and very con- siderable stenosis results. Etiology. — The causes are the same as those of external lepra, which in nearly, if not quite, all cases precedes the disease of the larynx. Symptomatology. — There are no characteristic symptoms, but the patient may become hoarse or suffer from dyspnoea, according to the thickening of the laryngeal walls or vocal cords. Pain in swallowing was only observed in one out of twenty-five cases reported by Morell Mackenzie {Journal of Laryngology, London, 1887 88). As noted by Lennox Browne, dyspnoea is commonly an unimportant symptom, even in cases of marked stenosis (" Diseases of the Throat," third edition). Diagnosis. — The diagnosis is based upon the presence of external lepra and the abnormal appearance of the larynx, as already described ; also upon the rarity of pain in speaking or swallowing, even though the disease may be far advanced; and on the infrequency of ulceration. Prognosis. — The prognosis is unfavorable. Treatment. — Tracheotomy is rarely indicated, but it may be neces- sary if oedema of the glottis develops. No treatment has yet been Fig. 143.— Lepra of Larynx. Besides the irregular thickening of the epiglottis and ary-epiglot- tic folds, five distinct tubercles can be seen on the vocal cords and ventricular band, and one is indistinctly seen on the anterior surface of the infra-glottic por- tion of the larynx. LARYNGITIS OF SCARLET FEVER. 455 discovered which will surely relieve lepra, but the internal administra- tion of chaulmoogra oil, five to sixty drops daily in an emulsion, has ap- parently benefited some cases. At the same time an inunction of an ointment prepared from the same oil with five or six parts of lard should be used. In the single case which I have observed, J. Kevins Hyde, of Chicago, employed this remedy with apparently much benefit to the patient. HYPERTROPHY OF THE LARYNX. In his work on " Diseases of the Throat and Xose," J. Solis Cohen cites one instance in which all of the tissues were thickened and hyper- trophied, but without congestion of the parts; the obstruction of the glottis became so great that tracheotomy was necessary. !No cause was known for the disease. LARYNGITIS DUE TO SMALL-POX. Laryngitis due to small-pox is always secondary to the eruption upon the skin, and may be either mild, or severe. In the latter case, the ex- udate interferes with respiration in the same way aa diphtheritic mem- brane in the same locality, and should be treated in a similar manner, intubation or tracheotomy being performed if dyspnoea becomes urgent. LARYNGITIS OF MEASLES. Most cases of measles are attended by inflammation of the larynx, either mild or severe. Usually there is simple catarrhal inflamma- tion in the earlier part of the attack, which gradually passes away as the disease progresses ; but in some cases, just as the eruption on the skin is disappearing the larynx becomes involved. This form of in- flammation is generally very obstinate and may permanently impair the voice. In some epidemics of measles there is a peculiar proneness to a deposit of false membrane in the larynx, occurring, as a rule, from the third to the sixth day. It causes the same symptoms as diphtheritic laryngitis and calls for the same treatment, but unfortunately the ma- jority of these patients die; so great, indeed, is the mortality that some authors have stated that none of them recover even after intuba- tion or tracheotomy. Intubation has seemed to be followed by more favorable results in this particular disease than tracheotomy. LARYNGITIS OF SCARLET FEVER. Laryngitis of scarlet fever is a comparatively rare affection which may be simple in character, but is sometimes complicated with oedema of the glottis or with a diphtheritic exudate. In the latter case it should receive the same treatment as diphtheritic laryngitis. 45G DISEASES OF THE LARYNX. CHRONIC STENOSIS OF THE LARYNX. Chronic stenosis of the larynx usually occurs in syphilitic subjects, or in persons who have suffered from chondritis or perichondritis result- ing from typhoid fever or tuberculosis. It is characterized by more or less alteration of the voice, and dyspnoea in proportion to the narrowing of the glottis. Anatomical and Pathological Characteristics. — The obstruc- tion usually occurs from vicious adhesions or from the contraction of large cicatrices. The chink of the glottis may have various forms, and in size may vary from the normal to a minute opening scarcely large enough to permit the passage of sufficient air to support life; the parts are usually thickened, hard, and distorted in various ways. The vocal cords, ventricular bands, or the arytenoid cartilages may be more or less adherent to each other. m** Fig. 144. — Syphilitic Laryngitis. A.lhe- Fig. 145.— Syphilitic Stenosis of Larynx. sion of anterior portion of vocal cords, and Adhesion of greater portion of vocal cords, swelling of arytenoids. Etiology. — The disease usually results from syphilis, but it may fol- low inflammations of the cartilage or perichondrium caused by wounds, typhoid fever, or tuberculosis; in exceptional instances it has been caused by chronic catarrhal laryngitis. The obstruction may be caused by submucous infiltrations or hyperchondrosis, or two or more of these conditions may be combined. Symptomatology. — In connection with the history of one of the causes already mentioned we may find that the larynx has become in- volved and that the disease has gradually or rapidly progressed until there is great difficulty in respiration. Sometimes there has been a sud- den amelioration of the inflammatory symptoms and apparent improve- ment of the condition, but the difficulty in respiration has gradually in- creased owing to the contraction of the cicatricial tissue which has been formed. The voice will be impaired, and respiration obstructed, accord- ing to the part of the larynx involved or to the narrowing of the glottis present. Distortion or thickening of the larynx and narrowing of the glottis may be seen upon a laryngoscopic examination. Diagnosis. — Chronic stenosis of the larynx is to be distinguished CHRONIC STENOSIS OF THE LARYNX. 457 from asthma, compression of the trachea or larynx by tumors or other causes, foreign bodies in the air passages, and paralysis of the abductors of the vocal cords. The diagnosis must usually be based upon the his- tory and the laryngoscopic appearances. In asthma, there is a history of sudden and repeated paroxysms of dyspnoea with more or less complete intermissions or remissions of the attack, instead of the gradually increasing obstruction found in laryn- geal stenosis; there are many instead of few bronchial rales and slight, if any, alteration of the larynx. A history and a laryngoscopic appearance entirely different belong to foreign bodies in the larynx. We are to diagnosticate tumors pressing on the larynx or trachea by a careful physical examination of the neck and chest. When this does not succeed, an inspection of the larynx enables us to distinguish between this condition and stenosis. Dyspnoea, often as pronounced as that of stenosis, is caused by pa- ralysis of the abductors. Here again the history must be carefully con- sidered, and upon inspection the position of the cords near the median line, their slight movements with respiration, and the absence of thick- ening or cicatrices, will indicate the true nature of the morbid process. Prognosis. — The voice is usually permanently lost, and the disease progresses gradually to a fatal termination unless appropriate treatment is adopted. By proper surgical procedures, however, life may be indefi- nitely prolonged, though the patient often has to wear a tracheal canula during the rest of his days. Teeatmext. — Whatever the cause of chronic stenosis, medicinal treatment alone is of little, if any, avail in most cases, for even when of syphilitic origin the disease usually progresses so rapidly that surgical interference becomes imperative. If dyspnoea is great, it is essential that it should be promptly relieved by intubation or tracheotomy, and it is highly advisable that these operations should be recommended early. The anaesthesia for tracheotomy in these cases is best obtained by the hypodermic injection of a few drops of a four per cent solution of cocaine (Form. 140) along the line of incision. If the dyspnoea is not pronounced, Schrotter's laryngeal bougies may be employed for gradual dilatation, but otherwise tracheotomy should be performed unle'ss one of O'Dwyer's laryngeal tubes of sufficient size to give the patient relief can be introduced. After tracheotomy, or when there is no immediate dan- ger to life, dilatation of the parts should be practised by some of the various methods recommended in standard works. The repeated and persistent use of Schrotter's bougies, gradually increasing sizes of which should be introduced two or three times a week, will sometimes prove successful, but the treatment is necessarily tedious, and there is much liability to recurrence of the stricture. Schrotter's, Mackenzie's, or Xavratil's dilators may be employed with satisfaction in some cases 45s /> is/-; AsK.s OF THE LARYNX. (Morell Mackenzie's Diseases of the Throat and Xose), but when adhe- sions of the ventricular bands or vocal cords have occurred, Whistler's cutting dilator will often be found more satisfactory. O'Dwyer's method Fig. 146.— Mackenzie's Laryngeal Dilator. A, Closed : B, open. The blades may be separated by turning the screw s, and the extent of the separation will be registered on the dial d. of intubation furnishes an admirable means of treating chronic stenosis of the larynx. The laryngeal tubes for this purpose are similar to those used for croup. They are ten in number, varying in size just below the head from six to ten millimetres in lateral diameter bv nine to nineteen Fig. 147. —Whistler's Cctting Dilator. A, Dilator ready for use ; B, knife protruding ; C, knife ; k. handle for protruding knife. millimetres antero -posteriorly. Several cases have been reported where these have given much satisfaction, and I have treated two with excellent results. If the opening of the glottis is very small, it should be enlarged with "Whistler's cutting dilator, followed by the laryngeal tube. A tube which can be easily introduced should be worn for a few days at first, CHRONIC STENOSIS OF THE LARYNX. 459 being succeeded by larger sizes from time to time as rapidly as may be without giving the patient discomfort. When the full size has been reached, it should be worn for several weeks, by which time in most cases the tendency to recurrence of the trouble has disappeared ; but if con- traction occurs, the tube should be worn occasionally to keep the glottis Fig. 148.— Tube for Laryngotracheal Stenosis. A, Tubes in position; B, outer tube which passes up to the larynx; C, middle tube which passes through the fenestra, in the outer tube, into the trachea; D, inner tube of sufficient length to relieve stenosis low down the trachea; E, valve which opens on inspiration and closes on phonation or expiration. open. Whatever treatment is adopted, the voice is apt to be permanently impaired. It has seemed to me that continual wearing of an O'Dwyer's tube is more liable to injure the voice than intermittent dilatation. Possibly these tubes might be used for much shorter periods with equally good results in keeping the glottis open, and without so much injury to the voice, but this is a matter to be determined by future experience. After tracheotomy when the lower portion of the larynx or upper part of the trachea become obstructed by vegetations or cicatricial con- tractions above the canula, these must be removed. The operation will be facilitated by the punch forceps spoken of when treating of post-tra- cheotomic vegetations (Fig. 178). The air passage may then be kept open by the combination tube shown in Fig. 148. This tube allows the patient to talk, and may be worn as long as necessary. Sometimes the constant tendency to contraction will necessitate its retention during the remainder of the patient's life. 460 DISEASES OF THE LARYNX. STENOSIS OF THE TRACHEA. The close relation of the larynx and the trachea in some sense com- pels the discussion of tracheal diseases with those of the larynx. Stricture of the trachea is a condition frequently, though not con- stantly associated with stricture of the larynx. . It is characterized by paroxysmal cough and dyspnoea, aggravated from time to time by congestion and swelling of the parts or the collection of mucus. The obstruction, which may occur at any part of the trachea, usually results from cicatrizations of syphilitic ulcers or from comjiression by intra- thoracic tumors. The diagnosis can only be made after careful physi- cal exploration of the throat and chest, and a painstaking laryngoscopic examination whereby obstructions above the vocal cords are eliminated. The prognosis is always unfavorable when the lesion is too low to be relieved by tracheotomy. In syphilitic cases, vigorous use of the iodides has sometimes given great relief. Dilatation through the larynx by means of long flexible catheters has been recommended. The best results are to be expected from tracheotomy with subsequent dilatation and the wearing of a long, flexible tracheotomy tube. TRACHEITIS. Tracheitis, is an inflammation of the mucous membrane of the trachea, which may be either acute or chronic. It sometimes occurs indepen- dently, but is usually associated with laryngitis or bronchitis. The dis- ease is generally mild, but severe cases sometimes occur. Anatomical and Pathological Characteristics. — In the acute cases the mucous membrane may be red and swollen, so that the inter- spaces between the cartilages cannot be seen. In chronic cases the membrane is usually slightly swollen and of a deep pink color, and the intercartilaginous spaces are not very distinct or may be invisible; there are some cases, however, in which post-mortem examination reveals no congestion. In chronic cases masses of mucus may often be seen ad- hering to the surface, and rarely, ulcers are present. A peculiar form of this disease is sometimes met with in which the mucous membrane is covered by desiccated and decayed secretions similar to those found in the nasal cavity in ozcata. Etiology. — The causes of tracheitis are the same as those of laryn- gitis and bronchitis. Chronic cases are frequently due to rheumatism. Symptomatology. — In acute cases the patient generally complains of a sense of soreness or rawness in the superior sternal region or at the upper portion of the trachea, with tickling or itching of the part and frequent cough. During the first few days the expectoration is scanty, thick, and tenacious; but as the disease progresses toward recovery, it becomes muco-purulent as in ordinary cases of subacute bronchitis. TRACHEITIS. 401 In the chronic disease there is sometimes localized pain over a small portion of the trachea, but usuall}* simply a sense of discomfort due to swelling of the mucous membrane, dryness, or a collection of mucus upon its surface. Sometimes the tickling sensation is very annoying. These symptoms are associated with a hacking or hemming cough and expectoration of small quantities of mucus usually discolored by dust. Occasionally the cough is paroxysmal. In many cases there is slight hoarseness, or simply a loss of control over the voice on attempting to sing. The general health is not impaired. Upon examination of the chest, mucous or sonorous rales are some- times found over the trachea alone, or transmitted over the entire thorax. When the mucous membrane is dry and the secretions are de- composing, the patient is greatly annoyed by constant efforts to clear the trachea, and by an offensive odor similar to that of ozama. In some of these cases the crusts collect just beneath the glottis and may give rise to spasm of the larynx; in others the symptoms are very similar to those of asthma. Laryngoscopic inspection will reveal the condition already mentioned. Diagnosis. — The disease is readily distinguished from laryngitis and bronchitis by laryngoscopic examination, and physical exploration of the chest. Prognosis. — Acute tracheitis usually subsides in from five to four- teen days. The chronic form may last for several months or even years. The variety attended by drying of the secretions is peculiarly obstinate. Neither form of the disease is considered serious; and the common fear of patients that it may extend to the lungs, causing phthisis, is appar- ently without foundation. There are some cases, associated with con- sumption, but this appears to be accidental. Treatment. — The acute cases may be given the same local treat- ment as acute laryngitis, and the internal remedies suited to acute bronchitis. At the same time, cold compresses over the chest in the earlier part of the attack, and hot compresses later, will often be found beneficial. The patient should be kept in as equable temperature as possible, and should avoid exposure. In the ordinary chronic cases treatment similar to that employed in chronic bronchitis is applicable, but the greatest benefit will be derived from local applications. Sina- pisms or blisters over the sternum are sometimes efficient. Whenever syphilis exists, or the rheumatic, gouty, or dartrous di- athesis is present, these should receive first attention. The local appli- cations which have been found most beneficial consist of inhalations of ammonium chloride with oil of tar or eucalyptol, and the application of various astringent sprays, and stimulating powders. It is difficult to apply a spray to the trachea because the glottis will close as soon as the application touches the larynx, but it may sometimes be accomplished by directing the patient to cough while the spray is being thrown in 462 DISEASE* <>F THE LARYNX. quite forcibly. The sprays which I usually employ consist of solutions of zinc sulphate or chloride gr. ii. to x. ad 3 i., the stronger of these being contra-indicated unless the larynx is also involved. In any case the patient should not experience unpleasant sensations for more than half an hour or at most an hour after the application. Some physicians favor injecting stimulating solutions with a syringe. Powders have given me the most satisfaction in the treatment of tra- cheitis, as they can be applied accurately and will remain in contact with the parts longer than solutions. These are used two or three times a week, beginning with mild applications, and gradually increasing the strength as found necessary to produce sufficient stimulation. They are applied while the glottis is wide open by means of a bent glass tube and an ordinary insufflator. Iodol usually has a salutary influence upon the inflamed mucous membrane, and many patients experience speedy relief; from half a grain to two grains may be used at each sitting. A slightly more stimulating powder, and one that answers a good purpo.se in some cases, consists of equal parts of iodol and boric acid. Where still more stimulation of the parts is desired, I usually combine with the iodol or the boric acid from five to fifteen per cent of alum thoroughly triturated with sugar of milk. Bismuth, gum benzoin, and other powders are occasionally used, but the three already mentioned generally work satisfactorily. Menthol may be used in the same man- ner, but it has no specially beneficial effect. Treatment of the fetid form is eminently unsatisfactory. Where the crusts collect close beneath the glottis so as to cause spasm of the larynx, inhalations of ammonium chloride or carbonate, or sodium car- bonate, with glycerin and water by means of the steam atomizer, have proved beneficial, the strength being regulated by the sensations of the patient. I have employed a great variety of substances and have had the patient use many different remedies at home, but most drugs seem to have no influence in separating the incrustations or in limiting their formation. The most satisfactory results have been obtained from the frequent inhalation of oil of mustard in combination with alcohol in proportion of about i\[\. ad?i.; a small quantity of this two or three times daily is poured upon the handkerchief and in- haled by the patient, with the result of enabling him more readily to clear the trachea and finally of greatly decreasing the collection of secre- tions and the offensive odor. CHAPTER XXVII. DISEASES OF THE LABYNX.— Continued. MORBID GROWTHS IN THE LARYNX. Laryngeal tumors include several varieties of morbid growths sim- ilar to those found in many other portions of the body. They are commonly benign, and of these the papillary form constitutes about seventy-five per cent. Next in order of frequency, respectively, come fib- rous tumors and fibro-cellular growths, the latter constituting only about five per cent of the whole number of intra-laryngeal tumors. Following these we find cystic, lipomatous, and malignant epithelial and sarcomatous growths; cartilaginous tumors are among the most infrequent. Intra-laryngeal tumors are usually characterized by dys- phonia or complete loss of voice, often by dyspnoea and occasionally by dysphagia. They occur most frequently in middle aged men, but they occasionally appear in advanced age, and are seen in children, sometimes being of congenital origin. Previous to the development of laryngos- copy in 1857, only seventy laryngeal tumors had been recorded. Sub- sequently, up to the year 1871, about three hundred were observed, ac- cording to Morell Mackenzie; but since then the number has run rapidly into the thousands, and many of these have been cured by intra- laryngeal operations. Anatomical and Pathological Characteristics. — The larynx is usually more or less congested, and the tumor may spring from any por- tion of the organ, though certain parts are especially liable to certain varieties of morbid growth. The appearance of the tumor and its path- ological peculiarities depend upon its character, size, and location. Their microscopical appearance is not unlike that of similar neoplasms in other parts of the body, but it frequently happens that it is impossible by such examination to determine the true character of the growth. Etiology. — Benign tumors nearly always have their origin in con- tinued local hyperemia; their causation is therefore often the same as that of chronic laryngitis. Cohen believes that they are not infre- quently caused by catarrhal inflammation, due to the exanthemata, or to that resulting from croup, diphtheria, pertussis, or the inhalation of irritating substances; he also shows that they sometimes occur in per- sons suffering from syphilis or tuberculosis (Diseases of the Throat and Nasal Passages). Morell Mackenzie, on the other hand, states that 4i 14 DISEASES <>F THE LARYNX. neither syphilis nor phthisis is a predisposing cause, though he admits that both may give rise to false excrescences or outgrowths (Diseases of the Throat and Nose, Vol. I). He attributes laryngeal neoplasms in many eases to the professional use of the voice. Symptomatology. — The symptoms of a tumor in the larynx depend upon its size and position, and are essentially the same whether it is benign or malignant. The usual symptoms, which vary, of course, with the size of the growth and the part of the larynx involved, are: cough, dyspnoea, dysphonia or aphonia, dysphagia, and occasionally pain. Cough is not apt to be troublesome unless the growth is large or in- volves the glottis, or unless it is attended by bleeding; that which does occur is often paroxysmal and may be of a croupy character. Dysphonia or aphonia, hoarseness, or even complete loss of the voice occur when the growth is located on the vocal cords, or Avhen its position or the con- current inflammation interferes with their vibration. It is surprising how small a growth located on the edge of the cord will cause hoarseness while large tumors differently situated some- times but slightly interfere with pho na- tion. Sometimes the aphonia is inter- mittent and it may disappear or change with alteration of the patient's position. Dyspnoea occurs whenever the neo- plasm is sufficiently large to materially obstruct the respiratory passages. Dysphagia is not a common symp- tom, but it may occur when the tumor involves the epiglottis or posterior laryngeal wall, or when by its size it encroaches on the pharynx. This symptom is more likely to be present in malignant growths. Pain is not a common symptom in benign growths, although patients frequently complain of a sense of aching or discomfort, or the sensation as of a foreign body in the throat. Occasionally, even with small tumors on the vocal cords, patients experience slight pain, especially upon deg- lutition. Severe paroxysms of pain are not uncommon in malignant growths, though even with these it is frequently absent. In adults a laryngoscopic examination will usually at once reveal the presence of a morbid growth, but laryngoscopy is frequently difficult, and sometimes impossible, in young children, especially in those less than six years of age. By forcibly pressing the tongue downward and forward with a tongue depressor similar to that shown in Fig. 140, a good view Fig. 149.— Mount Bleyer's Tongue Depressor Q£ siz^ > BENIGN TUMORS OF THE LARYNX. 465 may commonly be obtained even in rebellious children. In young subjects the larynx can be readily reached by the finger, and it is often easy to feel the growth, provided it is located above the cords. It is im- possible to be certain of the true character of a tumor until it has been subjected to a microscopic examination, and even then the diagnosis may remain doubtful, for sometimes laryngeal growths of malignant histological appearance possess a non-malignant history from beginning to end. Nevertheless, in most cases, inspection of the larynx will enable the physician to practically determine the true nature of the growth. BEXIGX TUMOES OF THE LABYNX. Symptomatology. — The most common symptom of these growths consists of alteration of the voice, though this is not invariably present. A growth upon the vocal cord usually causes hoarseness or aphonia, sometimes more marked from small tumors than from large ones. Growths below the cords usually affect the voice by being forced upward i£*r " ./ Fig. 150.— Papilloma of Right Vocal Cord. Fig. 151.— Papilloma of Larynx. Supra-glottic. during expiration. Those upon the ventricular bands usually cause no alteration in the intonation. Tumors upon the epiglottis and ary-epiglot- tic folds do not usually alter the voice unless they become very large. Cough is not a common symptom, but it sometimes becomes very an- noying. Dyspnoea is present in only a small proportion of cases, usually being inspiratory and sometimes paroxysmal. According to Morell Mackenzie, these paroxysmal attacks are due to sudden swelling of the mucous membrane in most cases, but occasionally to an unusual posi- tion of the growth. According to Lewin, if the inspiration is noisy and stridulous the growth is probably above the cords {Deutsche Klinik, 1862). If interference with expiration occurs, the tumor is usually be- low the cords. Dysphagia is much less frequent than dyspnoea. Papillomata are usually located on the upper surface or on the free margin of the vocal cord, but they may occur in other portions of the larynx. They are generally of a light pink color but may be white or even red. They usually have an irregular, cauliflower or raspberry like surface, and vary in size from a few millimetres in diameter to a mass large enough to completely occlude the larynx They are sometimes pedunculated, but most commonly they spring from a broad base; they 3° 400 DISEASES OF THE LABYNA". are generally single but not infrequently multiple (Figs. 153, 154). These tumors are usually soft and may be readily crushed or torn off with forceps, but sometimes they are quite firm. Fibromata are usually observed as small, round or oval pedunculated growths (Fig. 155) of a grayish or reddish color, and are most frequently attached near the anterior extremity of the vocal cords. They vary in size from a pin's head to ten or fifteen millimetres in diameter, though Fig. 152.— Papilloma of Vocal Cords. Fig. 153.— Papilloma of Vocal Cords. they seldom exceed the size of large pea. The surface of these tumors is usually smooth, but it may be rough and irregular; they are firm and resisting when touched with the probe. They are generally, though not invariably, single and pedunculated. Fibro-cellular tumors consist of more or less perfectly devel- oped fibrous growths, having a serous like fluid diffused through their substance (Fig. 150). They are small, pyriform or globular growths hav- Fig. 154.— Papilloma of Larynx Fig. 155.— Fibroma of Left Vocal Cord. ing a smooth or slightly irregular surface of a pale pink or reddish hue. They are usually pedunculated, but may be sessile, and are generally attached to the vocal cords or laryngeal surface of the epiglottis. Myxomata, or true mucous polypi, are seldom found in the larynx. They are generally of a light gray or pinkish color, commonly trans- lucent; the surface may appear smooth or irregular, and they are soft to the touch. Cystic growths, when found in the larynx, vary in color from a light yellow to a red, and are usually surrounded by a zone of congested mucous membrane. They are round or oval in form, and generally arise BENIGN TUMORS OF THE LARYNY. 467 from the epiglottis or ventricle of Morgagni. They vary in size from three to fifteen millimetres in diameter. They are ordinarily filled with a semi-fluid, sebaceous like material. Fig. 156.— Fibko-Cellular Tumor on Right Vocal Cord. Fig. 157 -Cystic Tumor affecting Base of Left Side of Epiglottis. Fasciculated saecomata, adenomata and lipomata possess no characteristic appearances, and are extremely rare. They may spring from the epiglottis or mucous membrane over the arytenoid cartilages or other parts outside the larynx, but not usually from within it. Fig. 158.— Cystic Growth in Right Ventricular Band. Fig. 159. — Cyst of Epiglottis (Mackenzie). Cartilaginous tumors are extremely rare. Fig. 162 illustrates one of this variety growing from the lower part of the thyroid cartilage. It had a smooth mucous covering, was of a yellowish color and carti- laginous consistence. Fig. 160.— Adenoid Tumor of the Larynx. Fig. 161.— Adenoid Tumor of Larynx, involving Ventricle of Morgagni. Angiomata or vascular tumors are also very rare. They are dark, blackberry-like in color and appearance. They are soft, and bleed easily when touched, and may give rise to severe hemorrhage if removed. Diagnosis. — Granulation tissue such as is frequently found in tu- bercular laryngitis might closely resemble papillary growths, but it is 468 DISEASES OF THE LARYNX. usually lighter in color and softer in consistence, and more or less cov- ered by the same secretions which are seen upon the neighboring ulcer- ated surfaces. The affections most likely to be mistaken for benign growths of the larynx are syphilitic or tubercular laryngitis, lepra, lupus, Fig. 162. — Cartilaginous Tumor of Larynx. Situated just below the vocal cord Fig. 163.— Vascular Tcmor of Larynx, involving Surface of Right Vocal Cord. Fig. 164.— Vascular Tumor of Larynx. Of a deep livid color and raspberry like surface fibrous, cartilaginous, or lymphoid outgrowths, eversion of the ventricles of the larynx, and malignant tumors. Benign growths of the larynx are distinguished from syphilitic con- dylomata as follows: Benign growths of the larynx. Commonly in middle and advanced life; occasionally in children. History of continued local hyperae- mia. Usually found upon the vocal cords or ventricular bands. Distinct line of demarcation between growth and surroundings. Usually no ulceration present. Operative measures usually neces- sarv. Syphilitic condylomata of the larynx. Commonly in early and middle life. History of infection; appearance five or six weeks after inoculation. Usually situated at back part of the larynx. Xo distinct line of demarcation. Ulceration frequently present. Rapid disappearance under anti- syphilitic treatment and use of local astringents. Benign growths of the larynx are distinguished from tubercular laryngitis as follows : Benign growths of the larynx. No cachexia or pulmonary disease. Absence of pain. Hyperemia or normal color of mu- cous membrane ; no ulceration or pe- culiar swelling. Benign papillary tumors less sessile than tubercular granulations: no pu- rulent secretion. TUEERCULAR LARYNGITIS. Usually grave constitutional symp- toms and signs of associated pulmo- nary affection. Usually painful. Pallor of the mucous membrane, with peculiar swelling of the aryte- noids and ulceration. Tubercular fungous granulations are of light color: appear as thickenings rather than outgrowths: and are as- sociated with ulceration and purulent secretion. BENI&N TUMORS OF THE LARYNX. 469 Lepra of the larynx is associated with similar manifestations upon the skin. The epiglottis and lower parts of the larynx are likely to be swollen and nodular, but no distinct tumors are present. Thickening and nodular outgrowths, which are generally soon fol- lowed by ulceration, are caused by lupus / and in nearly, if not quite all cases the disease in the larynx is preceded by ulceration on the face or in the fauces, which will materially aid in the diagnosis. We can recognize outgrowths of various character as merely thicken- ing of the tissues, lacking the distinct demarcation of true tumors. "We might possibly mistake eversion of the ventricle of the larynx for a tumor, but the condition is so extremely rare that the error is not likely to occur. Generally malignant tumors may be recognized through being more thoroughly blended with the surrounding tissues, which become irregu- larly swollen and thickened so that the tumor does not stand out dis- tinctly, an appearance very unlike that of benign growths. In some cases where diagnosis by inspection is extremely difficult, the presence of pain, the constitutional symptoms apparent in the later stages, the ulceration of the growth and the microscopic appearances, must all be considered in drawing a conclusion. Prognosis. — The growths tend to increase in size slowly or rapidly, according to their character, except in very rare instances of papillomata where sjDontaneous atrophy or expulsion may take place. Growths in the larynx which cannot be removed are always danger- ous, especially in young children, in whom smallness of the organ and disposition to spasm enhance the danger. In children, these tumors are more dangerous than in adults, because of the difficulty of endo-laryngeal operations, and the less favorable results of tracheotomy; an operation which if successful, removes one of the serious dangers by averting the tendency to suffocation. This operation, however, is often grave in young children, and is far from being devoid of danger in adults; for in either, a fatal bronchitis not infrequently supervenes. As regards the voice, the prognosis is favorable where the growth is single and pedunculated and an endo-laryngeal operation can be performed. In the opposite condition the prognosis is necessarily less favorable. Some forms of papillomata show a strong disposition to reproduction after removal. With the exception of sarcomata or carcinomata, other laryn- geal growths seldom recur. Treatment. — Small growths in the larynx situated above the vocal cords commonly cause little or no inconvenience, and often, especially when fibrous, enlarge but slowly. In such instances, active inter- ference is unnecessary, provided the growth can be inspected once or twice a year. Even when the tumor is situated upon the cords, causing more or less complete aphonia, it is frequently wise not to interfere, especially in the aged or in those whose occupation renders the voice 47U DISEASES OF THE LARYNX. relatively of little importance. Even the most skilful])- performed endo-laryngeal operations are not entirely devoid of danger, and occa- sionally they excite sufficient inflammation of the soft parts, cartilages, or perichondrium, to render tracheotomy necessary; and it is possible, though not probable, that the irritation of frequent attempts at removal may cause a benign growth to take on malignancy. Palliative treatment consists in the application of various astringent remedies, which sometimes apparently retard the growth; and where respiration is seriously impeded in the performance of tracheotomy or the introduction of an O'Dwyer's laryngeal tube. The latter is to be first recommended in most cases, because the pressure which it exerts may possibly cause atrophy of the growth, and the relief of dyspnoea is usually complete except in cases of large tumors at the upper part of the larynx, which may fall over the opening in the tube. Radical treatment for the destruction or the removal of the growth should in nearly all cases be carried out through the natural passage by the endo-laryngeal method; but in exceptional instances laryngotomy or a combination of the exo-laryngeal and endo-laryngeal methods may be required. The endo-laryngeal removal of neoplasms may be accom- plished by chemical or mechanical means, or by a combination of the two. Local treatment by astringents or mild caustics is sometimes ben- eficial, especially in removing concomitant inflammation, and so possibly preventing increased growth of the tumor. Mild caustics have little effect upon the growth itself, but accurate applications of escharotics, especially chromic acid, are not infrequently followed by most satisfac- tory results. The same may be said of the galvano-cautery and, with less confidence, of solid silver nitrate. Usually before any endo-laryn- geal operation is commenced for the removal of growths, the parts should be thoroughly anaesthetized by several applications, by spray or swab, of a ten per cent to twenty-five per cent solution of cocaine or the solution recommended for anaesthetizing the nasal mucous membrane (Form. 14-°)). This done, silver nitrate or chromic acid fused upon the end of an aluminium probe, and protected to prevent contact with other por- tions of the larynx, should be accurately applied to the growth with the aid of the laryngoscope. The skilful laryngologist may sometimes apply the escharotic without injuring other parts, by means of an un- guarded probe, but it is safer to employ some of the various instruments de- signed to prevent accidental contacts. The simplest, and to me the most satisfactory instrument is a comparatively stiff aluminium-wire probe, over which has been slipped a section of small rubber tubing about half an inch in length; about this tubing is tied, with a slip-knot, a piece of silk thread which is then wound about the stem and carried up to the handle, thus preventing the possibility of the tube slipping off into the trachea. The tube is slipped upward upon the stem while the caustic is being fused upon the probe and is pushed back to the end of the in- BENIGN TUMORS OF THE LARYNX. 471 strument when it has cooled. When it is desired to cauterize with the end of the probe only, the rubber tube is pushed down far enough to completely protect the caustic, for as the instrument is pressed upon the growth the elasticity of the rubber will allow the end to protrude sufficiently. If, however, it is desired to touch the tumor with the side Fig. 165— Common Laryngeal Forceps Qi size). These are grasping and cutting forceps bent at the proper angle, and with beak of the needed length, that the larynx may be reached with ease. of the probe close to its end, a small piece may be cut out of the rubber tube at this point, which can then be turned so as to expose the proper part. This was shown under trachoma of the vocal cords (Fig. 110). As soon as the escharotic has been applied, the instrument is quickly withdrawn without injury to other tissues. Various other instruments 472 DISEASES OF THE ZARY&X. have been devised for this purpose, the meet satisfactory of which are those recommended by Sajous, of Philadelphia, and Jarvis, of New York. The galvano-rautery is sometimes an excellent instrument for de- stroying these growths. It is important that the electrode employed should have a small platinum point which will heat or cool rapidly, other- wise much damage may be done to surrounding tissues. This cautery is more difficult to use than chromic acid, and is usually less satisfactory in its results, though in some cases it is preferable. The most satisfac- tory handle is one in which the circuit is closed by removing the finger from the button (Fig. Ill), instead of one in which the button must be pressed, as the former causes less movement of the end of the electrode. The mechanical treatment of these tumors is carried out by friction, evulsion, and crushing or cutting, which may be performed by various snares, ecraseurs, forceps, scissors, or knives. Fig. 16ti. — Mackenzie's Tube FoRctPS Q£ ordinary size). As a rule, patients cannot be operated upon under general anaesthesia unless tracheotomy has first been performed ; but since the discovery of the local anaesthetic properties of cocaine, it is seldom necessary to do a preliminary tracheotomy except in young children. Friction — VbltoZini's Method. — The simplest and sometimes the most efficient measure for mechanical destruction of laryngeal tumors is per- formed with a sponge firmly fastened to a staff preferably made of mal- leable steel. This is passed into the larynx, and, with the finger and thumb of the left hand holding the organ as firmly as possible, it is rubbed vigorously up and down for two or three times and then re- moved. The operation may be repeated after a week or ten days. In case of soft tumors, it will frequently be successful. This operation is peculiarly adapted to the laryngeal growths of infants, which are gen- erally of a papillary character and difficult to remove by forceps. In these patients it is more easily carried out if tracheotomy has first been performed and a general anaesthetic given. The probang may then be carried into the larynx by the aid of the index finger of the left hand, and the treatment accomplished without pain. As a rule, an expert may do this operation without previous tracheotomy, but O'Dwyers tube or Schrotter's dilator should be at hand for use in case of prolonged spasm of the glottis. BENIGN TUMORS OF THE LARYNX 473 F. H. Hooper, of Boston, recommends operating on these growths by forceps in children, who are thoroughly anaesthetized by ether and held by the nurse in a sitting posture so that the laryngoscope may be readily used. Under such cir- cumstances, previous tracheotomy renders the operation easier, but it is not al- ways necessary {International Clinics, October, 1891). Fig. 167.— Stoere/s Instruments: .4, ficraseur: B, C. (?, and H. gruillotines of various size and form ; 1), K, F, forceps blades of different kinds. Evulsion is effected with various forms of snares, forceps, or ecra- seurs. The snare forceps of Jarvis (Transactions of the American Laryngological Association, 1886) may be useful for removing growths below the cords in some cases. Evulsion is the method most commonly adopted and is most applicable to comparatively soft growths. 474 DISEASES OF THE LAB YAW. Crushing may sometimes be accomplished with stout forceps, and is especially applicable to firm growths where undue force would be necessary for their evulsion. Not infrequently a tumor which has been firmly nipped with forceps will be found to atrophy and completely dis- appear within two or three weeks. Catting operations are most frequently accomplished with cutting for- ceps, snares, or ecraseurs, though scissors and knives are sometimes useful. A guarded instrument should generally be selected for the purpose, and none but experts should use any other. For the removal of firm growths some form of snare, guillotine, or Mackenzie's guarded-wheel ecraseur is peculiarly serviceable. It is not well to repeat attempts at removal of these tumors more than three of four times at a sitting, because of the danger of setting up undue inflammation or possibly cedema. fl/bWijlVsYr Fig. 168.— Tobold's Laryngeal Knives (\\ size). After the operation, it is my custom to have cold applications made to the neck for from twelve to twenty- four hours, and subsequently to apply to the larynx once a day, or less frequently, some mild astringent spray for the purpose of reducing congestion. Extra- laryngeal methods, either by tracheotomy or thyrotomy, are of doubtful propriety in most cases— excepting where a growth interferes with respiration or deglutition — because by these operations the vocal function is apt to be entirely destroyed and life is often endangered. Thyrotomy. — It is occasionally, though not often, necessary to do a preliminary tracheotomy when thyrotomy is to be performed, but then the latter operation should be delayed for several weeks, and in the mean time the surgeon should attempt to remove the growth by endo- laryngeal means or through the opening in the trachea. For division of the thyroid cartilage, the patient should be placed with the head hanging over the end of the table, in the lap of the surgeon, who is seated at the end of the table with his back to the window. The pri- mary incision is made in the median line from the cricoid cartilage to the thyroid notch. The thyroid cartilage should then be carefully divided with a strong knife or, if ossification has taken place, with a small circular or convex saw. If possible, a small portion of the upper part of the thyroid cartilage should be left intact, in order that the parts may be accurately approximated afterward, so as to maintain the proper BENIGN TUMORS OF THE LARYNX. 475 relation of the vocal cords to each other. In order to avoid paroxysms of coughing, great care should be exercised that the instrument does not penetrate through the mucous membrane into the larynx before the car- tilage has been thoroughly divided. AVhen the division is complete, the alse should be drawn apart by blunt pointed retractors. If this cannot be done, the crico-thyroid membrane should be divided along the lower border of the thyroid cartilage, on one or both sides as may be found neces- sary. The division of this membrane, however, is quite apt to injure subsequent vocalization, owing to the direct continuity of the vocal cords with it, as pointed out by Joseph Leidy (Transactions of the American Laryngological Association, 1886). If the opening still remains too small the thyro-hyoid membrane should be divided along the upper border of the thyroid cartilage, but this is not generally necessary, and should be avoided if possible. When a sufficient opening has been attained, the ahe are held back with retractors, the cavity is carefully cleansed of blood, and under a bright light the tumor is seized with hook or forceps and torn off or divided with strong curved scissors. After the growth has been removed, Mackenzie recommends that the base be thoroughly cauterized with solid sliver nitrate, which, he states, is less liable to cause a subsequent laryngitis than the galvano- cautery, or other escha- rotic, and seems quite as efficacious on a raw surface (Diseases of the Throat and Nose). The alas of the thyroid are then carefully ap- proximated and fastened together in their normal position by two silver sutures, and the e.lges of the. wound carefully closed. If trache- otomy has been previously done, the tube should be allowed to remain until all danger from laryngitis has passed and the surgeon is confident that no other operation will be needed for destruction of the growth. Sometimes the firmness of the tumor or its extensive attachments pre- vent perfect removal, so that the operation must be abandoned without being completed; in such instances, as much as possible of the tumor should be removed, and the cut surface thoroughly cauterized with silver nitrate. Krishaber (Tait's Cliniques de Laryngotomie, Paris. 1869) says that division of the cricoid cartilage is never necessary for the removal of tumors above the cords, and that those below can be easily removed through the crico-thyroid membrane or the opening in the trachea. The operation, though not extremely difficult, is attended by some degree of immediate or consecutive danger to life from primary or secondary hemorrhage or inflammation of the air passages; therefore it should not be undertaken without due consideration of the possible consequences. Mackenzie has shown that in the majority of cases the voice is lost, and that the tendency to recurrence is quite as great as when the growth has been removed through the natural passages. Supra-thyroid laryxgotomy is accomplished by a transverse in- cision through the superficial tissues and thyro-hyoid membrane, either along the lower border of the hyoid bone or the upper border of the 476 DISEASES OF THE LARYNX. thyroid cartilage. It is less dangerous than division of the thyroid car- tilage, but it is of very little service, because the growths which could be removed by this method can usually be equally well removed through the mouth. Intra-thyroid laryxgotomy, that is, through the crico-thyroid membrane, according to Mackenzie, has been strongly recommended by Paul Bruns for the extirpation of growths originating from the free borders or under surface of the vocal cords, or below the glottis, provided previous endo-laryngeal operations have been unsuccessful. Sometimes division of the membrane alone is sufficient, but large or sessile tumors may require division of the cricoid cartilage or of some rings of the tra- chea also. The operation is done in the manner recommended for crico- thyroid laryngotomy, but all soft tissues are carefully dissected out from the crico-thyroid opening, so that only its cartilaginous borders remain. A canula is then inserted and allowed to remain for several days until acute inflammation has subsided; it is then removed, the head is thrown back so as to make the opening as large as possible, the growth located by an infra-glottic mirror, which is then removed, and the tumor is torn off by short forceps. When the crico-thyroid opening is too small, trache- otomy should be performed in the first instance. After the inflamma- tion has subsided, the edges of the wound should be drawn back and the attempt made to remove the tumor. The patient should wear the canula for a few months afterward, until the surgeon is convinced that recurrence will not take place. MALIGNANT TUMORS OF THE LARYNX The term cancer of the larynx embraces a variety of tumors of which epithelioma is by far the most frequent, and sarcoma next. Fauvel, Cohen, Bosworth and Gottstein also recognize medullary or encephaloid, and scirrhous, as possible varieties of cancer in this locality. Such growths give rise to hoarseness, dyspnoea, pain, sometimes dysphagia, and finally, in most cases, to that peculiar cachexia which generally attends malignant tumors. Anatomical and Pathological Characteristics. — The growth of these tumors is first manifested by localized hyperemia, with thick- ening of the parts which gradually increases, progressively involving all the subjacent tissues in the cancerous process. By a process of cell pro- liferation a large irregular tumor is formed intimately blended with the surrounding structures and early undergoing ulceration, which ultimately causes deep and widespread destruction of the parts. The microscopi- cal appearances of these growths, and their causes, are similar to those of like growths in other localities. Symptomatology. — The symptoms vary with the size, location, and condition of the growth. Pain, usually lancinating in character, is com- MALIGNANT TUMORS OF THE LARYNX. 477 tnonly present. This, at first, is generally confined to the larynx, and is not particularly severe, but after ulceration occurs, it becomes intense and frequently radiates to the ears and occasionally to the submaxillary and cervical glands. Mackenzie states that early external evidences of laryn- geal cancer are seldom present (Diseases of the Throat and Nose). Fig. 169.— Cancer of Larynx. Subglottic. Fig. 170.— Cancer of Larynx. Ary-epiglottie fold. In most cases after the disease has progressed for a few months the submaxillary or cervical glands, especially those near the cornua of the hyoid bone, will be found affected, and undue prominence of the thyroid cartilage may be seen or felt. In rare cases ulceration extends to the surface. Hoarseness is an early symptom, but the voice is seldom en- tirely lost. Dyspnoea on exertion is frequently an early occurrence; and later may be constant or subject to severe paroxysms. When ulcera- tion has taken place, usually the breath has a peculiar fetor which is Fig. 171.— Cancer of Larynx. and Arytenoid. Epiglottis Fig. 172.— Cancer of Larynx. Arytenoid. almost diagnostic. Sensations as of a foreign body in the throat cause frequent efforts for its expulsion, but cough is not a prominent symp- tom. The amount of secretion from the ulcers themselves is not very large, but there is profuse salivation which causes the patient great in- convenience or distress. The sputum consists of muco-pus, frequently tinged with blood; sometimes there is profuse hemorrhage. Dysphagia often attended by some pain is an early symptom with pharyngo- laryngeal epithelioma. When the disease is confined to the interior of the larynx, this symptom is not experienced so early, but later it is always present. Upon inspection the neoplasm appears at first as a circumscribed 478 DISEASES OF THE LARYNX. area of congestion and submucous thickening, the borders of which are not well defined. Usually it is located upon one of the ventricular bands; but occasionally the vocal cords, epiglottis, or ary-epiglottic folds are first affected. In color the growths vary from light red to scarlet Epitheliomata usually have the deeper hue. The most characteristic Fig. 173.— Cancer of Larynx. Supra-glottic. Fig. 174. —Canter op Larynx. Ventricular Bands. feature of malignant tumors in the larynx is the great deformity which attends their progress. As the process of proliferation and infiltration of the surrounding tissues advances, the growth which at first appeared as a limited area of submucous thickening without well defined borders presents a raised and irregularly nodular surface. These tumors may be single or multiple, and usually attain a large size-two or more centimetres in diameter. Laryngeal sarcomata are soft, light in color bleed easily, and ulcerate early. In epithelioma this process may be Fig. 175. 1- ig. 1«G. Fig. 175—Mixed Sarcoma. This tumor was found in a man about fifty years of ae-e who h»r< been troub.ed with dysphonia for about two years, and with some dyspncel'for a ew months S growth was so firm as to resist attempts at evulsion or crushing. I. N. Danforth made a micro scop.c exannnatton of some portions which I removed, and pronounced it a mixed sarcoma Fig. 1,6 -Cancer of the Larynx. Vocal Cord. This growth was supposed to be a slnmfe papilloma, but a microscopic examination showed it to be of a semi-malignant ela acter Tbout r ^ ra^coSr^ ^ "^ «— * ^ ™» r ™ - ^-epSttic^: long delayed. In either case, whether occurring early or late, the ul- ceration steadily progresses without any attempt at repair. Where both the pharynx and the larynx are involved, ulceration usually first occurs at the free edge of the epiglottis or on the glosso-epiglottic or ary- epiglottic folds, and quickly extends to the deeper portions of the larynx. The epiglottis is frequently so much swollen that the lower portions of MALIGNANT TUMORS OF THE LARYNX. 47 9 the larynx cannot be seen, but occasionally it is slowly destroyed with- out much tumefaction. Ulceration usually commences at a single point, though sometimes two or more ulcerated spots may be seen in the be- ginning. "When the disease is advanced, a large surface or the whole mass of the tumor appears in a state of fungous ulceration, bathed in an offensive, purulent secretion. Diagnosis. — In the early stages an accurate diagnosis of cancer of the larynx is often difficult and may be impossible, but as the disease progresses it can generally be readily recognized by the experienced laryngologist. Cancer of the larynx is to be distinguished from syphilis, chronic catarrhal inflammation, lupus, tubercular laryngitis, and benign growths. The essential points in the diagnosis are: the age of the patient, the pain, irregular thickening with marked deformity, extensive ulceration, glandular enlargement, and the microscopic ap- pearance. Cancer of the larynx is distinguished from syphilis by the history, the absence of cicatricial tissue, the more or less distinct tumor instead of simple thickening, the progressive ulceration in spite of treatment, and, in some cases, by the cancerous cachexia and by the effect of the iodides on the body weight. In tertiary syphilis free administration of the iodides, as a rule, is speedily followed by increase of weight, with other evidences of general improvement; whereas in malignant disease, although at first slight improvement may apparently follow the admin- istration of these remedies, it is soon observed that the weight is steadily diminishing and the strength failing. Great thickening seldom, and large ulcerating tumors never, arise from chronic catarrhal inflammation of the larynx, although occasionally considerable thickening and deformity of the parts is present; but in these instances the history of long continued inflammation and absence of the peculiar lancinating pain, of deep ulceration, or of a malignant cachexia and of the glandular enlargement establish the diagnosis. We have in lupus a slowly progressive disease occurring most often in young subjects: its development in the larynx is preceded by its ap- pearance upon the face or fauces. It is attended by little or no pain and comparatively slight swelling. The ulceration progresses but slowly, and repair may follow at some points. There is not the cachexia which is frequently witnessed in the patients of more advanced age suffering from cancer. Cancer of the larynx is distinguished from tubercular laryngitis by the history, the absence of pulmonary disease and severe cough, the presence of an irregular tumor instead of the more or less uniform thickening, and the deep destructive ulceration, with the peculiar fetid breath. In tubeiculosis when the epiglottis is involved, swelling is com- paratively uniform over the whole valve, and when the arytenoids or ary-epiglottic folds are affected there is a peculiar pyriform appearance 180 DISEASES OF THE LARYNX. commonly on both sides, not observed in cancer. The swollen tissues in tuberculosis, so long as ulceration has not taken place, are usually lighter in color and less dense than in the malignant tumor. The sar- comata have an irregular surface and the appearance of an abnormal growth, quite distinct from the more or less uniform swelling of tuber- culosis. When ulceration takes place in tuberculosis, it is usually super- ficial, though sometimes deep and destructive; but by the time the lat- ter occurs, the hectic and cough, the cachexia and pulmonary signs, will at once indicate the nature of the disease. In the early stage or until ulceration occurs, it is often very difficult to distinguish malignant growths from benign tumors. During the course of cancer, before ulceration has occurred, the age (past middle life), the pain, the irregularly defined tumor of a dirty gray or bright red color, with almost constant glandular infiltration in pharyngo- laryngeal cancer, and the occasional occurrence in in tra-laryngeal cancer of glandular enlargement farther down the trachea at the root of the neck, renders the diagnosis fairly certain. Prognosis. — Cancer of the larynx sometimes terminates fatally within from three mouths to a year; but the average duration is about eighteen months. Epithelioma is sure to terminate fatally, though life in some instances may be considerably prolonged by operative measures. Sarcoma may probably be completely eradicated in some cases. Death is finally caused by inanition, asthenia, asphyxia, or hemorrhage. Treatment. — All medicinal means have proved inefficient in check- ing the onward progress of the disease. There are certainly no specifies, and all drugs fail in the end ; even those which are held in most es- teem, such as arsenious acid, calcium sulphide, iodoform, carbolic acid, ergot, mercury, and turpentine. As a palliative remedy to relieve pain, opium in some form, and belladonna or cocaine are of importance. Morphine, tannic, acid, and carbolic acid locally (Form. 139, 148) ren- der the ulcer less painful and offensive. Continuous heat is especially valuable in relieving the severe earache which often attends this disease. Anti-syphilitic remedies should be thoroughly tried in all cases where there is any doubt as to the diagnosis, and sometimes they apparently check the progress of the disease for a short time. Surgical measures should be adopted in all suitable cases. These are : endo-laryngeal at- tempts at removal; endo-laryngeal cauterizations; tracheotomy; resec- tion of the larynx: extirpation of the larynx. It frequently happens that the true nature of the laryngeal growth cannot be determined at first, and under such circumstances its re- moval by endo-laryngeal methods should be attempted when there is any probability of success. In a doubtful case portions of the tumor should be subjected to microscopic examination and if cancer is demon- strated, all endo-laryngeal operations not calculated to effect complete eradication should be discontinued, except in extreme cases where re- MALIGNANT TUMORS OF THE LARYNX. 481 moval of portions of the growth will prevent suffocation. In cancer, partial operations hpon the tumor usually accelerate its growth. Lennox Browne (" Diseases of the Throat," second edition) recom- mends endo-laryngeal cauterizations in certain cases confined to the epi- glottis, and not susceptible of removal. However, he justly remarks that he fears the benefit of such measures is but temporary. Though I have never practised cauterization of laryngeal cancers, my experience with it in cancerous growths of the nasal passages leads to the belief that in this affection, as a rule, it would be j)roductive of more harm than good. Tracheotomy to prevent suffocation is frequently necessary, and may prolong life from three to twelve or even eighteen months. In case of myxo-sarcoma, I have known life thus prolonged for four or five years. Eesection, or partial extirpation of the larynx, in suitable cases, has been attended with very favorable results, where complete extirpa- tion of the disease is possible by removal of the epiglottis or the lateral half of the larynx. This operation is indicated in small endo-laryngeal epitheliomata confined to one side, and in sarcomata not yet markedlv infiltrating. It is useless when the larynx is invaded from the pharynx and whenever the adjoining structures and cervical glands are involved. Immediately fatal results have followed this operation in only a small percentage of cases, and usually life has been very considerably pro- longed; in a few instances the disease seems to have been completely eradicated. The following description of the operation is taken from the report of a case by Lennox Browne (op. cit.) : The patient being anaesthetized a high tracheotome was done, and Hahn's tampon canula introduced for twenty minutes, which time was allowed for the compressed sponge about the canula to expand. A median incision over the thyroid was made from just above the tracheal opening to the hyoid bone. The tissues were carefully divided down to the thyroid and cricoid cartilage ; the soft parts, with the perichondrium, were carefully lifted with a raspatoiy, the peri- chondrium being peeled away from the cartilage, while its relations to the soft parts remained undisturbed. The separation was carried back as far as the median line of the boundary between the larynx and pharynx, solely by the use of the one instrument. Part of the hyoid attachment of the thyro-hyoid muscle was divided, but the horizontal incision over the hyoid bone, as recommended by Hahn, was unnecessary. The thyroid cartilage was then split in the median line by cutting-forceps. The attachments to the pharynx were further separated by the raspatory, knife handle and finger nail, and the thyro-hyoid membrane was divided close to its thyroid attachment, the superior cornu of the thyroid carti- lage cut off by sharp pliers, and the cricoid cartilage severed with the same instru- ment in the median line in front and behind. The divided half of the larynx was then separated from the first ring of the trachea and removed entire. There was but little hemorrhage, and only two small blood vessels required torsion, the comparative freedom from hemorrhage being due to the use of the raspatory in keeping close to the cartilage. Laryngectomy, or extirpation of the larynx, has been recommended and practised in many instances, yet with but few successes. Since the 3 1 482 DISEASE* OF THE LARYNX. operation involves great danger, and the patient's subsequent condi- tion is most wretched, it should not be advised, unless we are confident that the disease is wholly confined to the larynx, and then only after the patient has been fully apprised of the danger and probable results. The operation is described by Mackenzie as follows : A vertical incision should be made from the hyoid bone to the second ring of the trachea, and the front and sides of the larynx should be thoroughly freed and exposed by careful dissection, partly with the cutting blade of the scalpel, but as far as possible with its handle. Should there be any decided arterial hemorrhage, the necessary ligatures must be applied. The trachea should be drawn forward with a hook, and cut across, care being taken to avoid penetrat- ing the oesophagus. A siphon tube of vulcanite is then to be inserted into the windpipe. In order that the siphon may fit accurately, it is well to have at hand several tubes of different sizes. The upper and posterior attachments of the lar- ynx should next be cut through, but in dissecting out the cricoid cartilage the risk of button-holing the gullet must be avoided by keeping the knife close to the cartilage (" Diseases of the Throat "). Sometimes the whole larynx must be removed, but not infrequently the superior cornua of the thyroid cartilage may be left. Hemorrhage may be stopped by ligature or torsion, or by some styptic solution. When the surfaces have healed and the gap in the throat has partially contracted, Gussenbauer's artificial larynx may be used. Though from the description the operation seems very simple, the disease will often be found more extensive than anticipated, making the procedure most formidable. J. Solis Cohen has recommended a modified form of laryn- gectomy (Transactions of the American Laryngological Association, 1887), which appears to offer many advantages over the ordinary opera- tion, when the disease is not extensive. As claimed, the wound is small, the operation may be done rapidly and with comparative safety to the patient, the attachments of many of the ligaments and muscles are preserved, important functional structures retained, and a firm natural support is left for an artificial larynx. His description of the opera- tion is as follows: 1st. Make an incision from the hyoid bone to the lower border of the cricoid cartilage and exactly in the median line. 2d. Carefully separate the sterno-hyoid muscles. 3d. Hold the soft parts aside and insert from above one blade of a strong cutting foiveps, with narrow blades, beneath one wing of the thyroid car- tilage, one-fourth inch from the angle of junction with its fellow, and sever the cartilage vertically its entire length to the crieo-thyroid membrane. 4th. Make a similar cut on the opposite side. 5th. Seize the freed angular portion of the thyroid cartilage comprising its entire respiratory contingent with a vulcellum forceps and draw it to either side, the soft parts being separated meanwhile, from the inner surfaces of the attached wings of the thyroid cartilages, with the handle of the scalpel. 6th. Make a transverse cut to sever the cricoid cartilage from the trachea. At this step in the living subject, a sterilized cotton plug should be inserted into the upper end of the trachea, preliminary tracheotomy TRACHEAL TUMORS. 483 having been performed previously. (If the cricoid cartilage is to be retained, dis- articulate the arytenoids and then sever the soft parts above the cricoid instead of below. This modifies the next step in the procedure accordingly.) 7th. Lift the cricoid cartilage forward, and carefully separate it with the edge of the knife from the inferior cornua of the thyroid laterally and superiorly, the nfrom the oesophagus posteriorly. 8th. Insert a finger into the pharynx from below and carry its tip over the epiglottis to draw that structure down. 9th. Divide the thyro-hyoid membrane and the fibrous tissues still holding. 10th. Lift out the exsected respiratory portion of the larynx. The arteries likely to require ligation will comprise small branches of the superior, middle, and inferior laryngeals. The operation should be strictly aseptic, and where practicable should liave been preceded several days by a preliminary tracheotomy. George E. Fowler has adopted this operation once for the removal of an epithe- liomatous larynx, with most satisfactory results {American Journal, of Medical Sciences, October, 1890). Gussenbauer's artificial larynx was placed in position on the forty-first day, and on the seventy-third day after the operation the patient was discharged, and was able to speak in a loud whisper without the aid of the artificial larynx. Sev- eral months later there was no evidence of recurrence, and the patient remained in good health. EVERSION OF THE VENTRICLE OF MORGAGNI. The eversion of the ventricle of Morgagni is a very rare occurrence. I am not aware that more than three cases are on record. One of these was diagnosticated before death by George M. Lefferts {Neio York Medi- cal Record, June, 1876), but the others were not detected until the autopsy; therefore we are unable to give any distinctive signs. The condition is likely to be mistaken for a morbid growth. In the case reported by Lefferts thyrotomy was performed, and the everted saccu- lus cut off with scissors. TRACHEAL TUMORS. Laryngeal and tracheal diseases, as already noted, are so nearly re- lated that it is most convenient to consider them in close connection. Tumors in the trachea are extremely uncommon. Those at its upper extremity may generally be seen by laryngoscopic examination, but it may be difficult to determine whether they are located below the cricoid cartilage or in the lower part of the larynx. Great care must always be observed in the diagnosis of disease in the trachea, otherwise we are apt to be misled by imperfect reflection of the light. Poor illumination may apparently reveal objects which do not exist. I have seen but three cases of tracheal tumor: one a large growth, as represented in the cut, and two others, papillary growths, upon the anterior wall of the 4*4 DISEASES OF THE LARYNX. trachea about two inches below the glottis. Tumors in this situation may be either benign or malignant. Etiology. — The causes are similar to those of corresponding tumors in the larynx. Symptomatology. — These neoplasms when small cause no distinc- tive symptoms, but as they increase in size dyspnoea results and there is usually considerable cough and some expectoration. Upon inspection the growth usually presents a cauliflower or papillary appearance, some- times congested, occasionally semi-transparent. It is usually sessile, but it may be pedunculated. Diagnosis. — A diagnosis can only be made by laryngoscopic ex- amination, and the exclusion of tracheal involution and syphilitic strictures. Prognosis. — The duration varies greatly according to the nature of the tumor, but the affection is ultimately fatal in the majority of cases. Fig. 177. — Tumor in Upper Part of Trachea. This tumor occurred in a patient about sixty years of age, but owing to the large size of his trachea it gave him very little inconvenience, and therefore he declined to have any attempt made for its removal. The symptoms in the case were hoarseness and moderate dyspnoea. Sometimes the growth maybe removed, but usually it is so deeply seated that it is reached with difficulty and the patient eventually dies of suffocation. Treatment. — When practicable, the tumor should be removed through the mouth by means of forceps or the snare, or destroyed with chromic acid. In either case the parts should first be thoroughly anaes- thetized by cocaine, and the operation performed with great care and precision. It is quite possible that some cases may be relieved by the introduction of an O'Dwyer tube, which by continuous pressure may cause absorption of the growth; but if the tumor cannot be reached by any of these methods, and respiration is seriously obstructed, trache- otomy should be performed, and if possible the growth removed by the cutting- forceps. Otherwise a long, flexible tracheal tube should be introduced and allowed to remain. Malignant tumors in the trachea are necessarily fatal, and no form of treatment will be found of value, excepting palliative measures some- times of a general, and sometimes of a local nature. INVOLUTION OF THE TRACHEA. 485 POST-TRACHEOTOMY VEGETATIONS. After tracheotomy, especially where the tube has been worn for more than two or three weeks, not infrequently granulations spring up about the point of incision in the trachea, which more or less occlude its cali- bre, and, when the canula is removed, interfere with respiration. In some instances true papillary growths are developed. Etiology. — These vegetations are apparently due to irritation caused by the tracheal canula, especially where one with a fenestra has been used. Symptomatology. — While the tracheal tube remains in place, no difficulty is experienced; but on its removal, respiration is impeded, or may be completely obstructed, by the abnormal growth. Diagnosis. — The symptoms already named will immediately sug- gest the nature of the affection, but an accurate diagnosis must rest upon the exclusion of stenosis by a careful inspection of the tracheal wound and of the larynx. It will be necessary in some instances to Fig. 178. — Lngals' Punch Forceps (3^ size). They were devised to remove granulations in the trachea, but are also serviceable for certain cutting operations on the nose or throat. pass a Schrotter dilator through the larynx to crowd the vegetation downward before it can be seen at the opening in the trachea. Prognosis. — The cases are usually very difficult to remedy, and in a few instances it has been impossible to remove the tracheal canula. Treatment. — Under general anaesthesia, the granulations should be removed by forceps, and their bases cauterized by silver nitrate ; or they may be destroyed by chromic acid or the galvano-cautery. It is some- times very difficult to grasp these with ordinary forceps, and in such instances a pair of punch forceps (Pig. 178) which I have had made specially for these cases will be found very serviceable. Sometimes it will be necessary to crowd the growth down, with Schrotter's dilator or some similar instrument introduced through the larynx, before it can be reached at the tracheal wound. Two or three such cases have been cured by wearing for a short time an O'Dwyer tube; but it is not wise to allow the tracheal wound to heal until we are certain that the vege- tations have been completely removed. In some instances the laryngo- tracheal tube shown in the article on stenosis of the larynx (Fig. 148) will be found necessary. INVOLUTION OP THE TRACHEA. Involution of the trachea consists of bulging inward of its walls re- sulting from external pressure. It is characterized by dyspnoea pro- portionate to the obstruction of the tube. 4si; DISEASES OF THE LARYNX. Etiology. — It may be due to pressure upon the trachea by an en- larged thyroid gland, or aneurismal tumor, or by substernal syphilitic growths, and rarely by disease of the cervical glands. Symptomatology. — The chief symptom is dyspnoea, increased by exertion, and sometimes occurring in severe paroxysms dependent upon swelling of the mucous membrane or partial closure of the opening by tenacious mucus. Diagnosis. — The affection is to be distinguished from asthma or any disease causing obstruction of the glottis. It can only be diagnos- ticated by exclusion after a careful laryngoscopic examination and con- sideration of the history, physical signs, and symptoms. For this in- spection, a bright light must be carefully focused upon the parts to be examined. Unless one is thoroughly familiar with the appearance of the region, it is easy to make an error on account of the peculiar re- flection of the light. Prognosis. — The prognosis depends upon the amount of obstruction and the nature of the growth causing the pressure, but sooner or later most cases prove fatal. Treatment. — If practicable, the cause of the pressure should be re- moved; if not, tracheotomy aud the employment of Kdnig's long, fle? ible canula (Max Schiiller, " Tracheotomie," u. s. w., Deutsche Chirurgie, L880) will afford the most relief. TRACHEOCELE. Tracheocele consists of a hernial protrusion of the mucous mem- brane of the trachea between its cartilaginous rings. Several cases have been reported by Larry under the title of Aerial Goitre. Anatomical and Pathological Characteristics. — The sac is generally lined with mucous membrane and contains some muco-puru- leut secretion. The walls of the sac vary according as it remains under the muscles or becomes subcutaneous. Etiology. — The origin of the disease is usually obscure, though in most instances it apparently results from accidental straining. Macken- zie cites two congenital cases (Diseases of the Throat and Nose). Symptomatology'. — The voice may be weak and there is occasional dvspncea. During ordinary respiration there may be but slight fulness in the front of the neck; but on forced expiration with the mouth and nose closed, or during cough, a tense, circumscribed swelling appears upon the front of the neck, the position corresponding nearly to that of the thyroid gland — sometimes median, sometimes upon one or the other side, occasionally bilateral. By pressure while the patient stops breathing or during inspiration, the tumor can usually be made to dis- appear almost entirely, although the thickened sac can ordinarily be felt under the skin. SYPHILIS OF THE TRACHEA. 4S7 Diagnosis. — The diagnosis is made by causing the patient to expire forcibly with. nose and mouth closed, or to cough, which will make the tumor distinct ; then by pressure during inspiration it may be reduced. The varying size of the tumor, its increase on obstructed expiration, the impulse during cough conveyed on palpation, together with the other signs just mentioned, render the diagnosis certain. Prognosis. — When congenital, the affection will usually last a life- time; but when due to accident, it may disappear spontaneously, or, if not, it can usually be cured by an appropriate appliance. It is not dan- gerous to life. Treatment. — Some mechanical appliance to prevent undue disten- tion of the sac is indicated and thus its enlargement may be retarded. Surgical interference has not proved advisable in the majority of cases. SYPHILIS OF THE TRACHEA. Various pathological changes are met with in the trachea similar to those found in the secondary and tertiary stages of syphilis affecting mucous membranes elsewhere, but they are comparatively rare, Fig. 179.— Tracheal Pustule. Specific. Anatomical and Pathological Characteristics. — Simple con- gestion or superficial ulceration, projecting ridges, small ulcers, and oc- casional ulcers of a larger size are observed. In the tertiary stage, gum- matous deposits in the submucous tissue seem usually to constitute the first change. These soften, leaving ulcers that on healing result in dense cicatricial tissue, accompanied by contraction and stenosis. Dilatation may occur above and below the stricture so formed. These changes usually extend over a large superficial area, and through the whole thickness of the tracheal wall; even the tissues surrounding it may be involved. Most frequently the lower portion of the trachea is the seat of the disease. The tube itself is sometimes shortened, according to Mackenzie, but stricture is the most common condition. Etiology. — The localized phenomena mentioned may be the result either of congenital or acquired syphilis. Symptomatology. — Tickling sensations in the trachea, a disposition to cough, and occasional expectoration of mucus or muco-pus, with more or less alteration of the voice in consequence of congestion of the cords 488 DISEASES OF THE LARYNX. or the collection of mucus upon them, and other symptoms of catarrhal tracheitis are the common symptoms, except where there is obstruction from growths or from stricture. Condylomata of considerable size or marked stenosis of the trachea cause dyspnoea proportionate to the ob- struction of the tube; this is usually associated with cough, expectoration, and occasionally with paroxysms of suffocation due either to acute swelling of the parts or to collection of tenacious mucus at the seat of stricture. When the stricture is very close, so as constantly to in- terfere with respiration, marked constitutional symptoms may result. By inspection of the trachea, lesions in its upper part may usually be seen, but those farther down often escape observation, and can only be detected by careful physical exploration of the neck and chest. Diagnosis. — The diagnosis must be based upon the results of a care- ful laryngoscopic examination, and the exclusion of diseases liable to cause compression of the trachea, as, for example, substernal tumors or aneurism. Prognosis. — The probable duration of the affection can never be accurately estimated, for under appropriate treatment some of the lesions may disappear, and the patient may remain well for years. When decided narrowing of the trachea has taken place, the result is likely to be fatal within a few months. Death may occur from exhaustion from apncea due to swelling, or suddenly from impaction in the stricture of tenacious mucus. Treatment. — Constitutional remedies are of prime importance. Mercurials or moderate doses of potassium or sodium iodide should be tried thoroughly. Where these fail, large doses of potassium or sodium iodide are often necessary. An excellent method of administering them is to begin with a dose of gr. xx. three times daily, largely diluted with water or milk ; increase the dose each day steadily by five to ten grains, until the maximum dose of from 3 i. to 3 ii. is reached; this maybe con- tinued two or three days, and then decreased to twenty grains. After two or three days, the dose should be again increased as before. Such large doses are not to be recommended except in extreme cases. Ten, fifteen, or twenty grains three or four times daily are sufficient for most patients, but occasionally a case which would improve promptly under large doses steadily progresses under the smaller quantity. In- sufflation of iodol or iodoform into the trachea, daily or three times a week, will be found beneficial in the hyperfemic stage and when ulceration is present. If the stricture is high, O'Dwyers laryngeal tube may be employed to dilate it; but if low in position, tracheotomy must be performed, and a canula which will reach below the obstruction must be inserted and worn. Konig's long flexible canula is especially adapted to this purpose. f CHAPTER XXVIII. DISEASES OF THE LARYNX.— Continued. FRACTURE OF THE LARYNX. Fracture of the larynx is a comparatively rare accident. Up to the year 1868 only fifty-two cases had been recorded in medical literature. In most instances the thyroid cartilage is the seat of fracture, the cri- coid being broken only by unusually extensive and dangerous injuries. Anatomical and Pathological Characteristics. — It is probable that ossification of the laryngeal cartilages renders them more brittle and liable to fracture, and that, as suggested by Panas, premature senility, a result of chronic alcoholism, is sometimes a predisposing factor {An- nates des Maladies de V Oreille, March, 1878). Etiology. — A direct cause is usually a blow, fall, or compression. As a result, extravasation of blood, oedema, or displaced fragments of the cartilage may so obstruct the air passages as seriously to impede respira- tion. Symptomatology. — The usual symptoms are cough, dyspnoea and expectoration of mucus tinged with blood, tenderness or actual pain in the parts, and external swelling and deformity. Subcutaneous em- physema of the neck is apt to follow early, in some cases extending to the arms and trunk, and on manipulation crepitation may be easily felt. Diagnosis. — The diagnosis may be made from the history of vio- lence and the symptoms just indicated. Prognosis. — The accident is always dangerous, and judging from the monograph by Henoque, fracture of the cricoid is nearly always fatal {Gazette hebdomadaire, 1808, No. 3,940); indeed, there are up to the pres- ent time but three or four cases of recovery known. If tracheotomy were promptly performed, probably the number of recoveries would be larger. Unfortunately, owing to the vital character of the structures involved in the injury, many patients die in spite of the operation; or, if recovery follows, they are subject for the rest of their days to trouble- some or dangerous deformity of the parts. Treatment. — Unless the symptoms are very slight, tracheotomy should be performed at once, and even if dyspnoea be absent the opera- tion is advisable, since not infrequently by a slight movement the glottis becomes suddenly closed and suffocation results. If the cartilages are much crushed, it will be best to lay open the whole length of the larynx 4'. H i DISEASES OF THE LARYNX. and endeavor to replace and fix the fragments in proper position. Leeches and cold applications should be applied to the neck to prevent extensive inflammation. It is probable that intubation of the larynx by O'Dwver's method would work well in some cases. DISLOCATION OF THE LARYNX. Attention lias recently been called to luxation of the crico-thyroid articulation, by II. Braun, of Kdnigsberg, according to whom it occurs unilaterally upon either side, and may take place daily or at intervals of weeks or months {Berliner klinische Wochenschrift, October, 1890). It may occur during deep inspiration, but more commonly during the act of yawning. Probably a loose capsule is the predisposing cause, and the sterno-thyroid and crico-thyroid muscles are the active agents. Intense pain and a feeling of anxiety are the chief symptoms, a slight prominence being produced at the inner border of the sterno-cleido- mastoid muscle on a level with the lower border of the thyroid car- tilage. Reduction may be easily effected by digital pressure outward and backward, or by a few efforts at deglutition. FOREIGN BODIES IN THE LARYNX. Foreign bodies of great variety from time to time have been found in the larynx, generally entering from the mouth while the patient is coughing or laughing during mastication, but sometimes they enter from the oesophagus in consequence of sudden inspiration during the act of vomiting, and in rare instances, especially in military service, they penetrate from without. The objects most frequently found are pieces of bread, meat, bone, and other substances taken into the mouth during a meal. In children, peas, beans, coins, buttons, and similar substances which have been put into the mouth in play, or drawn in through blow- guns, are most likely to be found. Pins, fruit-seeds, and coins are some- times found in adults. Soldiers upon the march, in drinking dirty water, have occasionally taken in leeches which have become lodged in the larynx. Artificial teeth, or natural teeth which have become loosened, have sometimes become lodged in the larynx during sleep; other sub- stances which were in the mouth on going to bed are apt to be drawn in in the same way. Symptomatology. — The symptoms vary greatly with the size, shape, and position of the object, and with the irritability of the larynx. A large body, or any object which has become impacted in the larynx in such a position as to cause clonic Gpasms of the glottis, is apt to cause immediate death; on the other hand, small bodies may remain indefi- nitely without very much annoyance. FOREIGN BODIES IN THE LARYNX. 491 I once saw a patient two years of age who had drawn into the laiwnx half a peanut kernel, which after remaining' for two months was coughed out, having caused in the mean time no symptoms other than cough and hoarseness. Usually, even small and smooth bodies give rise to much discom- fort and troublesome cough, while sharp or irregular bodies excite severe paroxysms of cough and dyspnoea due to spasm of the glottis, and in many cases produce hemorrhage. Sometimes a body which causes little discomfort in the larynx at first, upon changing its posi- tion gives rise immediately to severe symptoms. Even where irrita- tion is not sufficient to excite spasm of the glottis at once, the inflam- mation which supervenes within from twenty-four to thirty-six hours may cause extensive swelling, with narrowing of the glottis, which may be suddenly occluded by spasm of the laryngeal muscles. The fright which attends this accident often tends to increase the dyspnoea. Diagnosis. — The diagnosis will depend upon the history of the case, the symptoms already mentioned, and the results of laryngoscopic in- spection when this is practicable; but children, on account of fright, sometimes will not give an accurate history, and adults may greatly ex- aggerate their symptoms. In the former, laryngoscopy can seldom be ac- complished, and even in adults it is often difficult because of irritability caused by the foreign body, though this may generally be relieved by spraying the throat with a solution of cocaine. Prognosis. — In many cases death occurs immediately from closure of the glottis either by the body itself or by the spasm which it excites, and life is always in danger so long as the body is in the larynx. Fre- quently the immediate effects of the accident pass off, but the inflam- mation which the foreign substance excites causes closure of the glottis in from twenty-four to forty-eight hours by swelling or spasm. Some- times the body suddenly changes its position with a similar result, and even after its removal there is still danger until acute inflammation has subsided. Treatment. — A patient seen at the time of the accident should be immediately placed with the head at least forty-five degrees below the body, and should be slapped vigorously upon the back in the hope of causing expulsion of the foreign body; but if in this position respiration ceases, the head should be raised at once which possibly may so change the position of the object as to allow of respiration. If subsequently respiration should suddenly cease in consequence of change in the posi- tion, similar measures should be adopted. If by these methods res- piration is not re-established, the patient should be placed upon the back, preferably with the head lower than the body, and artificial respi- ration should be kept up until medical assistance arrives, even if this is delayed for half an hour. In cases not immediately fatal, the physician may try inversion of the patient with vigorous slapping upon the back in the hope of causing expulsion of the foreign body. If this does not 492 DISEASES OF THE LARYNX. succeed, unless suffocation is imminent, a laryngoscopic examination should be made where practicable and an effort made to remove the object with forceps. If all these methods fail, unless the body is very small and the symptoms slight, tracheotomy should be done as soon as possible, and another effort at removal made either through the tracheal opening or through the mouth, whichever is deemed best at the time. In cases of angular bodies firmly impacted, it is occasionally, though rarely, necessary to lay open the whole length of the larynx for their removal. Sometimes a body which has been firmly fixed may be re- moved by the methods already suggested after the inflammation and swelling have been reduced by external applications. Bodies which have been impacted in one or both ventricles will not infrequently re- quire crushing before they can be extracted. This has at times been accomplished through the natural passages. When tracheotomy has been done and the foreign body extracted, the tracheal tube should be allowed to remain four or five days until swelling has subsided; and it should not then be taken out until the physician, by corking the canula for several hours, lias assured himself that laryngeal respiration is easy. FOREIUX bodies in the trachea. Foreign bodies enter the trachea quite as commonly as the larynx, for the reason that small substances, as a rule, immediately pass through the glottis. Isolated cases of this accident have been recorded from a very early period, but the first extensive treatise upon the subject was by Lewis, in 1759, though the subject was not treated exhaustively until the publi- cation of the late S. D. Gross' work on Foreign Bodies, in 1854. Foreign bodies in the trachea are due to the same causes, and occur in the same way, as the similar affection of the larynx. Symptomatology. — The symptoms will necessarily vary with the character of the body which has been introduced, as well as with the irritability of the tracheal mucous membrane. Patients have occasion- ally drawn foreign bodies of considerable size into the trachea without causing any symptoms which would suggest to them that such an acci- dent had occurred. Large bodies or fluid drawn into the trachea may cause immediate death, or severe dyspnoea, which, growing gradually worse, induces pallor of the general surface with lividity of the lips and nails, cold sweating, and all of the symptoms of suffocation, which be- come more and more pronounced until death supervenes. Sometimes the symptoms are comparatively slight at the time of the accident, but a few hours later, owing to a change in the position of the body, to swelling of the mucous membrane, or to spasm of the glottis, sudden death may occur; or, the symptoms of suffocation soon subsiding, the patient may breathe easily again for a variable length of time until the FOREIGN BODIES IN THE TRACHEA. 493 "paroxysm is renewed, possibly with fatal effect. If the body is small and smooth, it may pass through the trachea and drop into the bronchial tubes, and unless soon removed it will ere long set up inflammation. Coins sometimes are lodged edgewise in the trachea and give rise to little or no discomfort, but they may suddenly become turned across the tube and cause suffocation. As a rule, bodies of moderate size soon set up irritation and inflammation resulting in cough by which the ob- ject may be thrown out or become lodged in the larynx with disastrous results; or the inflammation may finally extend to the lungs, causing pneumonic abscesses or, eventually, phthisis. Rarely, concretions form about small bodies, greatly increasing the difficulty which they cause. Kernels of corn, beans, and similar substances may be greatly enlarged by swelling, from absorption of moisture, and they sometimes germinate. In cases where severe dyspnoea immediately follows the accident, but suddenly passes off without expulsion of the body, we infer that it was first impacted in the larynx and subsequently drawn into the trachea. Frequently movable bodies in the trachea may be felt by the patient as they pass up and down during the acts of respiration or cough, and these movements may sometimes be felt by the finger over the trachea. Angular bodies cause more or less pain; smooth or small bodies may cause no sensations whatever. Bodies lodged in the trachea cause more or less diminution of the respiratory murmur, or a slight rale which may be heard over the entire chest. Usually the foreign substance drops into one of the bronchial tubes, about five out of eight gravitating to the right side; as a result, there is deficient movement and feebleness of the respiratory murmur over the corresponding side. Sometimes the body, or the mucus collecting about it, causes bronchial rales heard on one side only. These signs, when found, are very important from a diag- nostic point of view, but are not universally present, even though the body be lodged in the bronchial tube, especially in the case of buttons or coins turned edgewise. A'ocal fremitus is also diminished over the obstructed lung, and there may be slight dulness on percussion, due to collapse of some of the air vesicles or to collection of mucus in the bronchial tubes. By laryngo- scopy examination the foreign body can sometimes be detected in the trachea. Diagnosis. — Usually there is a suggestive history, but it is not al- ways possible to tell whether the body has been ejected or not. When the foreign substance can be seen or felt in the trachea, or when with a history of the accident the difference of the plrysical signs upon the two sides of the chest indicates obstruction of a bronchus, we may be posi- tive of our diagnosis. There are frequently cases where it is impos- sible to diagnosticate the presence of small or smooth bodies which have been drawn into the trachea ; in these we are obliged to wait for time to decide. 494 ZHHEA8ISS OF THE LARYNX. Prognosis. — Where the immediate danger has been survived, the greatest risk occurs between the second day and the end of the first month; during the succeeding month the mortality notably diminishes, but later it again increases. As already indicated, the prognosis is al- ways serious so long as the foreign body remains in the air passages, the gravity depending upon the size and nature of the body, the amount of dyspnoea, and the changes set up in the lungs. When it is ejected or removed, recovery is usually rapid. Foreign substances have sometimes been coughed up weeks, months, or even years after the accident, the patient in the mean time having suffered more or less from the irritation which they produced. For the encouragement of those in whom the body cannot be found, a case mentioned by Gross may be cited, in which a boy three years old drew a piece of bone into tbe trachea, which remained in the lung and was finally ejected during a fit of coughing six years later. A child was once brought to me who had drawn a button into the trachea. I did tracheotomy, but the button could not be obtained. The wound was kept open for several weeks and then allowed to heal, and about a month later the button was expelled during a fit of coughing. Treatment. — The indications are to remove the body as soon as possible. This may sometimes be done by inverting the patient and slapping him upon the back, as recommended for foreign bodies in the larynx, or by Padley's method which consists in placing a strong bench with one end upon a couch, with the other upon the floor, and causing the patient to sit on the upper part with his knees fixed over the end, and while taking a deep breath to lay himself quickly back supinely upon the bench (London Lancet, Vol. II, 18T8). The inspiration opens the glottis, and the supine position favors the expulsion of the foreign body. If it should happen to lodge in the larynx, the patient's hold upon the bench with his knees enables him quickly to regain the upright position, so that the body will again fall back into the trachea. Children may be held up by the feet, or the child's body may be allowed to hang from the nurse's lap, the back being slapped in the mean time. When at- tempting either of the above methods, the surgeon should be ready to perform tracheotomy at once, for sometimes the body becomes firmly im- pacted in the glottis and suffocation would immediately ensue unless the windpipe were opened. It is needless to say that the methods named are only likely to succeed where the body is small and smooth, as in the case of coins, buttons, peas, and beans, and but recently inhaled. The methods just recommended may sometimes be tried with advantage after tracheotomy has been done, providing the body cannot be found and re- moved by forceps. In most cases tracheotomy will be necessary, and the surgeon should advise it at once when he is sure that a foreign body is in the trachea, remembering that delay is always dangerous; yet he should not fail to inform the friends that some patients recover without opera- FOREIGN BODIES IN THE TRACHEA. 495 tion. In children chloroform is usually preferred as an anaesthetic, but in adults local anaesthesia may be produced by cocaine. Tracheotomy having been done, the foreign body will frequently be coughed out im- mediately, but if not, it should be sought with instruments. For this purpose Trousseau's tracheal forceps are well adapted, but I have had better results with Carl Seller's laryngeal tube forceps (Fig. 180), with which upon one occasion I was enabled to remove a swollen kernel of corn that was deep in the right bronchus, and on another, a small spic- ula of bone from deep in the left bronchus. A peculiar accident occurred a few years ago to the son of one of our well known physicians. The boy was playing with a blow-gun, in which he had a shawl-pin used as a dart. By a forcible inspiration the shawl-pin was drawn, head foremost, into the trachea, from which it was removed after tracheotomy with great difficulty because of its length and its position with the point upward. If the body cannot be found, it is recommended that the edges of the tracheal wound be stitched to the integument, or that ligatures be Fig. 180.— Seiler's Tube Forceps (2-5 size). passed through the trachea and fastened with an elastic behind the neck, in order to keep the wound open. This device will answer very well for two or three days, but it is not applicable where the tracheal wound must be kept open for several weeks ; in such instances I would recom- mend that a large tracheal canula be left in the wound, but that it be removed from time to time and efforts be made to remove the foreign body either by inversion or by forceps. After the foreign substance has been extracted, the trachea should be kept open for three or four days to allow all inflammation to subside, and to be sure that no other particles remain. The canula may then be removed and the wound allowed to heal. When tracheotomy has been done within a few hours after the accident has occurred, and where the body has been easily re- moved, the tracheal wound may be allowed to close at once. In the event that a foreign body becomes impacted in the bronchi so low that it cannot be removed by tracheotomy, the question of bronchotomy will arise; but notwithstanding the brilliant results of modern sur- gery, experience up to the present time is against it, as the danger to life far overbalances the chances of success, and there is a possibility that the object may eventually be expelled spontaneously. DISEASES OF THE LARYNX. SPASM OF THE GLOTTIS. Synonyms. — Laryngismus stridulus; spasmus glottidis; suffocative laryngismus; spasmodic, cerebral or false croup. Spasm of the glottis is a condition iu which there is a temporary, complete or incomplete, spasmodic closure of the glottis or vestibule of the larynx, preventing free inspiration. It is characterized in the former case by cessation of the respiratory movements, and in the latter by stridulous respiration, almost identical with that of true croup or that of whooping-cough. It is a purely nervous disease, and was formerly believed always to result from cerebral disorders. It is now known to be due also to direct or reflex peripheral irritation from a great variety of causes; for exam- ple, pressure on the recurrent laryngeal nerve, the presence of irritating substances in the alimentary canal, or irritation of the gums in denti- tion. Lubet-Barbon {Revue mensuelU des maladies de Venfance, Paris, Annual »f the Universal Medical Sciences, L892) states that adenoid hy- pertrophy in the uaso-pharynx is nearly always present. The attack is verv likely to occur during acute catarrhal inflammation of the larynx, and may be excited by mental or physical irritation of the child. With nursing babes it is frequently brought on by the entrance into the larynx of a little milk and sometimes by dandling the child in the arms. Symptomatology. — The great majority of cases occur between the a^es of four and twentv-four months, and verv few after the latter. It is most common in boys, and more frecpteut in poorly nourished chil- dren than in those well cared for. The attack usually comes on sud- denlv in the night, when the child awakens in fright from great dyspnoea or temporary suspension of breathing. After a few respirations it cries out, and soon falls asleep as though nothing had occurred. In severe cases the symptoms are more violent: the breathing suddenly becomes difficult, inspiration is prolonged aud stridulous, and in a few moments the respiratory movements cease in consequence of complete closure of the glottis: the face, which was flushed, becomes pallid, and this is sj)eedilv fullowed by lividity: the eyes roll, the veins in the neck become turgid : and there are spasmodic contractions of the hands and feet. General convulsions sometimes ensue. In mild cases the attack often does not recur until the following night. The severer the paroxy.-ms. the greater will be the rapidity with which they succeed each other. In some severe cases they follow each other in rapid succession, or there may be an almost endless spasm which does not relax until life is ex- tinct. In the more common form of the affection the child may appear perfectlv well the following day and there may be no return of the paroxysm, but usually it is repeated the next night or even within a few hours. As a rule, there is no fever, but profuse sweating, especially of the head, is a common symptom. Diagnosis.— The disease is not likely to be mistaken for any other SPASM OF THE LARYNX IN ADULTS. 497 except true croup, from which it may be diagnosticated by the absence of fever and the intermittence of symptoms between the paroxysms. Peogxosis. — The attacks last but a few minutes, but they may recur after a few hours or the following night, or in severe cases may be speedily repeated. In the milder forms, recovery is common, but others are often fatal, and sometimes during the first paroxysm, which may last but one or two minutes. In cases depending upon disturbance of the digestive organs or slight irritating causes, the prognosis is favorable, providing the paroxysms do not last too long or follow each other quickly; whereas in those resulting from cerebral disease, or in those where the intervals between the paroxysms are short, the prognosis is grave. As a rule, the greater the interval between the paroxysms and the slighter th.e individual attacks, the better the chances of recovery. Tkeatmext. — During the paroxysm, flagellation, and the dashing of cold water in the face, are the most common remedies. To terminate the spasm and prevent its recurrence, in the majority of cases nothing is better than v\ xv. to xxx. of the compound syrup of squills, which should be repeated every fifteen minutes until vomit- ing occurs. Tickling the fauces with a feather or the finger is some- times sufficient to excite vomiting, apomorphine in minute doses may be injected subcutaneously, or turpeth mineral may be given for the same purpose in doses of gr. ss. to ij. or even more. Teaspoonful doses of powdered alum act promptly and efficiently. To relieve the paroxysm a hot bath or a sitz bath at 95° F. may be employed, or chloro- form may be carefully administered. An enema of tincture of assafce- tida, Tit xx. to xxx., ad 3 i. of warm gruel or milk is sometimes a most useful remedy to prevent recurrence of the attack. Tincture of castor and musk are also valuable for the same purpose. The cause of the spasm must be sought and removed. It is most commonly found in some derangement of the digestive organs associated with slight catarrhal laryngitis. The spasm may be caused by an enlarged thy- mus gland, especially in young children. It has been known to arise from irritation of the prepuce. It is not infrequently caused by hysteria or cerebral or cerebro-spinal disease. Subsequent to the paroxysm, vege- table tonics, cod-liver oil, and the bromides are generally beneficial. SPASM OF THE LARYNX IN ADULTS. Spasm of the larynx is much less frequent in adults than false croup in children, and is most commonly observed in nervous women. Etiology. — Spasm of the larynx is sometimes a pure neurosis, but may also be produced by irritation of the larynx by foreign bodies, or by oedema, or by laryngeal tumors. Sometimes it results from irritation of the recurrent laryngeal nerve, and in some cases a paroxysm comes on during sleep, without apparent cause. 498 DISEASES OF THE LARYNX. Symptomatology. — The paroxysm comes on suddenly. There is stridulous inspiration, speedily increasing dyspnoea, and in severe cases temporary arrest of respiration, which may be followed by expectoration of a considerable quantity of viscid mucus. On inspection at the time, the mucous membrane of the larynx is usually found slightly congested, but it may appear perfectly healthy, and the vocal cords are seen to sepa- rate for an instant, and then to suddenly draw together. Diagnosis. — The diagnosis rests upon suddenness of onset, the pe- culiar obstruction of respiration, and the exclusion of foreign bodies or tumors by inspection. Prognosis. — The attacks are of short duration, and are seldom, if ever, dangerous excepting -when resulting from foreign bodies. Treatment. — Inhalations of steam impregnated with soothing rem- edies as conium, belladonna, or stramonium, or inhalations of the smoke of burning stramonium, are useful in relieving the tendency to spasm when the attacks are recurring with frequency. The inhalation of a few whiffs of chloroform will give speedy relief in most cases. After the attack, general and nerve tonics are indicated. For this purpose a pill containing one grain each of zinc valerianate, quinine valerianate, and iron, is an excellent combination. Potassium, sodium, or ammonium bromide may also be administered to relieve the irritability of the larynx. To prevent the spasm of the glottis which occurs in some patients dur- ing and after applications to the larynx, the patient should hold his breath during the application and for a second or two afterward and then recommence breathing slowly, through the nose. IRRITATIVE COUGH. A dry. hacking, and sometimes paroxysmal cough is apparently of nervous origin and not infrequently accompanied by hyperemia of the mucous membrane. The reflex form may be associated with disorders of the digestive organs or of the uterus; it is sometimes violent during dentition, and it may also result from varix or enlarged glands at the base of the tongue, enlargement of the tonsil, or elongation of the uvual. The cough is most frequent in the morning, and is usually referred to the region of the trachea. Treatment. — Any of the associated marked conditions should re- ceive appropriate treatment, and sedatives or antispasmodics in the form of troches and sprays should be given to check the tendency to cough. NERVOUS COUGH. By nervous cough we refer to a peculiar cough most frequently man- ifest in hysterical women, but sometimes occurring in men. It is usu- ally characterized by a resemblance to the cry of one or other of the ANAESTHESIA OF THE LARYNX. 499 lower animals, most frequently the yelping of a dog (Cohen: "Diseases of the Throat and Nose "). It is apparently purely of a neurotic origin, the most careful examination failing to detect any definite lesion. No very satisfactory method of treatment can be suggested, though electricity has sometimes proven effectual. Tonics, especially strychnine, arsenious acid, quinine, and iron, are useful in some cases. ANAESTHESIA OP THE LARYNX. Anaesthesia of the larynx consists in more or less complete loss of sensibility of the mucous membrane, usually characterized by dysphagia, which results from the tendency of food, especially liquid, to drop into the trachea during deglutition. The anaesthesia may be unilateral or bilateral; it maybe almost complete over the entire surface, even extend- ing into the trachea, or it may be confined to that portion of the larynx about the vocal cords. Etiology. — The affection seems to result form hysteria in a few cases, but is generally caused by diphtheria or bulbar paralysis. In some instances it has been due to tumors, hemorrhages, or deposits at the base of the brain (McBride: Edinburgh Medical Journal, July, 1885; and Schech : Diseases of the Nose and Throat) ; it may follow erysi- pelatous and variolous affections of the throat, and has been observed in cholera. Symptomatology. — The most important symptom is spasmodic cough on deglutition, caused by liquid or food entering the trachea and coming in contact with the sensitive membrane beyond the affected area. The epiglottis is generally found erect, and imperfectly closes the larynx during deglutition. Diagnosis. — A history of diphtheria or bulbar paralysis, with occur- rence of spasmodic cough on deglutition, and the absence of obstructions in the pharynx or oesophagus as determined by inspection and by the passage of an oesophageal bougie, are strongly suggestive of this condi- tion. Palpation with the laryngeal probe without causing appreciable sensations renders the diagnosis certain. Prognosis. — Except in cases of bulbar paralysis or other cerebral disease, recovery may generally be expected in from four to six weeks. In extreme cases, unless measures are taken to prevent the passage of food into the trachea, it is apt to cause fatal pneumonia. When asso- ciated with bulbar paralysis, death results within a few months. Treatment.— The employment, three to six times a week, of either the galvanic or induced electric current, or of static electricity is to be recommended. If either of the first two are used, the electrodes should be applied six or eight times at each sitting. Probably the most im- portant treatment consists of the internal use of strychnine in large and increasing doses, until its physiological effects are appreciated, as reconi- 500 DISEASES OF THE LARYNX. mended for paralysis of the vocal cords. When there is marked diffi- cult v in swallowing, the patient should be fed through the oesophageal tube, to prevent the entrance of food into the windpipe. Owing to the anaesthesia, special care is necessary to avoid the passage of the in- strument into the larynx. HYPERESTHESIA, PARESTHESIA, AND NEURALGIA OF THE LARYNX. Increased or perverted sensibility of the larynx, or intermittent pain in the organ, without structural lesions, is most frequently observed in preachers and others accustomed to excessive use of the voice. Simple neuralgia is very rare, and most cases which formerly would have been classed under this head are now recognized as rheumatic. Anatomical and Pathological Characteristics. — There may or may not be congestion of the mucous membrane; in some cases even pallor is present, especially when the condition is associated with phthisis. If hyperesthesia results from excessive use of tobacco or alcohol, there is usually congestion. Frequently there is disease of the glandular structure of the pharynx and larynx, or base of the tongue. Etiology. — Hyperesthesia usually results from excessive use of tobacco or alcohol, repeated subacute inflammations of the larynx, gas- tric disturbances, tuberculosis, pharyngitis, or over use of the voice. Paresthesia is commonly caused by debility, nervous prostration, hysteria, or hypochondriasis, and often follows the lodgement for a short time of some foreign substance in the throat. It is sometimes one of the early symptoms of phthisis pulmonalis. It is also a symptom of enlarged glands or varicose veins at the base of the tongue. Neuralgia is attributed to similar causes, but is more often due to anemia, gout, and rheumatism. Symptomatology. — In hyperesthesia, the larynx is so abnormally sensitive that cough is excited by slight irritation, such as the inhalation of cold air, smoke, or dust, or the contact of certain substances in deglu- tition. It is frequently attended by various sensations, as of burning, prickling, dryness, rawness, and constriction; and occasionally by spas- modic action of the muscles of the larynx and pharynx, the former oc- curring with respiration, the latter with deglutition. The most fre- quent sensation in paresthesia is that of a silver, or other large or small foreign body in the throat. Numbness and coldness are sometimes experienced. The so called globus hystericus is a familiar form of the affection. In neuralgia, the pain is often intermittent and unilateral and may be accompanied by areas or points of tenderness. Cough may be troublesome. Diagnosis. — The diagnosis must be based upon the symptoms, and the absence of physical signs. CHOREA LARYNGIS. 501 Prognosis. — The affections may be expected to continue for a long time., but, in the majority of cases, recovery eventually takes place, Treatment. — When hyperemia is present, it should be reduced by stimulant or astringent applications. Diseased glands and enlarged veins of the pharynx or base of the tongue are best destroyed with the galvano-cautery. Applications to the larynx once or twice daily, by spray, of solutions of morphine or cocaine, though the latter should not be used freely, or a combination of morphine, carbolic acid, and tannic acid with glycerin and water (Form. 93, 139), are often serviceable. Where cough is troublesome, troches of. lactucarium or of cannabis indica and codeia (Form. 29, 33) or other sedative preparations are especially useful. Sometimes the inhalation of a few whiffs of chloro- form, which may be carried in a small bottle in the pocket, gives great relief. Internally, the iodides and colchicum are indicated when a rheu- matic or gouty diathesis exists, and camphor monobromide, chloral or aconite, or the bromides, gr. x. to xv., three or four times daily are es- pecially useful for prolonged sedative effects. The various bitter and ferruginous tonics are frequently indicated, and good hygienic condi- tions are particularly important. CHOREA LARYNGIS. Chorea laryngis is an extremely rare affection of the larynx, charac- terized by regular monotonous recurrence, during waking hours, of a peculiar sound, often resembling a short bark or yelp, associated with, and dependent upon violent inco-ordinate involuntary movements of the vocal bands. The affection is accurately described by Ziemssen, but the first published uncomplicated case appears to be that reported by G-eorge M. Lefferts (Transactions of the American Laryngological Association, 1879). Cases have also been reported to the same association by F. I. Knight, of Boston, and E. Holden, of Newark, IS". J. Anatomical and Pathological Characteristics. — The disease is a neurosis the seat of which appears to be either in the brain or spinal cord, but the exact lesion has not been determined. The larynx is liable to be slightly hyperseniic, but presents no other physical changes. Etiology. — In most of the cases reported there has been no assign- able cause for the affection, which has come on in persons otherwise per- fectly well. It is sometimes attributed to hysteria, with which it is liable to be confounded. Symptomatology. — The affection may be a part of general chorea, but the term chorea laryngis should be limited to those cases in which only the laryngeal muscles are involved. There are no constitutional symptoms, the patient complains merely of the frequent recurrence of some peculiar sound at regular intervals during the waking hours. In some this is attended by spasmodic cougb, which may be excited by the 502 DISEASES OF THE LARYNX. act of swallowing. Upon laryngoscopic examination, there is often found some congestion of the larynx, and in the intervals between the pro- duction of the peculiar sound the motions of the cords may be perfectly natural, or they may quiver and tremble, and the adductors and abductors may be in constant motion ; but, even then, on phonation the cords as a rule act 'naturally ; sometimes, however, during this act their move- ments are irregular, speech being correspondingly altered. At the time the peculiar sound is produced, the cords are generally driven suddenly and sharply together, sometimes two or three times in succession ; this concussion probably accounts for the hyperemia, and it is immediately followed by a long inspiration after which the parts may remain natural until time for the next sound to occur. These peculiar sounds always cease during sleep. Diagnosis. — The affection is most likely to be confounded with hysteria, from which it is distinguished by the following points: Chorea laryngis. Hysteria. May accompany general chorea. Absence of general chorea. Occurs regularly d u r i n g waking Occurs at irregular periods, hours. Violent, prolonged, i n co-ordinate, Short spasms; may be voluntary and involuntary movements. and regular; never long-continued. In typical cases, confined to larynx. Seldom or never confined to larynx. Prognosis. — Under appropriate treatment most cases recover within a few months. Treatment. — Local applications of electricity have been tried in many cases, but are of doubtful value. Applications of astringent sprays, such as used in chronic laryngitis, are beneficial in reducing the hyper- semia, but the main reliance must be placed upon general tonic treat- ment, especially the administration of arsenious acid. F. I. Knight mentions one case in which the symptoms immediately subsided upon the exhibition of full doses of quinine (Transactions of the American Laryngological Association, 1883). Bromides have been found of some benefit in diminishing the frequency of the paroxysms. Strychnine has rendered little, if any, service. SPASM OF THE VOCAL CORDS. Closely akin to chorea laryngis is a spasmodic affection of the vocal cords most frequently observed in nervous overworked professional men past middle life. In this affection there is commonly congestion of the larynx, but no other visible change from the normal condition. The eti- ology and pathology are not understood, but the condition appears to be due to functional alteration of the nerve centres. In cases I have ob- served the individuals have been able at times to talk in a natural voice, FALSETTO VOICE. 503 but suddenly, without control, the voice rises to a high pitch, in conse- quence of spasm of the adductor and tensor muscles, and is apparentlv produced with much effort and straining of the laryngeal muscles. In this latter respect the symptoms differ materially from those attending paralysis of the crico-thyroid muscles, in which there is a somewhat sim- ilar change in the voice. The affection is likely to continue for years and is very refractory. Teeatment. — The treatment from which most relief is to be expected consists in good hygienic surroundings, including rest and pleasant travel, and systematic vocal culture. At first the larynx should be given, as nearly as possible, perfect rest for several weeks, the patient talking but' little and that only in a whis- per. After a time he should be given very short but increasing exercises in reading at regular hours two or three times a day, as a sort of vocal gymnastics. The reading should be in a low unvarying tone and must be stopped as soon as the voice breaks. At first these lessons may not exceed one or two minutes in duration, but they may be gradually prolonged a minute or more each day as the voice becomes more stable, and after the patient is able to read for half an hour in monotone, gradual changes may be tried in the pitch and in- tensity of the voice. During this time the congestion of the larynx may be removed by the use of weak astringent sprays, as for example zinc sul- phate gr. i.-iij. ad 3 i. At the same time the nervous system should be fortiiied by sedatives and tonics conjoined with abundant rest, regular exercise, and the removal of all sources of direct or reflex irritation. FALSETTO VOICE. Falsetto voice is a rare symptom, usually observed in young men who, although fully developed in every other respect, retain an abnormally high pitched, puerile voice. It is due to the misuse or non-use of muscles controlling the lower register, which should be brought into activity about the age of puberty. The condition is usually outgrown within a few months, or at most years, after puberty; but it sometimes persists to middle or even advanced life. It is purely functional and may generally be speedily cured if proper methods are adopted ; but if left to themselves such patients often suffer for many years from the mortification entailed by the childish or femi- nine voice. Tkeatment. — The work of the physician consists in demonstrating to the patient that he has a chest voice and inducing him to use it. The method recommended by J. C. Mulhall, of St. Louis (Transac- tions of The American Laryngological Association, 1888) I have found perfectly satisfactory in several cases. At first a thorough laryngoscopic examination is made, and then the patient is assured that the vocal appa- ratus is normal and that if he will carefully follow directions he will with a little training be completely cured. 504 DISEASES OF THE LARYNX. He is then caused to depress the chin firmly on the neck, and asked to imitate the physician, who sounds a deep chest tone. The imitation is usually prompt and easy. The patient is thus shown that he has another voice, and by repeated exercises taught to use it. The depression of the chin is merely to direct the patient's will more easily to the proper mus- cles, and may soon be omitted in subsequent exercises. A cure may often be effected within a few minutes, though in other cases more prolonged training is necessary. A few lessons have always proven sufficient in my experience. Sometimes the cure is delayed by the patient's fear to use his newly found voice, or by embarrassment in using it before his acquaintances. LARYNGEAL VERTIGO. Laryngeal vertigo is a rare affection characterized by momentary loss of consciousness, occurring during a fit of coughing. It is usually observed in men past middle life. The attack generally comes on sud- denly, with short spasmodic cough, which is immediately followed by giddiness. In most instances, during the attack, the patient becomes unconscious for a few seconds; but this speedily passes off, so that men- tal confusion remains only a short time, excepting in a small percentage of cases. Usually there are no other evidences of nervous disease. During the attack, the face may be unnaturally pale, though in most cases it is congested, and in a few there are twitchings of some of the muscles; but in none has there been frothing of the mouth or biting of the tongue, as in epilepsy. In the majority of cases, the larynx has been found hypergemic. Most cases have been relieved, at least temporarily, by the applica- tion of astringents to the pharynx and larynx, counter irritation over the larynx, and the administration of bromides internally. A very full exposition of the whole subject has been given by F. I. Knight, in the Transactions of the American Laryngological Association for 1886. CHAPTEE XXIX. DISEASES OF THE LARYNX.— Continued. PARALYSIS OF THE THYROEPIGLOTTIC AND ARY-EPIGLOTTIC MUSCLES (DEPRESSORS OP THE EPIGLOTTIS). A paealysis in the domain of the superior laryngeal nerve is char- acterized by dysphagia especially of fluid, and when complete and bi- lateral, by anaesthesia of the laryngeal mucous membrane. It is usually attended by paresis of the crico-thyroid muscles. Etiology. — -The paralysis named is most commonly caused by diph- theria, occasionally by progressive bulbar paralysis, and rarely by enlarged glands and inflammation of the areolar tissue beneath the angle of the jaw. Symptomatology. — In consequence of this paralysis, the epiglottis remains erect during deglutition, and fluids or particles of food find their way into the larynx and trachea, where they cause sudden parox- ysms of cough and dyspnoea attended by pain if anaesthesia is not also present. Particles of food aspirated into the smaller bronchi are apt to excite pneumonia. Though there are no characteristic signs _ of this affection, upon inspection the epiglottis may be seen to maintain an erect position during the imperfect acts of deglutition made with the mouth open and the tongue protruded, and upon palpation anaesthesia is often detected. Diagnosis. — When the affection follows diphtheria, it is usually asso- ciated with paralysis of the palate or pharynx and anaesthesia of the larynx. The symptoms and signs, taken in connection with dysphagia, paroxysms of cough and dyspnoea, and the appearance of the epiglottis, together with the absence of other signs, establish the diagnosis. Prognosis. — In complete paralysis of both superior laryngeal nerves there is considerable danger, but unilateral paralysis is not very serious. In the former, death may result from pneumonia caused by aspiration of foreign substances into the lung; but if this accident is escaped, the cases due to diphtheria usually recover. Treatment. — The greatest care should be taken to prevent the en- trance of foreign substances into the trachea. Feeding should be ac- complished either by the oesophageal tube, or by having the patient during deglutition assume a position with the head lower than the 506 DISEASES OF THE LARYNX. body. Ferruginous and bitter tonics fire indicated, but strychnine in large doses as advised for anaesthesia of the larynx is of most value. PARALYSIS OF THE CRICOTHYROID MUSCLES (external TENSORS OF THE VOCAL CORD). As a separate affection, paralysis of the crico-thyroid muscles is rare. It is either unilateral or bilateral in its occurrence, and is characterized by dysphonia or aphonia. It commonly results from diphtheria, ex- posure of the neck to cold draughts, or from overstraining the voice in singing or shouting, especially during inflammation of the larynx. It has been caused by injury to a small branch of the superior laryngeal nerve in ligating the common carotid artery, and it is sometimes associ- ated with paralysis of the adductors and internal tensors of the cords. Complete paralysis of these muscles is very rare. Symptomatology. — The voice may be very hoarse and inadequate to the production of the high notes, or altogether suppressed. Some- times during ordinary conversation there is a peculiar sliding rise in the pitch of the voice, which the patient is unable to prevent. Pro- longed use of the voice may be fatiguing or even painful. There are also symptoms of coexistent anaesthesia of the larynx. Sometimes by placing the finger over the crico-thyroid muscle at the lower lateral por- tion of the larynx during phonation, its non-contraction may be readily recognized. In some instances there is congestion, in others a pearly, translucent appearance of the vocal cords, which also have visible longitudinal relaxation. In well marked cases the glottis presents a peculiar wavy outline (Fig. 181), with a slight depression of the central portion of the cords in inspiration and a corresponding elevation in expiration and vocalization; the vocal process can seldom be seen. When the affection is unilateral, the corresponding cord remains on a higher level than its fellow. Diagnosis.— In moderate cases the diagnosis must rest largely upon the symptoms; where the paralysis is decided, the subjective symptoms and the appearance of the glottis, together with lack of tension of the crico-thyroid muscle, leave no doubt. Prognosis. — Most cases recover after a short time, from rest alone, but the restoration of the voice may be aided by appropriate treat- ment. Treatment. — In slight cases, wet compresses or mild counter irrita- tion is all that is necessary. In those more marked, daily applications over the muscles, of the faradic or galvanic currents will be found bene- ficial. Strychnine and other tonics are also indicated in some cases. When anaesthesia of the larynx coexists, food should be introduced through an oesophageal tube to prevent its passage into the trachea. PARALYSIS OF THE THYRO-ARYTENOID MUSCLES. 507 PARALYSIS OF THE THYROARYTENOID MUSCLES (INTERNAL TENSORS OF THE VOCAL CORDS). Paralysis of the thyroarytenoid muscles is a common affection, which may be either unilateral or bilateral. It is often associated with pa- ralysis of the crico-thyroids and the adductor muscles of the cords. It is characterized by harshness and high pitch of the voice, with fatigue and sometimes jjain in its use, and is most frequent among singers. ANATOMICAL AND PATHOLOGICAL CHARACTERISTICS. — The COrds are often congested, sometimes swollen, and the edges are not accurately approximated but leave an elliptical chink between them in phonation, which accounts for the hoarseness or aphonia. Etiology. — The affection usually results from over-use of the voice when the larynx is inflamed, or at the period of adolescence when the voice is changing, but it may be caused by a simple cold, fatigue, or strain of the muscles, and occasionally by diphtheria or hysteria. Symptomatology. — There may be fatigue or even pain upon use of the voice, with dysphonia, or, in case other muscles are involved, aphonia. Fig. 181.— Bilateral Paralysis of the Fig. 182. — Acute Laryngitis. Paraljsis of Crico-Thyroid Muscles (Mackenzie). the thyro-arytenoid muscles. Upon inspection during phonation, an elliptical chink about a line in width is usually observed between the vocal cords (Fig. 182), which, to- gether with other portions of the larynx, are liable to be congested. When the arytenoid muscle is also paralyzed, the laryngeal picture is peculiar, an elliptical chink appearing in front of the vocal processes, and a more or less triangular opening behind them (Fig. 183). Diagnosis. — The diagnosis is based upon the history, symptoms, and laryngoscopic appearance. Prognosis. — When associated with simple laryngitis, provided the paralysis is not complete, recovery usually takes place within a short time, but some cases extend over several months, and occasionally the paralysis is permanent. Treatment. — In over-fatigue and in cases resulting from acute in- flammation, rest for the voice, with soothing inhalations or feeble astrin- gent sprays, are most beneficial. In some instances, especially where fatigue is the cause, prolonged rest for many months is necessary. When the affection has already extended over several weeks, astringent or stimulating sprays to the larynx should be used; but if contraction of DISEASES <>F THE LAJiYNJT. the muscles is not readily induced in this way, the galvanic or faradic current should be employed for a few moments daily. Bitter and fer- ruginous tonics may be useful, but of all remedies strychnine- in large doses is most beneficial. BILATERAL PARALYSIS OF THE LATERAL CRICOARYTENOID MUSCLES (ADDUCTORS OF THE VOCAL CORDS). Synonyms. — Functional aphonia, hysterical or nervous aphonia. In bilateral paralysis of the lateral crico-arytenoid muscles, the vocal cords act imperfectly and are not approximated accurately during at- tempted phonation. It is characterized by loss of voice, and is most commonly observed in young women. It is often associated with paral- ysis of the arytenoid muscle, and sometimes the posterior crico-arytenoid muscles of both sides. Etiology. — The affection is caused by hysteria, anaemia, general de- bility, phthisis, ami sometimes by simple catarrhal inflammation in •v«^ Fig. 183.— Paralysis of the Thyro- arytenoid Muscles and Partial Paral- ysis of the Arytenoid. Fig. ]S4 — Paralysis of the Lateral Cfico-Arytenoid Muscles. Attempted phonation. wMch the congestion disappears, but the paralysis remains. It is prob- ably due in some instances to lead or arsenical poisoning. Symptomatology. — Functional aphonia often comes on suddenly without apparent cause, but sometimes is excited by shock or fright. Occasionally a patient who has retired in perfect voice finds herself unable to speak in the morning. In other cases resulting from an acute cold, hoarseness comes on, gradually growing worse for twenty- four or thirty- six hours, until the voice is lost. Occasionally exposure to a draught of air marks the beginning of the disease. Xot very rarely the affection is intermittent, the voice failing and returning every few days for a time. In some of these instances it is possibly of malarial origin. One peculiar feature of many cases is that while voluntary movements of the cords may be lost, the reflex often remain, so that, although the patient cannot speak, she may cough, sneeze, or laugh aloud. Sometimes such patients talk aloud in their sleep, but are unable to do so when awake. When the paralysis is complete, no sound is caused by laughing or coughing. The larynx is often paler than natural, but in catarrhal cases it is BILATERAL PARALYSIS. 509 congested. Upon attempts at phonation, the vocal cords remain in the respiratory position (Fig. 184) or move but imperfectly toward the median line; sometimes one is more completely paralyzed than the other. Usually on attempted phonation the cords are approximated to within about one-eighth of an inch of each other, and in not a few cases the edges may touch for a moment, and a short sound of a may be emitted at the time, though the patient is otherwise unable to talk. In complete paralysis, the glottis remains widely open without movement of the vocal cords during attempted phonation, and where the abductors are also involved the cords maintain the cadaveric position midway be- tween phonation and inspiration. J. Solis Cohen remarks that some- times this form of paralysis is associated with loss of voluntary control over the diaphragm, and then not only is the loud voice lost, but the patient is also unable to whisper (Diseases of the Throat, second edition). Diagnosis. — The affection may be confounded with cases in which the loss of voice is due to feeble respiratory action, or those in which Fig. 1K5.— Mackenzie's Laryngeal Electrodes. approximation of the cords is impeded by swelling of the inter-arytenoid folds, or by morbid growths, cicatricial tissue, or disease of the crico- arytenoid articulation. The history and symptoms, together with the laryngoscopic appearance just described, leave no room for doubt as to the diagnosis. Treatment. — In hysterical eases the voice may frequently be re- stored by very indifferent measures, such, for example, as simply intro- ducing a mirror, or throwing a mild astringent spray into the larynx: but in many cases prolonged use of the faradic current to the affected muscles, applying one electrode within the larynx and the other without, will be necessary to effect a cure. In most instances I have found astringent or slightly stimulating applications to the larynx every second day, combined with the administration of tonics, most effective; and of all tonics for this purpose, nothing can compare with strychnine in full doses. It is well to begin with about gr. -^ three times daily, steadily increasing the dose until constitutional effects are produced, which may not happen until the patient is taking as much as gr. -^ or 510 DISEASES OF THE LARYNX. even gv. | at a dose. When the physiological symptoms occur, the dose should be somewhat decreased, and then continued in an amount just short of producing spasmodic contraction of the muscles, until recovery is complete; or the quantity may again be increased, in the manner before mentioned. UNILATERAL PARALYSIS OF THE LATERAL CRICOARYTENOID MUSCLE (LATERAL ADDUCTOR OF THE VOCAL CORD). In unilateral paralysis of the lateral crico-arytenoid muscle one cord remains abducted during attempted phonation, thus rendering the voice hoarse or shrill. There is no lesion of the larynx itself, but the recur- rent laryngeal nerve is generally involved. Etiology. — The affection is caused in most cases by pressure upon the recurrent laryngeal nerve, as by an aneurism of the aorta, cancer of the oesophagus, malignant tumor of the neck, or enlargement of the . Fig. 186. — Unilateral Paral- Fig. 187.— The same as Fig. ysis of the Left Lateral Crico- arytenoid MrscLE. Due to the pressure of an aneurism on the left recurrent laryngeal nerve. 186, in Phonation. Fig. 188.— Unilateral Paraly- sis of the Right Lateral t Irico- Arytenoid Muscle, with Swell- ing of Left Ary-Epiglottic Fold. Phonation — left cord mov- ing far beyond the median line deep cervical glands. It is sometimes caused by chronic lead or arsen- ical poisoning, by exposure to cold, or muscular strain, and not infre- quently by hysteria. Symptomatology. — There are usually no constitutional manifesta- tions but the symptoms and signs of a tumor pressing upon the recur- rent nerve may frequently be detected. There is slight or considerable impairment of the voice with loss of volume, and, when paralysis is complete, aphonia. The sounds produced by coughing, sneezing, or laugh- ing are always altered more or less, and these acts are sometimes unac- companied by sound. In phonation, the affected cord remains at the side of the larynx (Fig. 187), and the supra-arytenoid cartilages cross each other, the one from the sound side passing in front. The mucous membrane covering the affected cord is often found congested. "When caused by pressure of a tumor, dysphagia is frequently present. Diagnosis. — The diagnosis is readily made by laryngoscopic exam- ination. BILA TERA L PARAL ISIS. oil Tkeatmext. — The cause of the difficulty must, if possible, be found and removed. Local treatment is of little or no value. In a feAV in- stances, evidently functional, which had existed for a number of months, I have brought about a cure by the administration of large doses of strychnine when many other remedial measures had failed. PARALYSIS OF THE ARYTENOID MUSCLE (central adductor OF THE CORDS). In paralysis of the arytenoid muscle, owing to the non-approxima- tion of the inner surfaces of the arytenoid cartilages in phonation, there is gaping of the posterior or inter-cartiiaginous portion of the rima glot- tidis, with consequent impairment of the voice. Congestion of the larynx is. usually present, for this form of paralysis most frequently re- sults from acute or subacute laryngitis. Fig. 189. — Ziemssen's Double and Single Laryngeal Electrodes. Symptomatology. — Hoarseness and fatigue in talking are prominent svmptoms. Inspection reveals a triangular opening at the posterior part of the glottis during phonation. Diagnosis. — The diagnosis is readily made by inspection. Treatment. — Stimulant inhalations and astringent applications ap- propriate for the laryngeal inflammation which coexists are indicated. In this, as in other forms of paralysis of the laryngeal muscles, if of long standing, faradization of the affected muscles and the administration of strychnine should be tried. BILATERAL PARALYSIS OF THE POSTERIOR CRICO-ARYTENOID MUSCLES (ABDUCTORS OF THE VOCAL CORDS). Bilateral paralysis of the posterior crico-arytenoid muscles is a dangerous affection of the larynx in which the vocal cords are not drawn aside during inspiration, but remain near the median line, closing the glottis and causing stridulous respiration and great dyspnoea, without alteration of the voice. 512 DISEASES OF THE LARYNX. Anatomical and Pathological Characteristics. — The affection is generally due to disease of the central nervous system, but may be produced by morbid processes which involve both pneumogastric or both recurrent laryngeal nerves. The recurrent nerves and their branches, and the muscles themselves, have been found atrophied. In a few cases the muscles have been found atrophied, though the brain and nerves have appeared healthy. Etiology. — The condition, as before stated, is usually caused by dis- ease of the central nervous system, and is evidently sometimes caused by syphilis, the lesion of which may be central or along the course of the nerve, or in the muscle itself. It is frequently due to pressure upon the pneumogastric or recurrent nerves by goitre, enlarged bronchial glands, or aneurism. Cancer of the thyroid gland or of the oesophagus may have a similar effect. Occasionally the paralysis seems to result from simple catarrhal inflammation, or from hysteria. Fig. 190.— Bilateral Paralysis of the Pos- Fig. 191.— Bilateral Paralysis of the Pos- terior Cricoarytenoid Muscles— Inspira- terior Crico- Arytenoid Muscles— Expira- tion, tion. Symptomatology. — The symptoms will depend upon the nature and extent of the lesion. Since the filaments of the recurrent nerve supply antagonistic muscles, those distributed to either the adductors or the abductors may be most involved, but experience shows that the latter are usually implicated first. Where the function of the nerve is com- pletely destroyed, the muscles of both sides are paralyzed and the cords remain in the cadaveric position, offering no impediment to respira- tion, though the voice is lost. When the abductor filaments alone are affected, the voice remains, but inspiration is greatly obstructed, and extreme dyspnoea supervenes upon the slightest exertion. A feeling of suffocation may occur not only on exertion, but occasionally from spasm of the adductors, especially during sleep. Expiration is quiet and unobstructed. When the abductor muscles alone are paralyzed the voice is not lost, but it is usually weak; if the adductors are also implicated to a certain extent, there is constantly a waste of air in phona- tion and the patient in talking becomes quickly exhausted on account of the great labor thrown on the expiratory muscles; cough and expecto- ration are also difficult. Loss of strength, emaciation and febrile excite- ment, are frequently though not always present. On inspection of the larynx, the vocal cords are seen very near the median line; during BILATERAL PARALYSIS. 513 respiration the rima glottidis will measure from one to two lines in width (Figs. 190, 191). On inspiration, the lips of the glottis are sucked downward and in- ward below their normal plane, and with expiration, are forced upward, the glottis being somewhat dilated, so that the air escapes freely. The vocal cords and mucous membrane of the larynx may be of a normal color or slightly congested. Diagnosis. — In adults the true nature of the disease is at once sug- gested by prominent inspiratory stridor; the characteristic appearance of the glottis on inspiration leaves no doubt as to the diagnosis, except as between this condition and adhesion of the inner surfaces of the aryt- enoid cartilages, which sometimes so closely resembles it that in the absence of previous history a differential diagnosis may be impossible. This affection may be distinguished from spasm of the adductors as follows : Bilateral paralysis of the Spasm of the adductors, abductors. Inspiratory dyspnoea constant ; may Inspiratory dyspnoea temporary ; di- be increased during sleep. minished or absent during" sleep. Vocal cords immovable. Vocal cords more or less constantly varying in tension. Prognosis. — The duration and final result necessarily depend upon the nature of the lesion ; where the paralysis is decided, the prognosis is always unfavorable, and a fatal result may occur at almost any time unless tracheotomy or intubation has been done. It is only in a few cases, of catarrhal, syphilitic, or hysterical origin, that good results can be expected from medicinal treatment. Treatment. — The great danger from suffocation renders it neces- sary to adopt some preventive measure. For this purpose, an O'Dwyer intubation tube may be introduced and worn while the influence of in- ternal remedies is being tried ; but if this does not succeed, tracheotomy had best be performed. Except when these patients can be closely watched it is not safe to let them go, even for a single day, without one or the other of these operations. Faradization should be tried, and such remedies used as are most likely to remove the cause, such as as- tringent and stimulating sprays in the catarrhal conditions, strychnine and other tonics in the hysterical form or where there appears to be functional interruption in the central nervous system, and the iodides in the syphilitic variety or when the pressure results from enlarged glands or goitre. 33 514 DISEASES OF THE LARYNX. UNILATERAL PARALYSIS OF THE POSTERIOR CRICOARYTE- NOID MUSCLE (ABDUCTOR OF THE VOCAL CORD). In unilateral paralysis of the posterior crico-arytenoid muscle, one vocal cord remains in the median line during inspiration, with conse- quent dyspnoea and stridulous respiration. It is due to lesions similar to those which cause bilateral paralysis, but it most frequently results from peripheral causes, as, for instance, catarrhal inflammation, or the implication of one pneumogastric or recurrent laryngeal nerve by malig- nant disease, aneurism, or other morbid growths. Symptomatology. — The symptoms are obstructed inspiration, stridor and dyspnoea, and slight alteration of the voice. There are also present more or less irritative fever and the symptoms of the primary disease. On inspection the affected cord is seen to remain stationary at Fig. 192.— Unilateral Paral- ysis of the Left Posterior Crico-arytenoid— Inspiration. Fig. 193.— Unilateral Paral- ysis of the Left Posterior Orico-Arytenoid — Phonation. Fig. 194. — Anchylosis of Right Vocal Cord— Speci- fic— Phonation. or near the median line, while the movements of the other are normal or slightly exaggerated. Diagnosis. — The symptoms and laryngoscopic appearance leave no question as to the diagnosis. Prognosis.— The affection is much less dangerous than bilateral paralysis, but it is usually best to give a guarded prognosis, since it is impossible to tell how soon the disease which has implicated one nerve may involve the other. "When clue to simple catarrhal inflammation, hysteria, or syphilis, recovery is the rule. Treatment. — If possible, the cause should be removed. Faradism or galvanism and constitutional treatment similar to that recommended in paralysis of both muscles should be employed. ANCHYLOSIS OF THE ARYTENOID CARTILAGES. Anchylosis of the arytenoid cartilages is a rare affection, the diag- nosis of which may be attended with great difficulty, since it closely simulates paralysis of the abductors or adductors of the vocal cords. It should be suspected whenever we find immobility of one or both cords, with irregularity of the cartilages; and should always be looked for when ATROPHY OF THE VOCAL CORDS. 515 a patient convalescing from typhoid fever complains of the symptoms of laryngeal disease. Teeatmext. — If the condition interferes with respiration, attempts should be made at dilatation by Schrotter's sound or O'Dwyer's intuba- tion tubes, and tracheotomy must be done if necessary. ATROPHY OF THE VOCAL CORDS. Atrophy of the vocal cords is extremely rare, and so far has not been proven by post-mortem evidence. The cords merely have a shrunken appearance, or they may be so narrow that although nothing intervenes to prevent inspection they cannot be brought into view. Diseases of the Nose. CHAPTER XXX. DISEASES OF THE NASAL CAVITIES. INFLUENZA. Synonyms. — Epidemic catarrh, epidemic catarrhal fever, grippe. Influenza is a specific epidemic fever, characterized by catarrhal in- flammation of the mucous membrane of the air passages or digestive tracts, and by marked and sometimes profound disturbances of the nervous system. It occurs in epidemics, which spread rapidly over an entire continent and attack the greater portion of the population irre- spective of age, condition, or sex, except that infants enjoy nearly com- plete immunity from the disease, although young children are fre- quently attacked. Anatomical and Pathological Characteristics.— No definite lesions can be described as peculiar to this disease, for in most fatal cases death results from some complication. There are usually signs of inflammation in the mucous membrane of the air passages and digestive tract, and not infrequently in the serous membranes covering the brain or lining the thoracic or abdominal cavities. Usually upon opening the chest, the lungs are found to contain here and there depressed spots of lobular consolidation. The mucous membrane of the larynx, trachea, and bronchial tubes is congested, swollen, and more or less covered with frothy or muco-purulent secretion. The bronchial glands may be en- larged and softened. Firm, whitish clots are often found in the right side of the heart. In many instances the gastro-intestinal mucous membrane is distinctly congested and swollen in patches. Etiology. — The disease is evidently caused by some powerful mor- bific agent in the atmosphere, but whether an irritating gas or a spe- cific micro-organism has not been determined. Generally sjaeaking, the disease cannot be communicated from one to another, and, though some observations seem to indicate its contagious nature, this is still an open question. Symptomatology. — The affection is sometimes preceded for twenty- four or forty-eight hours by general malaise, but usually it comes on sud- denly with chilly sensations or distinct rigors alternating with flashes of heat and attended by severe headache, pain in the back and limbs, constriction of the chest, and muscular weakness. This is usually fol- lowed by the ordinary symptoms of acute coryza, with sore throat, fre- 520 DISEASE* OF THE NASAL CAVITIES. quent hacking cough, arid in many cases dyspnoea, even without any affection of the lungs themselves. There are paroxysms of sneezing and sensations of stuffiness in the head, the eyes are suffused, and not infre- quently the inflammation extends to the Eustachian tubes and middle ear. Severe frontal headache is one of the most common symptoms, and often there is great soreness of the muscles, attended in many cases by sharp neuralgic pains; extreme prostration and great despondency, ■wholly disproportionate to the severity of the attack, are often observed, and actual delirium or mental vagaries are present in many cases. Diz- ziness is frequently experienced on rising suddenly. Most epidemics of the grippe have been characterized by great restlessness and insomnia, but in some the opposite condition has been quite pronounced. As the disease becomes established, the face is often congested, and occa- sionally jaundice, associated with hepatic tenderness, occurs. The fever rises rapidly to 101° or 102 c F., or sometimes even to 104° or !-\; it is of a remittent character, usually attended by profuse sweat- ing. Charles Warrington Earle (Archives of Pediatrics, March, 1892) states that in some children with influenza a high temperature persists for a long time during convalescence. In others he has observed a sub- normal temperature, which in one instance, in the axilla, ranged from 93° to 98 c F., for six days, although convalescence progressed favorably. The pulse commonly ranges from 90 to 100, though sometimes it runs much higher. In the milder forms of the disease, the catarrhal inflamma- tion does not extend below the larynx; but in those of a slightly severer grade, which I have witnessed during the recent epidemics, a severe inflammation of the trachea often occurs, and not infrequently the in- flammation extends beyond, giving rise to bronchitis or catarrhal pneu- monia. These changes are attended by more or less dyspnoea and cough, and are usually preceded by hoarseness. The cough occurs in parox- ysms, usually worse at night or in the early morning, and is at first attended by a frothy or clear expectoration, which later becomes muco- purulent and often quite offensive. The discharge from the nares is at first thin and watery as in an ordinary cold; later it becomes muco- purulent, and epistaxis is not uncommon. The tongue is usually coated, and the appetite lost; frequently there is tenderness, or colicky pains occur which may be attended by nausea, vomiting and diarrhoea. In many instances there is acute congestion of the kidneys: the urine is often scanty and not infrequently it is suppressed for a few hours. Inspection of the nares usually reveals hyperemia and swelling of the mucous membrane; and the mucous membrane of the fauces is similarly affected. Upon examination of the chest, the signs of bron- chitis are generally present, even in comparatively mild cases, and all too frequently the evidences of pneumonia or pleurisy will be obtained. Diagnosis. — Influenza is not apt to be mistaken for any disease ex- INFLUENZA. 521 cept acute non-specific rhinitis or inflammation of the larynx, trachea, or bronchi, from which it does not materially differ except in its epidemic nature and the severity of the symptoms. Isolated cases of the latter frequently precede an epidemic of influenza four or five weeks, present- ing much the same symptoms and possibly clue to the same cause; but it must not be forgotten that severe catarrhal inflammations of the upper air passages are common, independent of the peculiar conditions which cause influenza. Usually the history of an epidemic, the severe headache, mental depression, muscular pains, and sudden onset of the attack render the diagnosis easy. The symptoms and signs of compli- cating disorders will not differ essentially from the usual manifestations of these affections, except so far as they may be modified by the fever and nervous prostration attending the epidemic disease. Prognosis. — The catarrhal symptoms usually begin to subside in three or four days, and in mild cases the patient will not be confined to the house more than forty-eight to seventy-two hours; indeed, many persons continue their avocations in spite of the disease. When the disease is more severe, convalescence may not be established for a week or ten days, and in some the affection may be even more prolonged. This is especially the case when the affection is complicated by trachei- tis, bronchitis, or pneumonia, but in uncomplicated cases convalescence is usually fully established within ten or twelve days, even in the more severe forms of the affection. AY hen occurring in the very young or the aged, or in persons greatly debilitated from any cause, or in persons suffering from chronic pulmonary, cardiac, or renal disease, influenza must be regarded as a grave affection ; and when its various complicat- ing disorders are considered, it will be found that a considerable num- ber of cases, probably three or four per cent, prove fatal. When it at- tacks pregnant women, abortion is liable to follow. The experience of the epidemics through which we have passed during the last two years shows that functional disease of the heart, protracted fevers of a typhoid character, pleuris3 r , and pulmonary tuberculosis are common sequels of influenza. Eheumatoid or neuralgic pains not infrequently continue many weeks after the subsidence of the acute symptoms. Treatment. — No positive directions can be given for the prevention of the disease; but as it has been observed that those who are exposed to the outer air suffer most from the affection, it is wise, during epi- demics, for children and those enfeebled by age or disease to remain as much as possible indoors, hoping thereby to escape. As the main symptoms indicate great nervous depression, it is well during an epi- demic to fortify the system against an attack by tonic doses of quinine and nux vomica. Large doses of quinine are said sometimes to abort the* attack, and the same has been claimed for opiates, or opiates in com- bination with quinine, or ipecacuanha. During the progress of the dis- ease, rest in bed and gentle laxatives, refrigerant drinks, moderate doses of 5*22 DISEASES OF THE NASAL CAVITIES. quinine, and small doses of opium or other anodynes to relieve tiie cough are recommended. To relieve the pain in the inception of the disease no remedy has seemed to me more valuable than phenacetin; later, large doses of potassium bromide, which is peculiarly efficient in allaying irri- tabilitv and quieting cough, together with extract of mix vomica, ex- tract of hyoscyamus, quinine, and camphor, have proven most bene- ficial. The irritability and inflammation of the mucous membrane may sometimes be greatly relieved by the inhalation of steam, or steam im- pregnated with various soothing vapors, as of opium, belladonna, or hyoscyamus. When rheumatic symptoms are present, colchicum and the salic}-lates, together with alkalies, have been found most useful. Complicating diseases should be treated upon general principles, and in protracted cases the nutrition should be carefully attended to. If convalescence is delayed, a change of climate will frequently be of great advantage. RHINITIS. SIMPLE ACUTE RHINITIS. Synonyms. — Acute coryza, acute nasal catarrh, acute cold in the head, acute rhinorrhcea. Simple acute rhinitis is an inflammation of the nasal mucous mem- brane, sometimes of one passage, but usually of both, often extending into the maxillary or frontal sinuses, the lachrymal ducts, and Eusta- chian tubes. It is characterized by paroxysms of sneezing, hyper- secretion, and more or less obstruction of the nares. In infants it causes marked difficulty of breathing, particularly during sleep or nursing, and is occasionally attended by attacks very closely resembling laryngismus stridulus. The disease occurs in all climates and seasons and among patients of all ages and all classes of society, but it is somewhat more frequent among children, some of whom apparently have a congenital predisposition to it. It is said to be more frequent among persons of nervous temperament and in those subject to rheumatism, yet it is usu- ally independent of diathesis. Anatomical and Pathological Characteristics. — The mucous membrane becomes swollen, red, and at first dry, but is soon bathed in a profuse secretion of serum, which a little later becomes sero-purulent and is loaded with an excess of salines, which are very irritating to the nostrils and upper lip. In exceptional cases an excess of fibrin collects in irregular masses, as a membranous layer, which is most often found in the coryza of new-born infants or in that accompanying the exanthe- mata. Etiology. — The most common cause is exposure to cold when the body is overheated, but not infrequently it results from exposure to undue heat, or the inhalation of dust or irritating fumes or vapors. SIMPLE ACUTE RHINITIS. 523 Fraenkel believes that infantile coryza is generally due to direct infec- tion from the vaginal secretions at the time of birth. Among the occa- sional causes may be mentioned exposure to the rays of the sun, im- petigo or eczema, measles, scarlet fever, typhoid fever, tertiary syphilis, iodism, facial erysipelas, or extension of inflammation from the con- junctivae, pharynx, or larynx; and it is said to be caused in some in- stances by the cure of chronic discharges, such as those of otitis and ophthalmia, or bleeding hemorrhoids. Symptomatology. — The affection often comes on with a feeling of general malaise, which may last for two or three days, but more fre- quently there is aching of the back or limbs for only a few hours. Often constitutional symptoms are not present, and the onset is marked merely by an attack of sneezing, with more or less stopping up of the nose and hypersecretion of a thin, irritating serum, which, after one or two days, becomes thicker and bland. The nostrils and upper lip become red and irritated from the secretion and frequent use of the handkerchief. The nasal passages are so stopped that the patient is obliged to breathe through the mouth, with great discomfort, particularly while he is eating and during sleep. The general symptoms vary from slight disturbance to severe pain and headache, with sleeplessness, mental and physical debility, fever, and derangement of the digestive organs. There is sometimes a slight chill at first, but the earlier symptoms usually consist of sensations of dryness or irritation in the nose and a disposition to sneeze. "Within a few hours there is stopping up of the nares, with obtunding of the senses of smell and taste, more or less pain, and frequently extension of inflammation along the lachrymal ducts, causing redness and sensi- tiveness of the conjunctivae. If the inflammation extends along the Eustachian tubes, there is a sense of fulness, possibly with pain in the ears, and often abnormal auditory sensations and partial deafness. The inflammation may travel down the pharynx, causing sore throat, or it may involve the antrum, frontal sinus, or ethmoidal or sphenoidal cells, causing correspondingly severe pain in the cheek or forehead, or deeper seated. Occasionally the disease is intermittent, lasting for two or three days, and then subsiding, to be renewed after an equal length of time. Any or all of the symptoms excepting the secretion may be absent. The inflammation frequently attacks one side, not involving the other for two or three days or until its course is completed in the first. Exceptionally the cervical lymphatic glands become enlarged and sore. The body temperature may rise two or three degrees and the pulse be correspondingly accelerated. Obstruction of the anterior nares gives the voice a nasal tone; but if the swelling is mainly in the posterior part of the nares, the general character of the voice is normal, while the articulation is defective, the letter m being sounded like b, and n like cl. 5-^4 DISEASES OF THE NASAL CAVITIES. The secretion, which at first was thin, serous, and irritating, after a time becomes thicker, whitish, yellowish, or greenish, according to the intensity of the inflammatory process, and the cold is said to have broken. The secretion may amount to several ounces in twenty-four hours. The frequent use of a handkerchief after a time becomes painful, but, as the secretion becomes thicker, irritation gradually subsides. There is often an unpleasant catarrhal odor to the breath; and when the nose is com- pletely obstructed, the tongue becomes dry and brown from the continued mouth-breathing. The appetite is not infrequently impaired. Upon inspection, the mucous membrane is found to be swollen and congested, and sometimes, though not commonly, here and there are small, dark-brown stains, indicating extravasation of blood beneath the mucous membrane; or slight abrasions of the surface may be noticed. Early in the attack the thin secretion may be seen moistening the en- tire mucous membrane or flooding the floor of the nasal cavity; later, fine, cobweb-like shreds of mucus are often seen stretching from side to side across the nasal chamber, and more or less of the thicker secretion, mucous or muco-purulent in character, will be found collected in the nasal cavities, especially at the lower and back parts. Diagnosis. — Acute rhinitis is not likely to be confounded with any affections excepting hay fever, inflammation of the antrum or frontal sin- uses, or the commencement of measles. In any case the history, the character of the discharges, and the appearance of the parts will soon settle the diagnosis. Prognosis. — Attacks of acute rhinitis sometimes last but a few hours, but usually they continue for from three days to a week, and sometimes two or three times as long. The stage of dryness generally continues two or three hours, that of free, thin secretion from twenty-four to forty hours. The thick secretion commonly continues two or three days, when it gradually grows thinner until the end of the attack. The affection usually terminates by resolution; in children at the breast, and in the very aged and infirm, it has occasionally ]>roved fatal. Frequently repeated attacks are liable to eventuate in a chronic ca- tarrhal condition of the nasal mucous membrane. The inflammation may leave obstruction of the lachrymal ducts or the Eustachian tubes, or chronic inflammation of some of the adjacent sinuses, and it sometimes seems to be the starting point for nasal polypi. Where these growths already exist, they are often found to enlarge greatly during acute at- tacks of coryza. Treatment. — Prophylactic treatment includes daily sponging of the chest with cold water or salt and water, bathing the feet every morning in cold water, care respecting sufficient warmth of the clothing; and avoid- ance of sudden exposure, damp clothing, wet feet, and in a word all things which have been found to excite the inflammation. In the be- ginning an attack may frequently be aborted by moderately large SIMPLE ACUTE RHINITIS. 525 doses of opium, quinine, alcoholic stimulants, or the ammonium salts. Morphine gr. £ to i or its equivalent, atropine gr. T \^ with morphine gr. £, pulv. ipecac, comp. gr. x., quinine gr. vi. to x., or a hot sling taken at bed time will frequently abort the disease. It may also be checked in a similar way by one or two doses of ammonium carbonate, gr. x. to xx.; ammonium chloride, gr. xx. to xxx.; liquor ammonias acetatis, 3 L; tincture of belladonna, TTtx. to xx. ; tincture of euphrasia officinalis, tr^x. to xx. ; ammoniated tincture of guaiacum, 3 i. ; or an emetic dose of an- timony. These are best administered at bedtime, and their action may be favored by a hot foot bath containing a handful of mustard. Some- times the disease is speedily aborted by frequent inhalations of chloro- form, or the vapor of ammonium carbonate, camphor, iodine, or carbolic acid. But, as a rule, the most satisfactory abortive treatment consists in the administration of a comparatively large dose of quinine, and the application to the nose, either by spray or powder, of a small quantity of cocaine. Where opiates are well borne, one or two small doses of atropine and morphine act well. If the cold has existed for twenty-four hours, it can seldom be aborted, and must then be simply carried through to a speedy termina- tion, with as little discomfort as possible to the patient. Total absti- nence from liquids, as recommended by C. J. D. Williams, is said to be efficient in curing attacks of acute rhinitis (Cyclopaedia of Pract. Med., London, 1833), the coryza beginning to dry up in about twelve hours after liquids have been suspended, and ceasing completely in from twenty-four to thirty-six hours. Williams, however, allowed a table- spoonful of milk or tea twice a day, and a wine glass of water at bed time. If the disease was not aborted, Morell Mackenzie recommended five drops of the tincture of opium every six or eight hours. Ten drops of the spirits of camphor on sugar may be effectively taken in the same way. Five grain doses of potassium nitrate, twenty minim doses of the spirit of nitrous ether, or two drachm doses of solution of ammonium acetate repeated from time to time are often useful in cutting short the disease. Turkish baths are sometimes very efficient, though extreme care is necessary to avoid taking subsequent cold. Jaborandi and other diaphoretics have a similar effect, and diuretics and cathartics may expedite the cure; however, these should only be given when the patient can be kept indoors. Inspiration through the nose of warm aqueous vapors or sprays of mild solutions, gr. ij. ad 3 i., of ammonium chloride or carbonate, or sodium bicarbonate, or potassium carbonate, or boric acid, gr. viij. ad 3 i., are sometimes very grateful to the patient, and seem to aid much in prompting resolution. As a rule, the most satisfactory course of treatment will be found in the administration at first either of the morphine and atropine or of a comparatively large dose of quinine or of nux vomica and the application to the nares of a one or two per cent solution of cocaine in water, or better 526 DISEASES OF THE NASAL CAVITIES. still in oil, or the insufflation of a powder of four per cent of cocaine in sugar of milk and starch. In the latter case it is well to use also a spray of liquid alholene or benzoinol three or four times daily. Occasionally persons are met in whom oily sprays of any kind aggravate the disease. In these the solution of boric acid is apt to be most soothing. If the disease is not aborted at once, the cocaine may be continued in small quantities three or four times a day. The spray of liquid albolene should be continued during the attack, and the patient may be given with advantage, four or five times daily, small doses of cannabis indica and hyoscyamus, with medium doses of camphor and quinine, or quinine and phenacetin, or quinine and camphor mono-bromide. If opiates are given, care should be taken to keep the bowels open; and in any event it may sometimes be desirable to give gentle laxatives. Acute rhinitis in infants requires especial care to keep the nasal passages open. This may be done best by the application of sprays of liquid albolene, or, in cases where there is extensive secretion, by syring- ing the nose with a warm alkaline solution. The washing must be performed very carefully, and it must not be forgotten that often even very mild solutions are irritating to the nares and give the child pain. Whenever it is deemed necessary to syringe the nares in a child, it should be placed upon the face, and the warm solution introduced slowly, so that it may run out again from the opposite nostril, and not be drawn into the larynx. Excepting opium, most of the remedies rec- ommended in the treatment of the disease in adults may be used in smaller quantities for children, but usually it is best to rely upon oily sprays and small doses of quinine, with medium doses of the solu- tion of ammonium acetate. Tincture of euphrasia officinalis given in small and frequent doses is said to be peculiarly effective in the onset. TRAUMATIC RHINITIS. Inflammation of the mucous membrane is not infrequently excited by dust and vapors of chlorine, iodine, or other irritating substances suspended in the atmosphere. It may also arise from the entrance of larger foreign bodies, or may follow direct injuries to the nose. The in- flammation is not peculiar, and the remedies indicated for acute simple rhinitis are equally applicable here, except in case of fracture, when the parts must be replaced, and retained by nasal plugs and external splints. Hemorrhage should be controlled by the measures suggested for epi- staxis, and if abscesses result the pus should be promptly evacuated. The acute rhinitis due to the pollen of plants or other irritating par- ticles will be considered under the head of hay fever, but there is a form dependent upon the specific effects of potassium bichromate, arseni- ous acid, and mercury which deserves special notice here. It is charac- terized by ulceration leading to perforation of the cartilaginous septum. CHRONIC RHINITIS. 527 The nicer is at first small and round, but subsequently enlarges and assumes an oval shape. Since it does not extend to the lower and ante- rior part of the cartilage, the bridge of the nose never falls in. Ulcers are also occasionally found on the turbinated bodies, but are less exten- sive than those on the septum. Symptomatology. — The symptoms produced by the bichromate are tickling and sneezing, accompanied by profuse secretion; this is at first watery, but subsequently it becomes thick and greenish, and later contains crusts or particles of sloughing mucous membrane, and finally pieces of cartilage; but it is never offensive. Hemorrhage frequently occurs in the course of ulceration. The symptoms produced by the other substances are said to be similar; and whichever of these substances is the cause, the symptoms seem to result entirely from local irritation. Treatment. — -Persons employed in trades where they are likely to suffer from this affection should constantly wear plugs of wool in the nostrils. Where perforation has once taken place, it is difficult to pre- vent the formation of a large opening, but ordinary treatment will soon check the surrounding inflammation. Those who have once suffered from this variety of traumatic rhinitis are said afterward to enjoy im- munity from common catarrh. CHRONIC RHINITIS. Synonyms. — Rhinitis chronica, chronic catarrh, chronic coryza. Chronic rhinitis is a chronic inflammation of the nasal mucous mem- brane characterized by dryness and the collection of crusts, or excessive secretion and discharge from the nostrils or naso-pharynx, with fre- quent inclination to hawk and clear the throat. Both conditions may be characterized by stoppage of the nares and interference with res- piration. It is an affection found in nearly all climates and among all classes of people, and is most pronounced in the fall, spring, or winter months, when the temperature and moisture of the air are most changeable. It is most frequently met with near the northern seashore or on the borders of large lakes, yet it is prevalent even in some dry climates, especially where the air is filled with dust, as, for example, in Colorado and New Mexico. On the borders of the Great Lakes and at the seashore it is much more common among people who live within two or three miles of the water than among those farther inland, ap- parently owing to the greater exposure of the former to sudden changes, and to fogs and the damp, chilly winds, especially in the spring, when the southerly land winds have become warm and balmy, while the north- erly winds sweep over water often still containing ice, and colder than the land. The affection is most frequent in children and young adults between the ages of ten and thirty-five years, but it often occurs in infants, and not infrequently in people past the prime of life. Persons follow- 528 DISEASES OF THE NASAL CAVITIES. ing outdoor vocations become less susceptible to the influence of sud- den atmospheric changes, and are therefore less liable to this disease. For convenience of description, chronic rhinitis ma}- be divided into four varieties : first, simple chronic rhinitis, consisting of catarrhal inflam- mation with little or no swelling: second, intumescent rhinitis, a phase of the disease in which there is frequent swelling of the mucous membrane of the turbinated bodies or upper portion of the septum in one or both nares, which may come on speedily in one or the other side, and, after a time, may as quickly disappear, so that often when the nose is examined the cavities appear of normal size, though one or both may have been completely closed a short time before; third, hypertrophic rhinitis, an inflammation associated with more or less actual hypertrophy of the tissues; fourth, atrophic rhinitis, usually the sequel of the hypertrophic variety, in which the mucous and submucous tissues are wasted away, and as a result the nasal cavities become abnor- mally large. All these varieties usually originate in the same manner and frequently run the same course for a considerable period. The first variety is often but a commencement of the second, the second of the third, and the third of the fourth; but there are occasional instances in which either the second or third variety may begin or terminate without the supervention of the forms which generally follow, and there are occasional cases in which neither variety can be traced to any ante- cedent affection. Simple chronic rhinitis is a catarrhal inflammation of the mucous membrane attended by little or no swelling and characterized generally by great irritability and susceptibility to acute exacerbations. It is at- tended by congestion and by excessive watery or muco-purulent secre- tions. Etiology. — The disease may be induced by the frequent repetition of any of those conditions which cause an ordinary cold. It may result from inhalation of irritating substances, exposure of the throat, back, ankles, or of the whole body to cold, or the inhalation of damp, chilly atmosphere. A predisposition to inflammation of the mucous mem- brane may be inherited, or acquired by frequent attacks of the acute disease. Debility and a depressed condition of the nervous system often directly favor the onset of the affection, and in many cases hyperes- thesia of the terminal nerve fibres in the Schneiderian membrane is apparently the predisposing cause. In some cases it is favored by a scrofulous or dartrous diathesis. Symptomatology. — There is usually a history of frequently recur- ring attacks of acute inflammation which have finally resulted in con- stum irritation that is likely to have continued for months or years before the patient has applied for relief. Itching, burning, and tickling sensations in the nose are common, and sneezing usually occurs on the CHRONIC RHINITIS. 529 slightest provocation. Headaches and pain in the eyes are frequent symptoms. Xot infrequently there is loss of the sense of smell, and partial deafness ; and occasionally the sense of taste is obtunded. Pro- fuse lachrymation is an occasional symptom, and in most cases there is a profuse watery discharge from the nose, recurring upon the slightest irritation such as breathing of cold air. In some persons, after a time, the secretions become muco-purulent and of a more or less offensive odor. Usually the general health is not perceptibly impaired, but some- times it is poor, with derangement of the digestive organs mani- fested by capricious appetite and a sluggish condition of the bowels. When the secretion is thin and watery, the mucous membrane will gen- erally be found congested, of a bright red color, the surface moist, and a considerable amount of secretion collected in the lower part of the nasal fossae. Frequently cobweb-like threads of mucus will be seen stretch- ing from side to side of the nasal cavity, and occasionally small, opales- cent, transparent, or yellowish granulations will be seen studding the anterior ends of the inferior turbinated body. These are about a milli- metre in diameter and appear like solid masses, but when brushed over with the probe, they are found to be small drops of fluid. The nasal cavity normally is from three to five millimetres in width but in more than half of the cases examined, deviation of the nasal septum is present, or a cartilaginous or bony spur will be found projecting from one or both sides. These, however, may have no relation to the catarrhal condition, and are of no consequence as long as they do not obstruct nasal respi- ration. In most instances the mucous membrane of the naso-pharynx is congested, and here and there collections of tenacious secretions will be found adhering to its surface; or these may collect to be removed from time to time by the act of hawking. In rare instances the nasal cavity remains of normal size and free, excepting when obstructed by dry and decomposing secretion ; if this be removed, the mucous mem- brane is found irregularly congested and of a bright red color in spots, or pale and anamiic. In most of these cases, the atrophic condition is present, but in others there are evidences of hypertrophy. Diagnosis. — The diagnosis may be easily made by inspection and palpation of the part, with a consideration of the history. This form of chronic rhinitis is only likely to be mistaken for hay fever. The latter comes on at certain periods of the year, and is repeated season after season; while the former comes on at anytime, and is apt to be continu- ous, with frequent exacerbations. Upon inspection of the part, the nasal mucol^s membrane is found congested, and palpation with the probe frequently reveals here and there sensitive spots, similar to those which are present in most cases of hay fever; but the hypertrophic or atrophic changes usually present in chronic rhinitis are not. so common in hay fever. Prognosis. — The affection runs a tedious course, sometimes lasting 34 530 DISEASES OF THE NASAL CAVITIES. for many years. Some cases eventually recover spontaneously, but others go on from bad to worse, and finally terminate in some of the other forms of chronic catarrh. Treatment. — The treatment of this variety of rhinitis is tedious and often unsatisfactory, but usually considerable relief may be given and in some cases a cure effected by local applications. In the treat- ment, two objects are to be kept in view, viz., relief of irritability, and the checking of excessive secretion. If the secretions are profuse and watery, the nares will be kept clean, so that washes are unnecessary. In this class of cases, soothing j>owders or sprays are most efficacious, and mild astringents will often be found useful to toughen the membrane. All applications should be so mild as not to cause smarting for more than five minutes, and should, after brief discomfort, give a feeling of relief. The susceptibility of the mucous membrane varies greatly in different cases; therefore the mildest preparation should always be used in the beginning. Oily sprays are of utility in most cases. Those most commonly in use are derivatives from coal oil, such as oleum petrolina and liquid albolene; melted vaselin is also used for the same purpose. However, the effects of tbese are but tentative, and there- fore they should only be prescribed for the patient to use at home two or three times daily. In some cases of profuse secretion I have obtained most excellent results by having the patient apply twice daily a spray containing ffl x. of terebene ad 5 i. of liquid albolene. Indeed, this has seemed more effective than any other local application. A sedative powder consisting of about five or ten per cent of boric acid, twenty-five per cent of iodol, five per cent of starch, and sugar of milk to make one hundred grains, with occasionally one per cent of cocaine, may in some cases be applied in addition to the spray once or twice daily with much benefit. Certain patients in whom there is marked hyperaesthesia of the nasal mucous membrane, upon going into the wind or dust are subject to attacks of sneezing, accompanied by exces- sive secretion, necessitating almost constant use of the handkerchief. There is consequently soreness of the nose, which becomes the source of much annoyance. This is the most obstinate variety of simple chronic rhinitis, but fortunately it is rare. In searching for the sensitive spots a probe should be passed to the back part of the nasal cavity and drawn forward over the various parts of the mucous membrane; as a sensitive spot is touched, the patient winces from the pain or inclination to sneeze or cough, and sometimes says that the probe pricks or burns. The most effective treatment is superficial cauterization of the sensitive areas, as practised in the treatment of hay fever. Sedative powders and sprays should be used in the intervals between the cauterizations, which should not be made oftener than once in five to seven days. The cau- terizations destroy the terminal fibres of the hypersensitive nerve, but are not deep enough to destroy the mucous membrane. CHAPTER XXXI. DISEASES OF THE NASAL CAVITIES.— Continued. RHINITIS.— Continued. chronic rhinitis. — Continued. Intumescent rhinitis, also known as chronic catarrh, and by some considered as one of the forms of hypertrophic rhinitis, is the most frequent of all varieties of chronic rhinitis: it is characterized by in- termittent swelling of the Schneiderian mucous membrane, with more or less occlusion of the nasal passages. The swelling may involve both cavities at once but usually affects one side at a time and may change in a few moments to the opposite naris. This is most noticeable when the patient is lying upon the side, the undermost cavity being occluded, but the swelling generally changes to the opposite naris within a few minutes after the patient turns over. Anatomical and Pathological Characteristics. — The mucous membrane is usually congested, but is occasionally pale, and upon one or both sides may be swollen. The tumefaction is most frequently found over the inferior turbinated bodies, but it sometimes involves the middle turbinals and that part of the septum directly opposite. Frequently no swelling whatever is found at the time of examination, though the history clearly shows that it is present several times during the day or night. The swelling interferes with nasal respiration and favors accumulation of secretion in the nasal arid post-nasal cavities, consequent partly upon deficient evaporation, and partly upon in- creased activity of the secreting glands. In most cases the pharynx, and in many the larynx, finally becomes the seat of chronic inflammation; and in many cases partial deafness results from swelling of the mucous membrane in and at the mouth of the Eustachian tube. The pharyngitis and laryngitis, dependent in part upon extension from the nares, are chiefly the results of mouth- breathing, which becomes necessary when nasal respiration is obstructed. Etiology. — The causes are those of simple chronic rhinitis. Symptomatology. — In most cases there is a history of unusual sus- ceptibility to colds affecting the nasal cavities. These attacks are most common in the spring and fall months, though in some persons they are more frequent in winter, or occasionally even in warm weather. 532 DISEASES OF THE NASAL CAVITIES. After a variable time, during which the attacks of cold in the head have grown more and more frequent and prolonged, the affection finally be- comes fixed and the patient is annoyed much of the time, especially at night, by obstruction of nasal respiration attended by hawking and efforts to clear the throat, particularly in the morning or after eating. When tenacious mucus adheres to the upper surface of the palate, the violent effort to dislodge it often causes vomiting. Often the patients are annoyed by slight hacking cough, and by frequent hoarseness, espe- cially on attempting to sing. By Eaulin, of Marseilles (Revue de laryn- gologie, cV otologic et de rhinologie, Annual of the Universal Medical Sciences, 1892), this is attributed to muscular fatigue caused by excessive vibrations of the vocal bands in an effort to compensate for the loss of resonance caused by the nasal obstruction. In such cases the voice has often been speedily restored by reducing the hypertrophies of the septum or turbinated bodies. Nevertheless many persons who suffer from all the symptoms of nasal obstruction become so accustomed to it as scarcely to recognize the fact, and when questioned, affirm that they have no ditfi- cultv in breathing through the nose. They claim to sleep well, and assure the physician that the throat is not dry in the morning, that they always sleep with the mouth closed, notwithstanding the fact that inspection shows the nares to be more than half closed by swelling. Many complain of headache especially in the morning, of pains in the eyes, of frequent hawking to clear the throat, or a slight hacking cough, of dropping of mucus into the throat from the naso-pharynx, and of obstruction in the nares, especially upon taking cold, which they con- tract very easily. The symptoms in mild cases usually disappear during the summer months, or upon change of climate, even though it be but a slight change. This is peculiarly noticeable when patients leave the vicinity of our northern lakes, especially in the spring and early summer when the waters are icy or cold. In some there may be little difficulty in temperate weather; but in extremely cold or extremely warm weather, or upon slight exposure to draughts, or change -of temperature as in going from a warm to a cold room, or the reverse, or even from the shade into the bright sunshine, there is a tendency to sneeze, followed by speedy closure of one or both nares. I have seen one patient suffer- ing from this form of catarrh who would always sneeze upon going into bright gaslight. Sometimes the inhalation of smoke or of odors from certain plants, or drugs, will irritate the mucous membrane and excite excessive secretion, with swelling. Many patients experience sensations of itching or tickling in the mouth, or a feeling of dryness, fulness, pres- sure, or stuffiness in the nose, as the principal symptoms. Often the pharynx feels dry or uncomfortable, especially in the morning, and sometimes obstinate pricking or neuralgic pains are experienced in the fauces. Occasionally the patients are annoyed by repeated attacks of redness CHRONIC RHINITIS. 533 and inflammation of the end of the nose. In many instances the voice is thick or nasal, and it often becomes hoarse from the accompanying laryngitis, so that patients are usually unable to sing or shout, and easily become fatigued upon prolonged talking. Such persons are generally obliged to keep the mouth partially open much of the time, particularly when walking in the wind or during active exertion, and they are fre- quently in the habit of yawning or taking deep respirations to make up for the constantly deficient supply of oxygen. The secretions may or may not be increased ; they may be thin and watery or thick and tenacious, or they may dry into crusts which are re- moved every two or three days from the nostrils or naso-pharynx. In the nose these crusts are most likely to collect upon the anterior part of the septum, or the anterior ends of the middle turbinated bodies. Fre- quently fine cobweb-like shreds of mucus will be seen stretching from the turbinated bodies to the sejDtum, as in simple chronic catarrh. If the secretions collect and remain for any length of time, they become par- tially decomposed and offensive, giving the peculiar catarrhal odor, familiar even to the laity. The tongue is commonly coated with a white or yellowish fur, especially at its base, and the digestive system is so frequently disturbed as to lead to the belief that in some cases it is the direct cause of this disease. Gaseous eructations from the stomach, and constipation, are frequent concomitants. Upon inspection, the mucous membrane is usually found congested, though occasionally it may be paler than normal; and one or both nasal cavities are found to be from one-third to two-thirds closed by swelling of the inferior turbinated bodies. In many cases, no swelling is ob- served at the time of the examination; but on the other hand the nares may be completely obstructed. Swelling of the soft tissues over the septum is not infrequently observed, especially running horizontally along its upper half, and it is not unusual to find similar swellings run- ning vertically from half to two-thirds the whole height of the vomer near its posterior border. The swollen membrane at the upper part of the septum is usually of a slightly deeper hue than normal; that seen with the rhinoscope at the posterior border is of a grayish color. The posterior ends of the inferior or middle turbinated bodies are sometimes found much swollen and of a grayish hue; but this is more commonly present in hypertrophic rhinitis. By examination with the probe, ex- quisitely sensitive spots are frequently detected, as in simple chronic rhinitis. Whenever swelling is present, the soft tissues may be easily pressed down until the bone is felt beneath, but the dent thus formed quickly disappears as the probe is removed. Upon palpation, in this way, the mucous membrane over the septum will often be found swollen two or three millimetres in thickness, and that over the turbinated bodies from two to five millimetres. In uncomplicated cases of this affection, upon the insufflation of one or two grains of a four per cent pow- der of cocaine, or spraying the nares with a weak solution of the same 534 DISEASES OF THE NASAL CAVITIES. drug, the swelling will speedily subside aud the cavities appear of normal size. Sometimes this occurs spontaneously during the examina- tion, from the fright caused by suggestions as to the proper treatment. Sometimes the swelling will promptly disappear upon exercise, and it is not uncommon for patients to find that they can breathe much more easily after going upstairs, or for them to say that they have to get up and walk about in the night in order to breathe. DIAGNOSIS. — The affection is to be distinguished from simple chronic rhinitis, from hypertrophic rhinitis and from nasal mucous polypi. Intumescent rhinitis is differentiated from simple chronic rhinitis by swelling of the mucous membrane, and the occurrence of frequently re- peated nasal obstruction. It is distinguished from hypertrophic rhinitis by the intermittent character of the swelling instead of permanent occlusion of the nares; by the smooth surface of the membrane in place of an uneven, nodular appearance, and by disappearance of the swelling under the action of cocaine, which does not affect true hypertrophy. We find that nasal mucous polypi are of lighter color and more mobile; a probe may be readily passed upon either side of them, where- as it can only be passed upon one side of the swelling in intumescent rhinitis, and. although in the latter affection the swollen tissue may be compressed, the enlarged body cannot be moved upon its base as can a polypus. Again, cocaine diminishes the swelling in intumescent rhini- tis, whereas it renders the mucous polypus, in most instances, more prominent by diminishing the swelling about it. Prognosis. — If left to itself, spontaneous recovery from the disease occurs in a few cases, but usually it extends over months or years, and eventually terminates in hypertrophic rhinitis, though occasional cases appear to pass directly into the atrophic form. The frequent occlusion of the nares leads either to pharyngitis or laryngitis, or both; in many cases, throat-deafness results from involvement of the Eustachian tube, the inflammation extending not infrequently to the middle ear. The general health suffers from imperfect oxygenation of the blood; and although to the casual observer the patients may appear well, they become easily fatigued, are unable to stand exercise, and are often sub- ject to illness upon slight exposure. These tendencies may not be rec- ognized until the marked improvement in the patient's general condi- tion, under appropriate treatment of the nasal affection, demonstrates that they have been present. Treatment. — Prophylactic treatment is of the greatest importance in all persons predisposed to catarrhal affections. They should avoid exposure to draughts or cold or to undue heat, especially in badly ven- tilated rooms, and so far as possible the inhalation of air containing irritating substances. Woolen underclothing should be worn the year round. The daily practice of invigorating exercise, with cold sponging of the body, followed by vigorous friction, and bathing the feet morn- CHRONIC RHINITIS. 535 ings in cold water, are often useful adjuvants in the prevention of colds. Acute rhinitis occurring in individuals thus predisposed should be cured as speedily as possible. In all cases the condition of the digestive or- gans should receive careful attention. In the early stages the regular use by the patient of sedative remedies, and the occasional application of mild astringents or stimulants to the nares, constitute the best means for the cure of the disease. The milder stimulating applications, which may be made two or three times per week, consist of aqueous solutions of zinc sulphate, carbolic acid, and zinc chloride (Form. 94), of sufficient strength to cause smart- ing or discomfort for not more than ten minutes. Aqueous solutions may be employed for home use two or three times daily, such as : boric acid gr. x. ad 3 i., or listerine tt[ xl. to lx. ad 3 i., or sodium bicarbonate and biborate aa gr. iss. to ij. ad 3 i., or distilled extract of hamamelis or of pinus canadensis ttx xxx. to 1. ad 3 i. A saturated solution of boric acid in camphor water is also a useful soothing application. Oily prep- arations such as oleum petrolina or liquid albolene containing camphor gr. i. to ij., menthol gr. ss. to i., oil of cloves t\[ iij. to v., or terebene HI viij. to xij. ad 3 i. (Forms. 105, 106) are generally more beneficial than the aqueous solutions. The oleaginous liquid alone may be used as a soothing application to prevent the contact of irritating substances with the mucous membrane. In addition to these, the sedative powders al- ready mentioned in speaking of simple chronic rhinitis (Form. 166) may also be employed once or twice daily with benefit in certain cases. Cocaine in any quantity should never be used continuously, not only because of the danger of forming the cocaine habit, but because when used for any length of time it seems partially to paralyze the vasomotor nerves, thereby causing turgescence of the cavernous tissue and thus increasing the difficulty we are trying to remove; but it will be found most efficient in temporarily removing swelling and relieving the acute exacerbations of this affection. Cocaine is most conveniently employed in powder (Form. 166), which may be blown into the ob- structed nostril two or three times in twenty-four hours, in quantities not to exceed one-thirtieth of a grain of cocaine at a dose. Even in this quantity it should only be used for a few days, and it is seldom necessary then excepting at night or early in the morning. For the application of powders to the nares, I give patients a short glass tube about four millimetres in its internal diameter and four inches in length, flattened and expanded at one end, but round at the other (D B, Fig. 195). A small quantity is worked into the round end by moving it about in the powder ; the end of a piece of rubber tubing about nine inches in length is then slipped over the same end of the glass tube; its flattened end is placed in the nostril, the other end of the rubber tube between the lips, and the patient gives a short, quick puff, which blows the powder into the naris. The rubber tube is made of the common 530 DISEASES oF THE NASAL CAVITIES. drainage or nursing-bottle tubing with a calibre of about three milli- metres. When the physician makes the application himself, it is best to use a hand-insufflator (Fig. 195). Any application which is made as often as two or three times a day should not cause smarting or dis- comfort for more than three to five minutes, and should make the patient subsequently feel better, instead of worse; but stronger applica- tions, as already recommended, may be made every two to five days. The sprays may be applied by means of any suitable atomizer. The atomizer which I have found most satisfactory is shown in Fig. 196. Fig. 195.— Powder Blower. Three glass tubes 3 size). Straight tube for nasal, bent tubes for naso-pharyngeal or laryngeal applications. When secretions collect in large quantities, the patient should wash the nose once or twice daily with an alkaline solution, or with a salicy- late solution (Form. 187). An excellent alkaline solution may be made by dissolving an even teaspoonful of sodium bicarbonate in a half-pint of lukewarm water, or one-half of a teaspoonful each of sodium bicar- bonate and sodium chloride in the same amount of water. In some in- stances sodium chloride alone, in the same proportion, seems to answer a better purpose. This I recommend in cases where the sodium bicar- La.iOSO* RUBBC.R CO, Fig. 196.— Davidson's Oil Atomizer. N*o. 50 CV4 size). bonate causes an uncomfortable sensation of dryness. After the nose has been thoroughly cleansed, the applications already recommended should be made. In fully developed cases of intumescent rhinitis these remedies will give the patient temporary relief, but can seldom if ever effect a cure, and they should therefore only be employed as an aid to more radical treatment, which consists of the cauterization of the swollen CHRONIC RHINITIS. 53? tissue either by chemical agents or by the galvano-cautery; or in the re- moval of portions of the tissue with the steel-wire snare. The latter is better suited to the case of hypertrophic rhinitis. Before cauterization, the part should be thoroughly anaesthetized by cocaine, as recommended in speaking of hay fever. Of the various chemical agents which have been recommended, strong acetic or chromic acid is most useful, and of these two the latter is more generally preferred by laryngologists. It may be em- ployed in solutions of fifty to seventy-five per cent, or preferably a small amount of the acid may be fused upon an aluminium probe (Fig. 197) and employed in the solid form. I always apply it, if at all, in the latter manner, since its effects can be better controlled, and in- jury to other parts can be more easily avoided. A few of the crystals of chromic acid being placed upon the end of the flat aluminium probe, it is held over the flame in such position that the acid slowly fuses, and then so that it cools upon the desired place. The fused acid is then rubbed over the part to be cauterized, which becomes of a brownish color, and immediately afterward an alkaline spray is thrown into the nostril to neutralize any excess of acid, and to prevent it from being diffused to Fig. 19?.— Flat Nasal Probe (2-5 size). Made of aluminium and bent at an angle of 35°. other parts. The amount of acid used at one time should not exceed four or five times the bulk of a pin's head or about two-thirds the bulk of a flax-seed. The acid should be applied along a narrow strip of membrane about three or four millimetres in width and from ten to twenty in length according to the depth of cauterization, care being taken not to use too much acid at one time or to cauterize too large a surface. Bosworth prefers touching only at separate points with the acid, claiming that the small eschars, as he expresses it, pin down the mucous membrane to the bone beneath; but in my hands this plan has been less satisfactory than the one already recommended. I would not advise a repetition of cauterization until complete healing has oc- curred, which will require from ten to twenty days. H. Holbrook Curtis, of Xew York, who has had excellent results in the treatment of this form of catarrh, informs me that he touches the lower half of the inferior turbinated body along its whole length with chromic acid, which he commonly uses in strong solution, and repeats the cauterization within four or five days. Chromic acid causes much more pain than the galvano-cautery, a more irritating discharge, and a sore which heals more slowly than that by the latter, while its effects cannot be so accurately controlled. The treatment is therefore more tedious and gives the patient much 538 DISEASES OF THE NASAL CAVITIES. more discomfort, and the result is no better than that obtained by the hot electrode. In using the galvano-cautery I employ an electrode (No. 2, Fig. 91), with a blade about fifteen millimetres in length consisting of No. 21 platinum wire. One, two, or more narrow, linear incisions the whole length of the turbinated body, and deep enough to just graze the bone in two or three places, should be made, one at a sitting, with a sufficient interval for healing to occur before the cauterization is repeated. These lines are usually made at the junction of the middle with the inferior or superior third of the lower turbinated body; and in from ten to fifteen days afterward, a similar cauterization is made upon the other side. In the same length of time subsequently the first cauterization will have healed, and if necessary the treatment may be repeated upon the side first treated. <■ Immediately preceding or following the cauterization I apply to the nares a solution of it[ v. ad 3 i. of oil of cloves in liquid albolene, and after the cauterization follow this by the insufflation of two or three grains of iodol. A light pledget of cotton is then placed in the nos- tril, and the patient is directed to wear this, changing it as he wishes, for the next forty-eight hours, whenever out of doors. He is also given a four per cent powder of cocaine (Form. 168) which he is directed to use three or four times daily, providing the tissues swell so as to occlude the nares. At the end of four or five days he returns, and a probe is passed between the septum and the turbinated body to prevent adhe- sion; or if the thick mass of exudate, resembling false membrane, which usually covers the wound, is still present, it is gently removed, and the line of the cauterization touched with a ten grain solution of silver nitrate; or the parts are simply sprayed with a stimulating solution of zinc sulphate and carbolic acid, aa gr. ij. ad 3 i. The patient is then given, to use once or twice daily, instead of the powder first employed, a similar powder to which has been added twenty-five per cent of iodol. In most cases two or three times each day after the cauterization the patient also uses at home a spray containing gr. J of thymol, gr. ss. of carbolic acid, and Ti[ iij. of oil of cloves ad 3 i. of liquid albo- lene, or, if this causes any irritation, a still milder application. Most patients find this soothing, and it prevents the formation of dry scabs; but for patients to whom oleaginous sprays of any form are irritating, a spray of boric acid, gr. viij. ad 3 i., will be found most beneficial; though any of the soothing sprays already recommended may be em- ployed to suit the indications of the case or the fancy of the patient. If the soft tissues over the middle turbinated body or the septum swell, they may be treated in the same manner. In a few cases a single cauterization upon each side will be sufficient to effect a cure, and in the great majority of cases two cauterizations uj^on CHRONIC RHINITIS. 53£ each side are sufficient; but occasionally three, four, or even more will be necessary before the disease is checked. During the treatment, and for a few weeks afterward, it is usually best for the patient to use some of the sedative or slightly stimulant sprays recommended for the treatment of mild cases of the disease. If the treatment is properly carried out recovery may be confidently expected in at least nineteen cases out of twenty. The treatment usually requires from six to twelve weeks with an average attendance at the physician's office of about once a week, though many cases are cured much more promptly, and rare cases demand more extended treatment. In using the galvano-cautery, I employ a current sufficiently strong to heat the platinum wire to a white heat within two seconds after contact is made. The electrode having been carried to the back part of the tissue to be cauterized, and turned so that the platinum wire rests against the tissue, the circuit is closed, and as soon as the sound of burning is heard, the electrode is drawn slowly forward, or, if the bone is not felt, moved slightly backward and forward until it grazes the bone, and then drawn slowly to the anterior end of the turbinated body, where it should be lifted from the soft tissue before the current is turned off, and then allowed to cool' before it is with- drawn from the nostril. If the circuit is broken before the electrode is lifted from the tissues, the eschar is pulled off with it and bleeding- results. If the wire is too hot, it cuts like a knife, and much bleeding- may follow; if it is only of a cherry-red heat, or if it is too small, it will cut through the mucous membrane too slowly, so that the time necessary for a sufficiently deep cauterization will allow enough radiation of heat to burn surrounding tissues. Occasionally, in spite of all precautions, adhesions will take place be- tween the two walls of the nasal fossa, though this is not apt to occur except where there is hypertrophy of the turbinated bone, or an out- growth or deflection of the septum. If adhesions form, they must be cut or broken down, and the parts kept apart by a pledget of wool or bit of rubber or gutta-percha until healing occurs. Sometimes an application of monochloracetic acid will prevent subsequent adhesions. When patients find it inconvenient to call within four or five days after the cauterization, they are directed to come again at any time that suits their convenience after two weeks, and most of them will progress very well in this way, though there is more liability to adhe- sion, and occasionally the wound does not heal as it would if proper at- tention could have been given at an earlier date. In a few cases too much reaction will follow a cauterization of the ex- tent recommended; in these a line only half way across the turbinated body should be made at once. Usually the treatment causes little or no pain, and no subsequent inconvenience except such as would be ex- perienced from an acute cold in the head. The discomfort following 540 DISEASES OF THE NASAL CAVITIES. the cauterization most frequently results from the cocaine; it may often be relieved by a cup of strong coffee or ten to fifteen grains of potassium bromide. Headache occasionally follows, which is best re- lieved by five or ten grain doses of phenacetm, repeated in one, two, or three hours as needed. Coexisting pharyngeal or laryngeal in- flammation should receive appropriate treatment at the same time; though the physici ;n may with perfect candor assure his patient that, as soon as the nasal obstruction is removed, at least four-fifths of the difficulty arising from the other affection will disappear, and that the remaining trouble will probably disappear within a few months even without treatment. In this form of rhinitis a slight change of climate, especially moving from the vicinity of large bodies of chilly water, will often give immediate relief, though the affection is liable to recur as soon as the patient returns to his former abode. Hypertrophic rhinitis is a common affection, next in frequency to intumescent rhinitis. It is usually characterized by excessive dis- charge from the nostrils or into the naso-pharynx, with hawking and clearing of the throat, and more or less permanent obstruction of the nares, though it varies much from time to time in consequence of the swelling. Anatomical and Pathological Characteristics. — The mucous membi'ane is usually congested, but may be paler than normal, and hyperplasia of the mucous and submucous tissues causes permanent thickening of the turbinated bodies, especially the inferior (Fig. 198), and sometimes also of the septum, usually at its upper part. Occasionally the bones themselves are likewise hypertrophied, and constantly narrow the lumen of the nares. The condition may be pres- ent upon one side only, but commonly involves both. It is frequently associated with deflection or exostosis, or enchondrosis of the septum, in which case the inferior turbinated body upon the concave side of the septum is apt to be much more hypertrophied than its fellow; indeed, the latter will sometimes be found atrophied, so that patients can breathe more easily through the side which appears most obstructed. In addition to hypertrophy, swelling of the soft parts is usually present, so that the nasal cavity is from one-half to two-thirds closed or entirely obstructed. Etiology. — Hypertrophic rhinitis is usually preceded by frequent attacks of acute catarrhal inflammation, from which intumescent rhini- tis is at length developed, finally terminating in true hypertrophy. It is produced by the same conditions that cause the intumescent form of the disease. Symptomatology. — The patient usually states that for a long time he has taken cold easily, and for several months or years has been an- noyed by stopping up of the nose, especially at night or in the early morning, and by excessive discharge from the nostrils, or into the naso- CHRONIC RHINITIS. 541 pharynx, with hawking and clearing of the throat, or hoarseness. More recently one or other naris has heen constantly obstructed, so that the mouth must be kept open upon any exertion and during sleep. Fre- quently the sense of hearing is obtunded; indeed, most cases of deaf- ness are the result of hypertrophic rhinitis. Frequently the general health suffers in consequence of imperfect oxygenation of blood. Often the patient suffers from frontal or occipital headache or a feeling of pressure over the bridge of the nose or forehead, and occasionally the eyes are affected so that reading is painful or impossible, except for Fig. 198. — Hypertrophy of Inferior Turbinated Body. Cross-section of head, froni frozen section, a, Middle turbinated body: b, inferior turbinated body hypertrophied; c, superior turbi- nated body ; d, sphenoid cells ; e, orifice of Eustachian tube. a few minutes at a time. There is usually some dysphonia and dysp- noea, the mucous membrane, especially over the inferior turbinated bod}", is thickened, and its surface is usually more or less uneven in ap- pearance, sometimes presenting distinct nodules. The amount of swell- ing varies much from time to time, and it may be uniform over the whole turbinated body or limited to portions of it. Thus, it is common to find either the anterior, middle, or posterior portion of the cavity most occluded ; or along the upper portion of the turbinated bodies there maybe but little thickening while the lower portion touches the septum, the inferior border resting upon the floor of the nares. Whenever the 542 DISEASES OF THE NASAL CAVITIES. mucous membrane of the two sides of the nasal cavity is in con- tact, we usually find a considerable collection of mucus or muco-pus at the lower portion of the fossa. In many cases cobweb-like shreds of mucus will be found extending from side to side as in other forms of rhinitis already discussed, or the dried secretions may have collected in crusts upon the cartilaginous septum, or about the middle turbinated body. Usually the vault of the pharynx is congested, and contains tenacious mucus or dried masses, and the posterior ends of the inferior or middle turbinated bodies are enlarged (Fig. 199). These commonly appear in the rhinoscope of a gray color, but occasionally of darker hue, even purple, and the surface has a nodular or raspberry-like appearance. The posterior ends of the turbinated bodies of both sides may be so enlarged as to project into the naso-pharynx, and may even come into contact behind the septum, nearly or quite occluding the choana?. The middle turbinated bodies are much less frequently hypertrophied Fig. 199.— Hypertrophy op Posterior Ends of Inferior Turbinated Bodies. than the inferior, but when enlarged they press against the septum, frequently causing neuralgic pains in the forehead and eyes, and sensa- tions of pressure on the bridge of the nose. Occasionally the middle turbinated bodies are found hypertrophied, while the inferior are normal in size or perhaps atrophied. Hypertrophy of the soft tissues upon the septum in the majority of cases is found at its middle or upper third, running nearly horizontally, or extending vertically near the posterior edge of the vomer. Diagnosis. — Unless the parts are carefully examined, the affection is apt to be confounded with any of the other causes of nasal obstruc- tion; but by a consideration of the history, and a careful inspection and palpation of the parts, it may be easily distinguished from all diseases except intumescent rhinitis and syphilitic affections of the nose. The tissues are easily impressed with the probe in intumescent /■hi /li- tis, and swelling rapidly and completely disappears on application of cocaine, signs not obtained in true hypertrophy. It is impossible to distinguish hypertrophic rhinitis from syphilitic disease of the nose, attended simply by persistent swelling without ulcer- ation, except by careful consideration of the history and watching re- CHRONIC RHINITIS. 543 suits of specific treatment. It is often difficult to get the specific his- tory of syphilitic patients, for reasons already indicated. Excessive hypertrophy of the anterior or posterior end of the tur- binated bodies is distinguished from mucous polypi by inspection, and joalpation with the probe, which can be passed between a polypus and the external wall, but cannot be so manipulated in hypertrophy. The posterior end of the turbinated body when hypertrophied has much the color of a mucous polypus, but its surface, unlike that of a polypus, is uneven and slightly nodular, and it is usually of a deeper hue and has not the translucent appearance of the polypus. Prognosis. — Hypertrophic rhinitis left to itself may extend over a period of several years. I have known of no case terminating in less than one year, but have seen one well-marked case where the affec- tion merged into atrophic rhinitis within eighteen months. In many instances the hypertrophy gradually increases or, after a certain point has been reached, appears to remain without change; but in a considera- ble number of cases, atrophy finally begins and continues until the secretions become much altered, and the cavities greatly enlarged and more or less obstructed by decaying mucus and muco-pus, which cause the offensive odor of ozasna. In more favorable cases, atrophy continues for a time until the nasal cavities once more become free, and then ceases, whereby spontaneous recovery results. There is a common belief with the laity, and among physicians who have been in practice for more than ten or fifteen years, that little or nothing can be done for chronic catarrh by treatment; and this belief was well founded until the advent of the improved methods of treatment in vogue during the last decade. Although the general health is often somewhat impaired by this affection, there is little or no evidence that it ever terminates in tuber- culosis. It is true that patients suffering from chronic catarrh fre- quently die of tuberculosis, but apparently no more frequently than those free from the nasal disease. On theoretical grounds, it would ap- pear that obstruction of the nares, by interfering with free expansion of the lungs, would sooner or later cause collapse of some of the air cells, with a consequent chronic inflammation and finally tuberculosis. I have seen some cases which seem to substantiate this hypothesis. Treatment. — Various medicinal substances have been recommended internally and locally for the cure of hypertrophic rhinitis, but none of them are of much value excepting when used in connection with proper surgical measures; and a cure can seldom be effected except by the re- moval of some portion of the redundant tissue. This may be accom- plished by means of chemical caustics, the galvano-cautery, burrs, tre- phines, scissors, saws, or the snare. Among the chemical agents which have been recommended are the mineral acids, especially nitric and sulphuric, solution of mercury nitrate, London paste, glacial acetic, and chromic acid; all of these have passed into general disuse excepting 544 DISEASES OF THE NASAL CAVITIES. acetic and chromic acid. The former, especially, in the form of mono- chloracetic acid, is useful particularly in cases where there is liability to adhesion of the opposing surfaces after cauterization, and either this or the glacial acetic acid may be used to reduce hypertrophy of the soft tissues, but they are less efficient than chromic acid, which, though an effectual remedy, is open to the objections mentioned under intumes- cent rhinitis. Injections of carbolic acid, beneath the mucous membrane, by means of a hypodermic syringe, have been recommended, and the treatment appears to have been successful in some instances. The majority of cases may be cured by cauterization as already de- scribed in the treatment of intumescent rhinitis. I prefer the galvano- cautery for most cases, and make linear incisions, as already recommended, two. three, or more of which may be necessary upon the inferior and possibly the middle turbinated bodies of each side. In cauterization of the middle turbinated body, I frequently use a small loop-like or pointed electrode (Xo. 3 or 4, Fig. 91), which is thrust into the lower edge of the turbinal in three or four places. In cauterizing the inferior turbinated body I sometimes use the same lance-pointed, slender elec- trode, and carry it all the way from before backward beneath the mucous membrane without burning through to the surface except at the points of entrance and exit. In seventy-five per cent of cases, not more than two lines are necessary upon either turbinated body, and in only five or ten per cent will more than three be needed. When the middle turbi- nal is involved, generally one or two cauterizations are all that will be useful, and if they do not succeed, some portion of the bone must be removed. In hypertrophic rhinitis, Harrison Allen has recommended press- ing the incandescent loop of the galvano-cautery into the tissue and drawing it forward until a small piece has been scooped out by the burning wire. In some cases, especially in hypertrophy of the middle turbinated body, when the soft tissue stands out prominently it may be caught and removed by the galvano-cautery ecraseur. particularly where there is objection to the bleeding which would follow removal by the cold steel wire. When there is great hyper- trophy of the soft tissues, it is far better to remove the redundancy by the scissors or snare. Sometimes with the nasal scissors (Fig. 200) I cut off the lower edge of the inferior turbinated body, but I prefer the snare where the wire can be made to hold. As a rule, in all these opera- tions the parts should first be thoroughly anaesthetized by cocaine, but sometimes the swelling is so reduced by this agent that the snare cannot be made to hold, whereas the redundant tissue could be easily secured before the cocaine had been applied. In such cases it is sometimes best to introduce and tighten the snare first and subsequently to apply cocaine. In those patients who can easily endure pain the snare may be used with- CHRONIC RHINITIS. 5+5 out cocaine, being gradually tightened until it causes the patient to wince; then after resting two or three minutes it is tightened still more until it again causes pain, when another rest is taken; this process is continued until the mass is cut off. This slow process has the advan- tage of causing a minimum amount of bleeding. In hypertrophy of the anterior end of the turbinated body, if the snare cannot be made to hold alone, the tissue may be transfixed with a needle, as recommended by Jarvis, of New York, the wire being slipped over the end of the nee- dle and tightened down behind it. In posterior hypertrophy the snare should be armed with a No. 5 steel jnano-wire; the loop, of proper size, should be bent sharply over the end of the canula, as recommended by Bosworth; and then drawn slightly into the canula to straighten it during introduction into the naris. When it has been passed to the back part, the wire is again crowded forward until the bend is brought to the end of the canula, when it springs outward, and may be made to engage the diseased mass. Fig. 800.— Ingals 1 Nasal Scissors (^size). The end of the snare should then be pressed firmly against the tur- binated tissue, the wire drawn taut, and subsequently gradually tight- ened by the milled wheel. When this method is practicable, it is to be preferred to the slower process of cauterization, for by it a large amount of the redundant mass is at once removed, and the reaction which follows, as well as the consequent discomfort to the patient, is much less than after cauterization. When any operation liable to be followed by much, bleeding is done, the naris should be tamponed with lint or gauze, as recom- mended in speaking of epistaxis and the operation for exostosis. Even in cases where the snare or the scissors are applicable, it is usually also necessary to cauterize. It will be seen that the treat- ment of this affection is essentially the same as that of the intumes- cent variety of rhinitis, except that here we desire to remove redund- ant tissue, while in simple swelling we aim to destroy as little tissue as possible. In both instances it should be the effort of the physician to save as much mucous membrane as would normally cover the farts, and to form as little cicatricial tissue as possible. In a considerable number of eases of hypertrophic rhinitis the bones are also enlarged so much 35 546 DISEASES OF THE NASAL CAVITIES. that no treatment of the soft tissue can sufficiently remove the obstruc- tion. In these the bony tissue may be removed with saw and scissors, or better with the dental burr (Fig. 201) or the nasal trephine (Fig. 202). These instruments, attached to the electric motor or dental engine, are run beneath the mucous membrane, enough of the bone being removed to allow the soft tissue to contract until sufficient space is obtained. Between the operations the same sedative or slightly stimulating powders and sprays should be employed that were recommended for treatment of intumescent rhinitis. If adhesions of the opposing sur- faces occur, they must be broken down or cut with scissors, and the surfaces kept apart by gutta-percha, or a rubber plug, or by a pledget of wool, until healing occurs. The wool is much better than cotton, as it becomes larger when moistened by the secretion, whereas the cotton plug becomes smaller. Sometimes by cauterizing the raw surface with monochloracetic acid, which has the property of forming an eschar that usually remains until healing has taken place beneath, subsequent ad- hesions of the part may be prevented. Where a spur of cartilaginous or bony tissue projects from the septum, it is usually necessary to remove it before the hypertrophied turbinated bodies can be satisfactorily treated; otherwise adhesions are very apt to take place. Metallic, gutta-percha, or soft-rubber tubes, sponge and laminaria tents, have also been recommended for the cure of hypertrophic rhinitis. Fig. 202.— Nasal Trephines (actual size). Modification of Curtis. When tents are used which swell by absorbing moisture, they should be allowed to remain for only a short time, and should be moved slightly back and forth frequently as the swelling progresses, to prevent them from becoming fixed too firmly in the cavity. Tubes may be introduced and worn for several hours at a time, providing they do not cause too much pain; theoretically, this procedure is excellent, but practically a tube large enough to affect all gf the diseased tissue can seldom be in- troduced into the nostril. Furthermore, in the majority of cases the nares are so sensitive that tubes cannot be tolerated; therefore, this form of treatment has been abandoned except for some special cases. CHRONIC RHINITIS. 547 Whatever treatment is adopted, the cavity should, not be made larger than normal. Frequently patients will urge the physician to make it so large that they will never be troubled again, even upon taking cold; but this procedure is injudicious, and would subsequently be regretted by both patient and physician; for if the calibre is greater than normal, secretions are liable to collect, decompose, and give offeiisive odors, as in atrophic rhinitis. It is better to do too little than too much; but the patient should not be kept under treatment while we are accomplishing nothing. The physician must not be contented with making soothing applications which give but temporary relief. These can be made quite as well by the patient, and if for any reason the soothing form of treat- ment seems best, we are to remember that no good will result by seeing the patient of tener than once or twice in a month. Submucous infiltration of the sides of the vomer is common in chronic rhinitis, especially in the hyper- trophic variety; it is characterized by more or less difficulty in nasal respiration and increased secretion. It is often associated with chronic in- flammation of the pharyngeal mucous membrane, and sometimes with adenoma of the vault of the pharynx. The altered mucus collects in the posterior nares and drops into the throat or causes r . | Fig. 203.— Submucous In- frequent hawking. I he symptoms are those of filtration at sides of post-nasal catarrh. Inspection by the aid of the VoMER (Cohen). rhinoscope reveals a yellowish white or gray puffiness on one or both sides of the vomer, near its posterior margin (Fig. 203). Diagnosis. — There can be no difficulty in the diagnosis when pharyn- geal affections have been excluded and the characteristic appearances just mentioned are discovered. Treatment. — We should contract or destroy the cedematous tissue by means of the galvano-cautery, or we may tear it off with forceps. The former is most effective. Astringents have little effect. Atrophic rhinitis is a chronic inflammation of the nasal mucous membrane, characterized by abnormal enlargement of the cavities, and the collection within them of drying secretions, giving rise some- times to an extremely offensive odor. It occurs in all countries and among all classes, but is most frequently found in children or young adults, and according to Greville McDonald (Diseases of the isose) is most common in girls. I have never observed it in children under eight years of age nor in adults over forty; most cases occur before the twenty-fifth year, very few being observed in patients more than thirty-five years of age. Anatomical and Pathological Characteristics. — The nasal cavities are widened, even to two or three times their normal size, the turbinated bodies appear smaller than normal, and in advanced cases 548 DISEASES OF THE NASAL CAVITIES. they may have entirely disappeared. It is not unusual to find the in- ferior turbinated bodies much smaller than normal, while the middle turbinals are still hypertrophied. As a result of changes in the mucous membrane, involving its blood vessels and glands, the secretion be- comes tenacious and of a muco-purulent character; and in consequence of the large size of the nasal cavities it is impossible for the patient to secure a sufficient blast of air for its expulsion; therefore it dries upon the surface, partially decomposes, and thus forms crusts which may completely block the cavities. These crusts are finally separated by the increased secretion beneath them and may then be expelled, but only to be soon replaced by others of the same character. The pathology of the disease is still a mooted question, and it would be profitless for us to enter into the controversy. I favor the theory that in most cases the atrophy is the result of previous hypertrophy. The mucous membrane is usually anaemic, but seldom if ever ulcerated, excepting that in some instances abrasion of the septum may have been caused by picking the nose. Etiology. — The cause cannot always be ascertained, but in some persons a history of frequent colds, with more or less complete obstruc- tion of the nares for a considerable period, sometimes dating from an exanthematous fever, and at others from an injury, leads to the belief that the affection is usually preceded by chronic catarrhal inflammation, and favors the theory that atrophy results from an antecedent hyper- trophy. Symptomatology. — The patient is usually in good health at the beginning, but commonly the general condition suffers with the advance of the disease. Usually the nose is broad, the ala? thick, the lips thickened and prominent, and the whole physiognomy is lacking in ex- pression, as is often seen in the strumous diathesis. The eyes are often affected, the sense of smell is usually lost, and partial deaf- ness commonly exists. The secretion, which is of a muco-purulent character is tenacious, and usually there is but little discharge from the nose except at intervals of once or twice a week, when the crusts formed by drying of the secretion are expelled. The breath has an exceedingly offensive odor caused by decomposition of the retained secretion. So great indeed is this that it will often speedily permeate a whole room, though, perhaps fortunately for the pttimt the sense, of smell is usually lost, so that he is spared much personal discomfort. The foulness of this indescribable odor is only second to that of syphilitic necrosis of the nasal bones, and is so peculiar that, when once detected, it becomes a valuable diagnostic symptom. Upon inspection of the nares, we are at once impressed with the abnormal size of the cavities, unless they be choked by dried secre- tions. "When the crusts are removed, Ave observe the small size, or absence, of some or all of the turbinated bodies, with perhaps hyper- trophy of others, and find that usually we may easily see the naso- CHRONIC RHINITIS. 549 pharynx and often the orifice of the Eustachian tube through the nostril. The secretion which has remained longest in the nose is of a brownish or blackish color; that less old, of a yellowish or greenish hue. In most cases where crusts are found upon the surface, atrojmy of the mucous membrane is very apparent, and the odor is offensive. In some cases the secretion is thin, of a purulent character, and may be easily washed away, even though the patient cannot expel it by blowing the nose. Immediately after washing the nares the mucous membrane may appear redder than normal, as the result of the cleans- ing process, though it is commonly anaemic. Diagnosis. — The affection is liable to be mistaken for lupus, syph- ilitic disease of the nose, suppuration of the accessory cavities, and rhino- liths or foreign bodies in the nose. There is usually no difficulty in distinguishing it from lupus, because of the. external manifestations of the latter disease; but in lupus vulgaris, crusts and scabs similar to those found in atrophic rhinitis are formed; these are usually closely adherent to the septum instead of the turbinals; and unlike the crusts in atrophic rhinitis when removed, they leave an ulcerated surface which usually bleeds and is marked in one or more places by the typical lupus tubercle. On account of the offensive odor, syphilitic disease of the nose is espe- cially liable to be mistaken for atrophic rhinitis; but in syphilis, upon examination with a probe, dead bone is often detected, and upon cleans- ing the part, ulceration or perforation of the septum or hard palate is apt to be found ; at the same time there may be falling in of the bridge of the nose, which does not occur in simple atrophy. An offensive odor arises from suppuration of tl?e accessory cavities, but unlike atrophic rhinitis this is almost always unilateral; the correspond- ing naris is not likely to be enlarged, and the sense of smell is seldom lost; therefore the patient can generally appreciate the odor sooner than those about him. An offensive odor, with profuse discharge from one side, arises from rhinoliths or foreign bodies in the nose; but after the parts are cleansed, offending bodies may be readily detected by inspection or palpation with the probe. Prognosis. — If left to itself, atrophic rhinitis continues for many years; but it is seldom observed after the thirty-fifth year. ' As the history shows that even with the most indifferent care most patients eventually get well, it is probable that there is a spontaneous tendency to recovery about middle life. Under appropriate treatment, most cases may be cured within from six to twenty-four months, if the patient will give it proper attention. In nearly every case the offensive odor may be speedily relieved, and it will not reappear if perfect cleanliness is observed. We cannot hope, however, to cure the anosmia, and the deafness associated with atrophic rhinitis is seldom remediable. Eestoration of the atro- 550 DISEASES OF THE NASAL CAVITIES. phied structures can seldom be expected, though I have seen a few cases in which undoubted atrophy, with great enlargement of the nasal cavi- ties, has so far disappeared as a result of treatment, that the nares be- came of normal size, and in one case even smaller than desirable. There- fore I agree with Moure, of Bordeaux, who holds out hope of regeneration of atrophied structures in some cases. Impairment of the general health resulting from constant inhalation of the fetid air from the nose, and probably from partial absorption of the secretion is speedily remedied as the local disease is relieved. Teeatment. — Judging from the great importance attached by vari- ous authors to special forms of local treatment it is probably of little consequence what remedies we employ, so that they be used in such manner as to keep the nares cleansed and disinfected, and the mucous membrane slightly stimulated. Cleanliness must be insisted upon, otherwise any form of treatment will be of little avail. It is maintained by some that this cleansing must be done by the physician, to which there is no objection, providing he has sufficient time and it does not entail too much expense upon the patient; but it is entirely unnecessary Fig. 204.— Ingals' Nasal Syringe (^ size). for the physician to perform these ablutions if he will insist that the patient do it himself. The patient should be directed to wash the nose thoroughly two, three, or four times daily, using from half to one and a half pints of fluid each time, as may be found necessary to accomplish the object. In some cases it is sufficient for the patient to snuff fluid through the nose from the palm of the hand. In others it is better to use some form of nasal syringe (Fig. 204) or the nasal douche, though the latter should be avoided if possible, on account of the danger of causing deafness by forcing fluids through the Eustachian tubes to the middle ear. In using any form of nasal syringe or douche, but little force should be employed, the mouth should be kept open, and the patient must be careful not to swallow during the washing process. As a rule, the solution should be warm, though with some patients the stimulation of cold douches answers an excellent purpose. Pure water is sometimes sufficient, though usually it is better to use solutions of some of the sodium salts, of which sodium chloride or bicarbonate, or the salicylate mixture (Form. 187) may be employed in the proportion CHRONIC RHINITIS. 551 of a heaping teaspoonful to a pint of hike-warm water. Sea salt may be used in place of the common article, but is no better. Carbolic acid, listerine, or other antiseptics in small quantity may be added to this solution if desired. After the part is thoroughly cleansed, various reme- dial agents may be employed, the object being to slightly stimulate the mucous membrane with the hope of improving its nutrition, increasing the glandular secretion, and preventing suppuration and decomposition. For the latter purpose iodoform is an excellent agent, though too offen- sive for use in private practice. In hospital and dispensary work no remedy has given me more satis- faction in atrophic rhinitis than a powder consisting of equal parts of iodoform and boric acid, which is thrown freely into the nasal cavities two or three times a week, after the parts have been cleansed by the patient as directed. In private practice, europhen or iodol may take Sharp &* Smith. Fig. 205.— Nasal Douche. Fig. 206.— Travelers' Nasal Douche. the place of iodoform. I use the latter much alone, and also variously combined with mercury bichloride, myrrh, gum benzoin, berberine, boric acid, aristol, and cocaine, with sugar of milk as a base (Form. 170 to 172 and 181). Powders are used when there is free secretion, and sometimes, even though there is much dryness of the part, they have a most satis- factory effect, especially if associated with the oleaginous sprays of car- bolic acid, menthol, oil of cloves, or other similar substances in liquid albolene; the rule being that whatever application is made should not cause the patient discomfort for more than five or ten minutes. The powders and sprays I generally give in the following strength, to be used by the patient two or three times daily: mercury bichloride, from one-tenth to one-fifth of one per cent; iodol, twenty-five per cent; boric acid, ten per cent; aristol, five to eight per cent; gum benzoin or myrrh, twenty per cent; berberine muriate, ten per cent; cocaine, two 552 DISEASES OF THE NASAL CAVITIES. or three per cent. The sprays contain of menthol one-tenth to one- fifth of one per cent, carbolic acid one-fifth of one per cent, oil of cloves one-half to one per cent (Form. 104 to 10G). Ichthyol used as a spray in five per cent oily solution is reported to have given good results in these cases. Where the secretion is profuse and of a muco-purulent character, from one-eighth to one-half grain to the ounce of mercury bichloride in an aqueous solution is an excellent remedy. Similar applications should be made by the physician sufficiently strong to cause discomfort for half an hour. It is best for the patient at first to visit the physician once or twice a week, in order that he may be certain that the cleansing process is properly accomplished and that the ap- plications are of proper strength, but after a short time twice a month is usually sufficient. In mild cases from one to two per cent of cocaine added to the powder which the patient uses at home has appeared to have a most beneficial action in stimulating the flow of blood to the parts. The effects of cocaine in causing contraction of the blood vessels and caver- nous tissue is well known; it is also true that if used continually for a considera- ble length of time, it frequently increases the congestion and swelling, which probably accounts for the benefit sometimes derived from its use in these cases. McDonald (op. cit.) recommends tincture of sanguinaria, five to thirty drops to a pint of warm water; also tampons saturated with glycerin or boro-glyceride, but especially Gottstein's wool tampons, or what he terms the physical method of stimulating the circulation by partially closing the nostrils with cotton wool and causing the patient to inhale through this obstructing mass two or three hours daily. He also recommends a simple nasal respirator for a similar purpose. D. Bryson Delavan (Xew York Medical Journal, 1837) and other laryngol- ogists report satisfactory results from stimulating the mucous mem- brane with the electric current, the positive pole applied to the nape of the neck, the negative to the mucous membrane by means of a piece of copper wire enclosed in a pledget of moistened cotton, with a current of from four to seven milliamperes. In addition to the local remedies, great benefit is often derived from constitutional treatment. Quinine, iron, strychnine, arsenious acid in some form, and iodine are most beneficial. The latter, in moderate doses just sufficient to excite nasal secretion, is frequently found most advantageous. Good diet and proper clothing should always be supplied, and a change of climate will sometimes be found beneficial. CHAPTER XXXII. DISEASES OF THE NASAL CAVITIES.— Continued. HAY FEVER. Synonyms. — Hay asthma, rose cold, June cold, autumnal catarrh, rhinitis hyperaesthetica, catarrhus sestivus. Hay fever is one of the neuroses occurring periodically and charac- terized by irritation and inflammation of the mucous membrane of the eyes, nose and air passages, attended by profuse secretion and asthmatic attacks. Isolated cases may occur at any time of the year, but in this country the affection usually prevails from about the middle of August until the latter part of September, or until the early frosts; though a considerable number of cases are observed in May, June, and July, and occasional instances even in mid-winter. In England it is most preva- lent in June and July. It is rather more common in men than in women. It occurs at all ages, but is most frequent before the prime of life; I have seen it in children five years of age, and have known it to afflict those as old as eighty or ninety. Seldom found among the working classes, it attacks preferably those of education and cultivation, and res- idents of towns and cities rather than dwellers in the open country. Anatomical and Pathological Characteristics. — The inflam- mation generally affects the nasal mucous membrane and conjunctivas, but often extends to the frontal sinuses, and may be severe in the fauces or entire respiratory tract. The membrane is usually highly congested and swollen, but in some cases, although swollen, it is much paler than normal. Though its pathology is not fully understood, the affection apparently results from a peculiar irritability of the nervous system, sometimes being manifested by constitutional symptoms and again by localized abnormal sensibility either in the whole or a part of the respi- ratory mucous membrane. Etiology. — Heredity and nervous temperament predispose to this affection, but a great variety of substances may excite the attack where the predisposition exists. William H. Daly, first pointed out the re- lation between hay fever and certain morbid conditions in the nasal passages (Transactions of the American Laryngological Association, 1881). Subsequently his observations were repeated, and his conclu- sions confirmed, by Roe, Hack, J. N. Mackenzie, Sajous, and others; and although the disease is not so uniformly dependent upon the condi- 554 DISEASES OF THE NASAL CAVITIES. tion of the nasal mucous membrane as some of these authors supposed, yet in most cases such a relation is undoubted. Commonly the attack appears to be brought on by inhalation of the pollen of ambrosia arte- misia? folia, known also as Roman wormwood, rag-weed, or hog-weed, or that of solidago odora, known commonly as golden-rod, but it is frequently excited by dust and smoke, especially in railway travel, and by the emanations of roses and other fragrant plants, or the pollen of certain grasses, as wheat, barley, oats, rye, or even indian corn. It may also be excited by the dust of ipecac, salicylic acid, benzoic acid, and lyco- podium, and sometimes it is brought on by exposure to heat or light, or by over-fatigue. So strong is the neurotic influence in this disease that imagined exposure to influences which had formerly excited an attack have been sufficient to induce the return of the paroxysm; for example, an artificial flower or even the painting of a full-blown rose has brought on an attack of the disease. Symptomatology. — The attacks often come on the same date of suc- ceeding years, regardless of the temperature, the conditions, or surround- ings; but in some is a variation of a few days, apparently dependent upon atmospheric conditions or environment. There are two well- marked types, the catarrhal and the asthmatic. In the former the dis- ease usually comes on suddenly, with irritation of the mucous membrane of the fauces, conjunctivae, and nares, attended by frequent sneezing; in the latter, asthmatic features are usually developed after the nasal symptoms have existed two or three weeks, but they may come on inde- pendently. The asthma in this affection commonly differs from ordinary spasmodic asthma in that the paroxysms are likely to occur during the day-time. In most instances the patient is made aware of the onset of the disease by a tickling or stinging sensation in the Schneiderian mucous membrane, accompanied by violent sneezing and itching of the con- junctiva?, with profuse lachrymation; or by burning or stinging sensa- tions in the throat, or in some instances by severe neuralgic pains in the eyeballs or back part of the head. Swelling of the conjunctiva?, eyelids, lips, or tip of the nose is frequently present. Constitutional symptoms are often marked by elevation of temperature, aching of the muscles, general malaise, and sometimes great weakness. One of the most uniform concomitants is swelling of the Schneiderian mucous membrane, which causes obstruction of the nares, and thus interferes with respiration, in many cases leading to the asthmatic attacks. Pro- fuse watery discharge from the nose, subsequently becoming muco- purulent, and which is often very irritating, is nearly always present. The mucous membranes affected are usually of a bright red color, though occasionally anaemic. Diagnosis. — Hay fever may be confounded with simple acute rhini- tis or spasmodic asthma. The essential points of difference are the his- HAY FEVER. 555 tory, the abrupt commencement, the excessive irritation; and the oc- currence of asthmatic paroxysms during the day instead of at night. This history, together with the detection of very sensitive areas of the nasal mucous membrane by lightly touching it with the probe, are suffi- cient to establish the diagnosis, except during first attacks or in young children, where it is sometimes necessary to watch the patient for some time. Urticaria is frequently observed in connection with hay fever. Prognosis. — The attacks usually continue, with daily varying se- verity, from four to six or eight weeks, according to the patient's surroundings and the atmospheric conditions, and not infrequently the patient remains greatly debilitated for several months. The asthmatic attacks may continue several hours or two or three days, and then disappear as suddenly as they came. Some lose susceptibility to the disease with advancing years. The affection is not dangerous to life. Treatment. — In most cases the attacks maybe prevented by change of climate — sometimes a change from city to country or vice versa is sufficient — but most patients find the greatest relief in cool localities by the northern lakes, in places near the seashore, or at high altitudes; or from a lake or ocean trip, which removes them from the pollen- laden air. In this country, the most favored spots are in the White Mountains of New Hampshire, and in the region about Mackinac, in the northern part of Michigan. Many obtain complete immunity from the disease in the high altitudes of our western states and terri- tories. No locality will be found equally beneficial for all individuals, and some will suffer severely where others have complete relief. As the disease commonly occurs in neurasthenic persons, nerve tonics and sedatives are especially indicated. It is well to begin the administration of these remedies a month before the attack usually comes on, and to continue them until convalescence is established. To this end the various preparations of quinine, strychnine, or arsenious acid, and asafcetida or some of the preparations of valerian are most serviceable. I have found peculiarly beneficial a pill containing medium doses of brucia phosphate, alcoholic extract of hyoscyamus, quinine valerianate, and camphor monobromate, with or without small doses of sodium salicylate, phenacetin, acetanilid, or asafcetida. These may be given before and during the attack, with the effect of greatly mitigating the patient's sufferings. During the attack, opiates and belladonna in small doses are often of the greatest benefit; for example, five to eight drops of the tincture of belladonna or the deodorized tincture of opium, or both combined; or instead of these from a twelfth to an eighth of a grain of morphine, or from one two-hundredth to one one-hundred-and- twentieth of a grain of atropine, or both together. Atropine in small doses or hyoscyamus is especially beneficial in checking the profuse secretion and tendency to sneeze; the after effects of the latter are less likely to be unpleasant. Local stimulating inhalations, of ammonia, DISEASES OF THE NASAL CAVITIES. iodine, or chloroform are sometimes useful, though they must he em- ployed guardedly lest tbey increase the irritation. Fur relief from the itching of the conjunctiva?, weak solutions of lead acetate are especially recommended by Mackenzie. I have found most beneficial a solution of sodium biborate gr. v. to x. ad 3 i. of camphor water. With this, the eyes may be bathed as frequently as desired. The lips and nostrils may be protected from the irritating effect of the secretion by applying the ointment of zinc oxide, or better the iodol and lanolin ointment (Form. 9), to each ounce of which has been added ten or twenty grains of zinc oxide. The irritation of the nasal mucous membrane may sometimes be largely prevented by wearing plugs of wool in the nostrils to exclude dust and other irritating substances. Bathing the eyes and nose with either of the solutions recommended, or with very hot or very cold water, will sometimes give great relief. As a local application to the Schneiderian mucous membrane, a spray of a saturated solution of boric acid will sometimes be found very grate- ful. In some instances it is well to make this solution in camphor water; in others it will be necessary to add to it small quantities of atropine, morphine, or cocaine. The latter remedy gives more immediate relief than any other we possess; but unfortunately its continued use is frequently followed by most serious consequences. With some patients, oily sprays will be found more beneficial. For this purpose a most excellent combination is that of thymol gr. ^, oil of cloves iTliij., and liquid albolene 3!., to which in some cases a small amount, not more than one-half of one per cent, of the alkaloid cocaine may be added. The strength of this solution may be slightly incieased in some cases with advantage, but care should be taken not 1 1 make it irritating. A similar spray used five or six times a day will sometimes prevent the paroxysms of this disease. A powder containing three or four per cent of cocaine hydrochlorate (Form. 166) will be found more convenient for general application. In whatever way cocaine is employed, the patient should not use more than one-third of a grain daily, and this should not be long continued. Because of the temporary relief af- forded, patients are very apt to use this remedy to excess, therefore physicians should never give written prescriptions containing it, and should insist upon knowing exactly how much the patient is using. I have known several lives wrecked by neglect of this precaution. During an acute attack of hay fever, nasal douches of weak solutions of quinine, salicylic acid, sulphurous acid or other antiseptics have been recom- mended on the theory that the irritation is due to the local action of microbes. These applications seem to have been beneficial in the hands of some physicians, but in my experience they have been disappointing. When the attacks are due to sensitiveness of the nasal mucous membrane, the disease may be cured by judicious operative measures. These consist in removing any spur from the septum that may be large HA Y FEVER. 557 enough to impinge upon the outer wall, the removal of polypi, linear cauterization along the turbinated body to prevent extreme swelling, and, most important, superficial cauterization of all spots found to be ex- tremely sensitive. The superficial cauterizations should simply sear the mucous membrane, leaving it in much the same condition as the integu- ment after a blister; it must not be burned so deeply as to cause any amount of cicatricial tissue. The linear cauterizations are the same as those recommended for hypertrophic rhinitis. The operations on the septum and for polypoid growths are described elsewhere. The nasal cavity should first be thoroughly examined with a flat probe, the various parts being gently touched and the sensitive spots marked upon a diagram representing the two surfaces of the nares. A solution of cocaine (Form. 140) is then applied by means of a small pledget of absorbent cotton wound on the end of a flat nasal applicator (Fig. 197). The pledget saturated with the solution is carried back to N the posterior part of the naris and as it is brought forward is rubbed gently over every part of the mucous membrane to be ana3sthetized. This occupies about thirty seconds. A minute later the application is repeated with a fresh pledget. From two to four such applications are generally sufficient. The cauterization may commonly be done without pain as soon as the patient ceases to feel the probe rubbed lightly over the surface, even though pressure may still be felt. The part, having been thoroughly anaesthetized, should be sprayed with liquid albolene, and then rubbed over quickly two or three times with a flat, guarded electrode (1, Fig. 91) until a spot about a centimetre in diameter has been seared and appears of a white color. It should not be burned deeply enough to cause an appreciable scar after healing has taken place. The cauterized part should be noted upon the diagram, and after four or five days a similar cauterization may be made in some other part of the nasal cavities, preferably upon the opposite side. These operations should be repeated from time to time until the whole surface has been treated and no part remains peculiarly sensitive to the probe. After the cauterization, the patient may be given a four per cent powder of cocaine, which may be insufflated into the nares once in three to five hours for the following three or four days. Together with this it is well to give an oily spray similar to that already recommended. These cauterizations may sometimes be repeated every two or three days; but it is generally better to make the intervals longer, otherwise the nares are apt to become quite sore, and the patient experiences much discomfort. When the longer interval is allowed, treatment may usually be conducted without in any way interfering with the patient's vocation, and without serious discomfort. From fifteen to thirty treat- ments are generally necessary to cover all of the diseased surface. The following year a few spots may be found still sensitive, which were 558 DISEASES OF THE NASA L CAVITIES. overlooked previously or not burned deeply enough; or possibly these may result from new development of the disease. The treatment is best carried out during the warmer portions of the year, either before the usual time of the attack or after it has subsided; for during the attack it is liable greatly to increase the patient's distress. By this method from forty to fifty per cent of the oases of hay lever may be cured, about twenty-five per cent more may be greatly benefited, and the remainder will usually obtain sufficient relief from the nasal symptoms to compensate for the discomfort expe- rienced during the treatment. The treatment is most apt to be bene- ficial where asthma has not yet developed, and where the general nervous symptoms are not pronounced. Cauterization of the surfaces with chromic or carbolic acid and other caustics has also been recommended. Asthmatic attacks occurring in connection with hay fever call for the same treatment as simple spasmodic asthma. It is always best for the patient to seek a different climate during the season if possible; and this is especially important in those who suffer from debility for several weeks or months after the attack, and in children, in whom we may hope to cure the disease by interrupting for two or three years the vicious habit of the nervous system, which otherwise might last a life- time. t FURUNCULOSIS OF THE NOSE. Furunculosis of the nose is a comparatively frequent affection, char- acterized by the development of small pustules or larger furuncles, the cavities of which vary in diameter from one to five millimetres or more. These suppurative points are attended by redness and great soreness of the end of the nose, and a larger furuncle by constant pain. The inflammation usually originates in the hair follicle. The affection lasts from three to seven days, and. upon discharge of the pus, healing quickly takes place. In many individuals the attack frequently recurs, and in some, one or more of these small abscesses are nearly always present. Treatment. — As in all other abscesses, the indications are to evac- uate the pus; but it is most important to adopt some measure which will prevent a recurrence of the attack. For this purpose remedies calcu- lated to prevent the occurrence of suppuration in any part of the body are indicated, such as calcium sulphide, potassium chlorate, saline diu- retics and laxatives; brewers' yeast has also been used for this purpose, with apparent success. Of the above, potassium chlorate has seemed to me most valuable. Local applications of tincture of iodine or solutions of silver nitrate and of various oils and ointments have been employed, with almost uniformly unsatisfactory results: for although the remedies appear beneficial at the time, the affection persistently recurs. It is true that in many cases any of these remedies may be used with appar- EPIiSTAA r IlS. 559 ent benefit; but it is doubtful in such instances whether the patient would not have recovered almost as speedily without them. In obstinate examples the fact remains that local applications, as a rule, do but little good. In two or three cases, under a suggestion for which I am in- debted to J. E. Best, of Arlington Heights, 111., I have seen speedy im- provement and permanent cure result from the use, four or five times daily for two or three weeks, of a two per cent aqueous solution of car- bolic acid, which should be thoroughly applied Avith a small swab of absorbent cotton wound upon a toothpick or other applicator. EPISTAXIS. Synonyms. — Nose-bleeding, hemorrhagia narium. Epistaxis consists of hemorrhage from the nose, originating either in the nasal cavities or the adjacent sinuses. It is most frequent about the age of puberty, is more common in early childhood and advanced age than in the prime of life, and occurs more often in men than in women. Anatomical and Pathological Characteristics. — The mucous membrane may be congested and swollen, or may appear normal; but in most cases erosion, actual ulceration, or a small bleeding point may be found upon the cartilaginous septum. Sometimes the septum is per- forated, and the bleeding comes from the edge of the opening. In other cases the mucous membrane is thin and the blood vessels are near the surface, so as to easily rupture upon engorgement from any cause. Occasionally the bleeding comes from the mucous membrane over the turbinated bodies, from the adjacent sinuses or posterior nares, or from the easily bleeding surface of a fibrous or malignant tumor. Etiology. — Among the local causes are injury from picking the nose, the introduction of instruments, violent sneezing, coughing, strain- ing, the inhalation of irritants, or the presence of polypi or other foreign bodies in the nasal passages. The constitutional causes are alterations of the blood, such as occur in anaemia, plethora, eruptive and relapsing fevers, diphtheria, scurvy, purpura, and haemophilia; or changes in the walls of the blood vessels accompanying phosphorus poisoning, acute yellow atrophy of the liver, Bright's disease, gout, rheumatism, and oc- casionally syphilis or chronic alcoholism. The affection is also due in some instances to obstructed circulation through the jugular vein, en- gorgement of the right ventricle, obstructed pulmonary circulation as in severe bronchitis or emphysema, or to engorgement of the liver or kidneys; and it may result from the effects of strong emotional excite- ment upon the vasomotor nerves. It is sometimes vicarious, taking the place of menstruation or of the habitual bleeding from hemorrhoids. Symptomatology. — In the plethoric, and in patients suffering from fever, the bleeding is often preceded by flushing of the face, a sense of 560 DISEASES OF THE NASAL CAVITIES. fulness in the head, with buzzing in the ears, and giddiness, and some- times itching in the nose. It usually begins without apparent cause, frequently even while the patient is asleep, and flows from one side in drops, which follow each other in rapid succession; in severe cases it may run in a small stream. Usually not more than a drachm of blood is lost at one time, although it may seem very much more, to the patient and his friends; but in others, bleeding is rapid and persistent, and sometimes sufficient to prove fatal. A large amount of blood may be lost within a few hours, and the bleeding may continue for several days. Martineau mentions a case in which twelve pints of blood were lost in sixty hours (& Union Medicale, 1868, troisieme serie, Tome VI). When the bleeding is excessive, syncope is liable to occur, and may prove fatal. Where epistaxis occurs frequently, or continues for several days, serious anaemia may result. Usually bright red blood flows from one nostril only, but it may pass back to the posterior nares and escape around the septum from the other nostril, or run down the throat. Diagnosis. — Simple epistaxis may be confounded with certain neo- plasms, or with ulceration, and can only be distinguished therefrom by careful inspection of the parts. Prognosis. — Most cases terminate spontaneously within ten or fifteen minutes; but in some the bleeding continues several hours or even days. The cases occurring in children without apparent cause, and those resulting from various injuries to the nose, are seldom, if ever, dangerous. When occurring in old people without provocation, epi- staxis indicates degenerative changes in the blood vessels, which are ominous. In subjects of haemophilia, bleeding is liable to prove fatal. Nasal hemorrhages frequently recurring and' lasting several days at a time, unless properly treated, cause dangerous anaemia, and many there- fore terminate fatally. In low forms of fever, and in diphtheria, it is a grave symptom. As has been shown by Hughlings Jackson, this symptom occasionally precedes apoplexy (London Hospital Clinical Lectures and Reports, 1866, Vol. Ill); on the other hand, in malarial fever, in plethora, and in congestive conditions of the brain, the bleeding is some- times beneficial. Instances are on record in which mania, epilepsy, and asthma seem to have been induced by checking the flow. Treatment. — In the majority of cases the bleeding does no harm and need receive no treatment. When of a vicarious nature, and where there is evidence of plethora or of obstructed venous circulation, it should not be checked unless long continued. Owing to the fact that most cases stop spontaneously within ten or fifteen minutes, a great variety of methods for checking bleeding from the nose are implicitly relied on by the laity. To aid in checking hemorrhage, the head should be kept erect, applications of cold may be made to the neck or directly to the nose, or the application of hot water at a temperature of 120° to I25 c F. As in most instances the blood flows from a small point on the EPI8TATI8. ' 561 cartilaginous septum, it is easy to check it by continuous compression of the alse nasi for ten or fifteen minutes or by direct pressure of the finger upon the septum. Compression of the facial artery is also recom- mended. In continued bleeding which occurs from points far back in the Dares, other methods must be employed. The insufflation of pow- dered alum, tannin, or matico leaves will often be found efficient. The alum is liable to cause excessive pain, and tannin also is frequently pain- ful; powdered matico, however, has been found much less painful, and ap- parently is quite as effective. The application of a spray of tannin gr. x. ad 3 i. answers well in some cases, or a solution of iron perchloride TT[ xx. ad | i. may be used in the same way; of the two, the tannin is prefera- ble. Injections of ice water, or better, small bits of ice frequently introduced, are often satisfactory. Internal remedies may be given at the same time with more or less benefit. For this purpose the fluid extract of ergot in doses of half a drachm every one to two hours, or ergotine in proportionate quantity, is recommended; also, tincture of opium in doses of from five to eight minims or medium doses of lead acetate, alone or combined with opium. In the epistaxis of purpura, MacXamara commends a wineglassful of spirits of turpentine in a tumbler of brandy or whiskey punch taken as rapidly as possible (Mackenzie: "Diseases of the Xose and Throat," 1884). Harkin, of Belfast, Ireland, claims to have obtained excellent results (Transactions of the Mirth International Medical Congress, Vol. IV), in preventing the recurrence of epistaxis by counter-irritation over the liver. In persistent bleeding, when simple remedies fail, plug- ging must be resorted to. Simple plugging of the nostril with cotton or lint, and holding the head forward until coagulation has taken place, will be sufficient in many cases. When it fails, plugging of the posterior nares must be the resort, or better still, filling the whole nasal cavity with a styptic and antiseptic tampon of gauze or lint. Sometimes the nares may be easily and effectually plugged by an air sack, operated on the plan of Barnes' uterine dilator, but this method is not usually very successful. Compressed sponge or simply strips of sponge may be packed into the nares with the forceps or applicator and will usually quickly check bleeding, but these are removed with difficulty, and occasionally some jfiece is left behind, causing an infinite amount of trouble, which might be avoided by carefully tying each bit of sponge with a strong thread, and numbering the threads by knots to indicate which should be removed first. One of the most convenient tampons for the nose is made by tying a strong thread to the middle of a bundle of fifteen or twenty ravellings from surgeon's lint, about four inches in length; one or more of these bundles being used. After the naris is filled, all of the threads may be wound about a bit of lint x6 562 DISEASES UF THE NASAL CAVITIES. and tucked into the nostril. This tampon has the merit of causing little pain and of being easily extracted, providing the threads have been numbered as already mentioned. In using any of these, it is well first to blow into the naris four or five grains of iodoform or of a mix- ture of equal parts of iodoform and boric acid. A most efficacious method of checking excessive bleeding from the nose, which I adopted some years ago, and one easy of application, con- sists of saturating a strip of antiseptic gauze about an inch in width by four feet in length with a thick syrupy mixture of tannin in water, to which has been added a little glycerin and a few drops of carbolic acid. This is stuffed into the nose, fold after fold, until the naris is filled. Sometimes to the end first introduced, I attach three or four strung threads about two inches apart. This end is then passed through the naris into the naso-pharynx, the free ends of the thread being left hang- ing from the nostril. The strip is then rapidly pushed in until the posterior part of the cavity is full, after which the threads are drawn upon so as to pack the gauze firmly into the posterior naris. The whole cavity is then filled with the strip of gauze, any remaining por- tion being cut off. This is to me the most satisfactory means of plug- ging the naris, and has proved efficient in the most severe cases where jiosterior plugging would be indicated. The gauze may be rapidly and easily introduced, and readily removed, and the method obviates the danger of pressure upon the openings of the Eustachian tubes and consequent inflammation of the middle ear. The only disadvantages I have observed are that its removal is sometimes painful, especially after operative procedures in the nose, and the tannin causes some in- dividuals considerable smarting. Walton Browne, of Belfast, Ireland, recommends a similar procedure, the gauze being impregnated with powdered alum instead of tannin, and he says it is not painful (Trans- actions of the Ninth International Medical Congress, Vol. IV), though from my observation alum appears to cause much more smarting than tannin. Plugging the posterior nares has long been practised for checking obstinate epistaxis. It is commonly performed with the aid of Bellocq's canula, by drawing through the nose from the throat a strong string to which is attached a plug of cotton or lint of a sufficient size to fill the posterior naris. By traction on the string, this plug is firmly packed into the choana. A plug is then introduced into the nostril, and the string tied about it. Lint is much preferable to cotton for either of these plugs, as the latter tends constantly to become smaller when it be- comes saturated with the secretions. A loorj at least two inches in length should be left hanging from the plug that is drawn into the posterior naris, or a string should be attached and left protruding from the mouth to aid in removing the tampon. Both sides may be treated in the same way, but the impaction of a large mass into the naso- EPISTAZ1S. 503 pharynx is to be deprecated. It is unsafe to leave the post-nasal plug in position for more than twenty-four hours without renewal, as inflam- mation of the middle ear or suppuration of the mastoid cells is liable to follow such practice, and occasionally death from gangrene, tetanus, erysipelas, or septicemia has resulted. To remove the tampon, the pledget should be taken from the nostril, and, when only one side has been stopped, warm water to which has been added a teaspoonful of sodium bicarbonate to each pint should be gently injected through the opposite side to loosen the tampon. The affected side may be carefully washed in the same way, but force should not be used. The string hanging in the pharynx or protruding from the mouth should then be pulled upon, and if necessary, the tampon gently pressed back by a probe until it is released and drawn out through the mouth. An ordi- nary soft catheter is often more convenient for introducing the string than the Bellocq's canula; it is passed through the nostril into the throat and drawn out at the mouth by forceps ; a suitable thread is then attached and drawn back through the naris. A well waxed thread may usually be easily passed through the naris without the aid of catheter or sound. To prevent recurrence of the attack, the cause must be sought and removed. In the majority of cases this will be found in a bleeding point upon the cartilaginous septum, but occasionally upon other por- tions of the mucous membrane. Sometimes cauterization of this with solid silver nitrate will be sufficient to cure ; but usually it is best to touch it with the galvauo-cautery, the point of which should be heated to a cherry-red and quickly touched to the spot several times, until the surface is thoroughly seared. In most cases a single treatment of this kind, provided the exact spot has been found, is sufficient to effect a cure, but in others subsequent cauterization will be necessary. CHAPTER XXXIII. DISEASES OF THE NASAL CAVITIES.— Continued. .NASAL MUCOUS POLYPI. Syn on y m. — Nasal myxomata. Nasal myxomata are tumors which grow from some part of the mu- cous surface, producing obstruction of the passages and usually excessive mucous discharge. They are very common, occurring more often in men than in women, but are seldom seen in children under twelve years of age. Anatomical and Pathological Characteristics. — Mucous polypi are grayish or pinkish in color and semi-transparent; they are round, oval, or pyriform, and vary in size from five to fifty millimetres in diameter. They are somewhat yielding and elastic to the touch, their surface being smooth and often marked by minute blood vessels. They are commonly pedunculated, but sometimes sessile; they are generally multiple, and in about thirty per cent of all cases occur on both sides. Most of them spring from the middle meatus or the external surface of the middle turbinated body, a considerable number from the superior turbinated body and superior meatus, and not a few from the ethmoid cells. They occasionally start in the antrum or frontal sinus, and very rarely, spring from the septum. These tumors are usually covered with ciliated epithelium, beneath which are found a few dilated capillaries. Nerves have not been traced into these growths, but that they contain nervous filaments is demonstrated beyond perad venture by the pain caused by cutting them off. The bulk of the polypoid mass is made up of embryonic connective tissue and a gelatinous substance rich in mucin, the density of the growth depending on the degree in which the connective stroma or mucous substance predominates. Sometimes their structure is fibro-cellular. Etiology. — Though their ultimate cause is not known, polypi are generally attributed to chronic congestion or to the irritation resulting from denuded bone. Woakes holds that mucous polypi are always as- sociated with necrosis of the ethmoid bone (Nasal Polypi with Neu- ralgia, Hay Fever, etc., H. R. Lewis, London). While this may be an antecedent in many cases of polypi, either condition not infrequently occurs independent of the other. Symptomatology. — At first the patient suffers from increased nasal NASAL MUCOUS POLYPI. 565 secretion and more or less occlusion of the nasal passages, which is often aggravated by damp weather, and is increased by colds, to which he is very susceptible. The occlusion is usually more marked in one naris, but the sense of obstruction frequently changes quickly from one side to the other. Nightmare, headache, giddiness, epilepsy, congestion of the fauces, hay fever, asthma, and other reflex disturbances sometimes result from the presence of these growths; but Mackenzie justly re- marks (Diseases of the Throat and Nose) : Whilst fully admitting that many reflex phenomena may arise from dis- eases within the nose, I must caution the younger specialist that the various complaints referred to as resulting from nasal disease are much more frequently due to other conditions, and that every other possible cause must be eliminated before the nose is incriminated. Bosworth shows that mucous polypi are found in thirty-two per cent of all cases of asthma (Diseases of the Throat and Nose, 1889, Vol. I). Patients often experience a sensation as of a movable foreign body in the nose; headaches are comparatively common, and the senses of smell and taste are often obtunded, although in many cases they may be restored by the removal of the growth. The voice is modified in a characteristic manner by the obstruction, and respiration is disturbed, so that the patient may be obliged to breathe entirely through the mouth. A profuse watery and sometimes muco-purulent, though not offensive, secretion from the nose is common. Epistaxis is not infrequent. "When the tumor protrudes from the nostril, it is usually much con- gested. By anterior or posterior rhinoscopy the smooth, glistening, grayish or pinkish, growths may be seen ; frequently only one or two large ones are visible, removal of which discloses many more of smaller size. A flat probe may be easily passed upon either side of the tumor, and to the touch it is found soft and elastic. Diagnosis. — These polypi are to be distinguished from deviation of the septum, thickening of the turbinated bodies, chronic abscess of the septum, foreign bodies in the nose, and from fibrous, sarcomatous, and cancerous growths. The polypi are readily distinguished from deviation of the septum by their semi-translucency and the fact that a probe may be passed between them and the septum. They are distinguished from thickening of the turbinated bodies by their color, which is usually much lighter ; by their density, which is much less; by passage of the probe between them and the external wall of the naris, and by their movability. They are distinguished from chronic abscess of the septum by their color and density, by their presence usually in both nares, and by the passage of a probe between them and the septum. Mucous polypi resemble foreign bodies, especially in causing obstruc- DISEASES OF THE NASAL CAVITIES. tion and a profuse discharge, but the discharge in the case of foreign bodies is nearly always offensive — not so with mucous polypi. The his- tory of the case, together with inspection and palpation of the nares, will establish the diagnosis. Fibrous, sarcomatous, and cancerous growths in the nasal cavity are usually of deeper color, and more resistant to the touch, they bleed easily, and, the fibrous growths excepted, have a more irregular sur- face than polypi. The malignant tumors usually grow much more rapidly, often causing considerable pain, much disfigurement, and sooner or later grave constitutional symptoms. We would readily de- tect cartilaginous or osseous tumors by the sense of touch. We frequently see hypertrophy of the mucous membraiiQ associated with myxomata, but, on the other hand, the mucous polypi may cause atrophy of the soft tissues and sometimes even of the bony structures. Prognosis. — The affection, if not relieved by operative procedure, usually continues for a lifetime, causing the patient much discomfort and annoyance. Although the obstructed respiration must eventually compromise the general health, the affection does not appear to threaten life. Often the tumors remain so small as not to attract the patient's attention, but when they have become large there is no reason to ex- pert retrogression. Spontaneous expulsion of one or more polypi some- times occurs. They are very liable to recur after removal, and are sometimes very difficult to eradicate. Rarely myxomata are trans- formed into sarcomata, and according to Schiffers, of Liege, such change occurs only in subjects past the fiftieth year (Transactions Interna- tional Congress Laryngology and Otology, 1889). Treatment. — For destruction of the growths the injection of vari- ous substances has been recommended, such as zinc chloride, iodine, alcohol, carbolic acid, and solution of iron perchloride; also local appli- cations of saturated watery solutions of potassium bichromate. F. Don- aldson, of Baltimore, has also recommended introduction into the tumor of chromic acid on a sharp pointed probe. While these methods have sometimes succeeded, they certainly generally fail, even in the hands of skilful operators. Evulsion with the forceps, the oldest method, is still most com- monly practised by general surgeons, though seldom employed by laryngologists. Sometimes, however, the polypus forceps will be found useful. As commonly performed by surgeons, this operation is very painful, there is much bleeding, often some of the turbinated bones are torn away at the same time, and rarely are the polypi completely re- moved. Some surgeons advise that the nose be laid open and the parts thoroughly curetted. This would evidently be more effectual than re- moval with forceps in the old way. but it cannot be more thorough than removal with the snare, followed by cauterization (or, if the operator prefer, curetting), when done under good rhinoscopic illumination, by NASAL MUCOUS POLYPI. 567 which every part can be seen quite as well as if the nose had been laid open. Sometimes polypi may be cut off with forceps or scissors. The galvano-cautery ecraseur (Fig. 207) affords the advantage of searing the base and thus destroying it at the time when the tumor is cut off, but it is a clumsy instrument compared with the ordinary steel-wire snare which is the one now generally adopted by laryngologists. When polypi Fig. 207. — Galvano-Cautery Handle, with Ecraseur Attachment (14 size). bud again after removal, the best treatment is thorough searing with the galvano-cautery while they are still small. The operation which I have found most satisfactory for the majority of cases is done with the steel-wire ecraseur or snare (Fig. 208). This is a modification of the snare devised by Clarence Blake, of Boston. Good instruments for the same purpose have been devised by Jarvis and Sajous, and various modi- fications of these have been made by other laryngologists. The snare is armed with No. 5 steel piano wire, which in practice has been found to answer much better than other sizes. The loop is passed in vertically, its under edge turned beneath the polypus, and then with a backward and forward movement it is worked up as near the pedicle as possible. The loop is now tightened, and, if thought best, the polypus cut off at once, but usually better results are obtained if it is torn from its base by traction. There is little danger in this way of Fig. 208.— Ingals' Snare, with Extra Tubes 04, size, angle 25°). removing any of the normal tissues, for it is almost impossible to in- clude within the snare anything but the polypus. Where polypi grow from broad bases, and are attached over the whole surface of a tur- binated body, the bone may be torn off with the snare if much traction is made. Under such circumstances the experienced operator, noticing the increased resistance of the normal tissue, instead of continuing the traction, will tighten the screw and cut the growth as near its base as possible. Where polypi grow from a large surface of the turbinated body, it is sometimes better to remove the bone to prevent recurrence. The operator should have at hand forty or fifty applicators (Fig. 568 DISEASES OF THE NASAL CAVITIES. 209), wound with absorbent cotton, for swabbing out the blood while the operation proceed.?, as it is useless to try to catch the tumors when the nose is rilled with blood. Whatever operation is performed, the parts should first be thoroughly anaesthetized with a four to ten per cent solution of cocaine, which is best applied by means of a hypoder- mic syringe fitted with a long, blunt silver nozzle (Fig. 210) bent at the end so that the solution may be thrown up about the base of the Fig. 209. — Cotton Applicator (2-6 size). Made of copper. tumors. Sometimes both cavities may be cleared at once, but it is usually preferable to remove what growths may be easily reached, and to complete the operation at one or two subsequent sittings, as this generally gives the patient much less discomfort than one long sitting. It will be remembered that the effects of cocaine disappear in about ten minutes, and after blood has once begun to flow it is difficult to anaesthetize the parts again; furthermore, if too much cocaine is used, its constitutional effects, even if not alarming, are ex- tremely annoying. After the polypi have been removed, the patient should cleanse the nose once or twice daily with the salicylate wash (Form. 1ST), or with a wash of sodium bicarbonate, a teaspoonful to the pint of lukewarm water. Antisepsis and healing will be promoted by insufflation two or three times daily of a powder containing twenty per cent of boric acid, fifty per cent of iodol, and sugar of milk sufficient to complete the mixture; together with the use of a spray containing about one minim of oil of wintergreen, two minims of carbolic acid, three minims of oil of cloves Fig. 210.— Hypodermic Syringe (^ siz»0. L< m^ silver nozzle. to an ounce of liquid albolene. If secretion is profuse, ten minims of terebene may be added advantageously. The patient should return in about a week, when it will often be found that sacs which were invisible at the time of operation have rilled, and may be removed. He should return again in four or six weeks, so that if the polypi are growing they may be thoroughly cauterized with the galvano-cautery. If the sur- geon is not provided with this instrument, chromic acid may be used instead. In some cases mucous polypi do not return after thorough removal, but usually recurrence takes place, and operative procedures must be repeated from time to time until complete destruction of the growths is effected. ITASAL PAPILLARY TUMORS. oii'.J NASAL FIBROUS POLYPI. Synonym. — Fibromata of the nares. Fibrous polypi are extremely rare in the nares, although not uncom- mon in the naso-pharynx. Generally, growths in the nasal cavity which resemble fibrous tumors in appearance really occupy a histological posi- tion midway between mucous and fibrous polypi, termed fibro-mucous. These growths differ from mucous polypi in being harder and bleed- ing more easily. They should be removed, when possible, by the natu- ral passages, with cutting forceps, snare, or galvano-cautery ecraseur. The latter is best when it can be accurately applied. NASAL PAPILLARY TUMORS. Synonym. — Papillomata of the nares. Nasal papillary tumors, though occurring more frequently than fibrous polypi, are still infrequent, though Hopmann states that small warty growths are more common than generally supposed, and he has met with numerous cases (Virchow's Archiv, Band XCIII, 1883). He also states that Schaffer, of Bremen, lias observed them quite as fre- quently. This is different from the observations of Mackenzie, Zuc- kerkandl, and various other laryngologists, and from my own expe- rience. Anatomical and Pathological Characteristics. — The true pa- pillary or warty growths are stated by Hopmann to spring invariably from the lower turbinated body, though I have seen one such tumor growing from the septum alone, and another instance in which several of these tumors grew from the septum while others came from the turbinated body directly opposite. They vary in size from two to fifteen milli- metres in diameter. In five cases observed by Mackenzie, the tumors "were situated on the septum or on tbe inner plate of the alar cartilage. Symptomatology. — The symptoms which I have observed were those referable to dry catarrh, with the usual signs of obstruction of the nasal passage when the tumor was large. Hopmann also observed frequent cough and expectoration, which he attributed to the papillary growths. Diagnosis. — The diagnosis must be based upon the peculiar appear- ance of the growths, which, unless they are moistened by secretion, is similar to that of warts upon the integument, and upon microscopic examination, which will determine their papillary character. Prognosis. — The tumors tend to increase in number, and are very apt to recur when removed. Treatment. — The growth may be destroyed with nitric, acetic, or chromic acid, the cutting forceps or curette, or the galvano-cautery. In one obstinate case under my care, all of these methods were tried 570 DISEASES OE THE NASAL (J A YITIES. unsuccessfully; the warts repeatedly returned again in four to six weeks after each removal. Finally the patient was given a strong tincture of thuja occidentalism which he applied to the part two or three times daily. This, with a few applications of chromic acid, finally eradicated the disease. NASAL VASCULAR TUMORS. Synonym. — Angiomata of the nose. Vascular tumors in the nose are extremely rare. In their removal, Jarvis, who judges from his own experience and a tabulated report of sixteen cases by J. 0. Roe, of Rochester {New York Medical Journal, January, 1886), considers the cold-wire snare safer, simpler, and more satisfactory than the galvano-cautery or other agents (International Jour- nal of Surgery and Antiseptics, 1889). In one successful case reported by him, the gradual removal occupied three hours and there was no hemorrhage. Reasoning from analogy only, the galvano-cautery would appear to be the best instrument in such cases. NASAL OSSEOUS CYSTS. Osseous cysts of the middle turbinated body have recently been the subject of articles by H. Zwillinger, of Budapest, Charles H. Knight, of Isew York, and Greville Macdonald, of London. This variety of tumor is rare, and its etiology, pathology, and symptomatology are not yet fully understood. Charles E. Sajous (Annual of the Universal Medical Sciences, 1892) quotes Macdonald as follows: "Whenever an osseous tumor presents itself in the middle meatus of such a size that it is obviously something further than a simple osteophytic periostitis, whether presenting an osseous surface covered only by mucous membrane or whether it is concealed partially or entirely by polypoid growths, the probability is strongly in favor of cyst. When, moreover, these appearances are accompanied by a purulent and fetid discharge, one may safely surmise that he is dealing with a suppurating cyst or abscess of the middle turbinate. The diagnosis is finally substan- tiated by the removal of a portion of the walls of the tumor by snare or forceps. " The treatment is simple enough in cases when the tumor has not attained enormous dimensions. The simplest way of effecting removal is to throw a strong snare around the mass and remove as large a portion as possible. The remaining portion of the walls may afterward be broken away with forceps." I have seen but a single case of the kind, which was easily removed with snare and forceps. The cyst was filled with a soft, yellowish cheesy mass. NASAL BONY TUMORS. 571 NASAL CARTILAGINOUS TUMORS. Synonym. — Ecchondromata of the nose. True cartilaginous tumors in the nasal cavities are extremely rare, though a few cases have been reported. Ecchondroses or cartilaginous outgrowths, however, are very common, and will be considered else- where. Anatomical and Pathological Characteristics. — Cartilaginous tumors closely resemble fibrous polypi; they are, however, sessile, gen- erally grow from the cartilaginous septum, and if not interfered with may attain an enormous size, causing great deformity of the face. Symptomatology. — The symptoms are those of nasal obstruction. Diagnosis. — The cartilaginous growths, when large, are liable to be mistaken for fibrous polypi, malignant growths, exostoses, or osteomata. Practically we may exclude fibromata, because of their rarity. When present, they bleed more easily and are less dense than cartilaginous growths. It is to be observed that malignant tumors are softer, bleed easily, and grow rapidly. We readily distinguish exostoses and ecchon- droses by inspection as being simple outgrowths. It is distinctive that bony tumors are harder and cannot be penetrated by the needle like car- tilaginous growths. Prognosis. — The prognosis is favorable if the disease is detected early, before great deformity has occurred. There is no tendency to recurrence when the tumor has been removed. Treatment. — Removal by galvano-cautery ecraseur is the most sat- isfactory surgical operation. NASAL BONY TUMORS. ^wowz/m.— Osteomata of the nose. Nasal bony tumors are usually characterized by obstruction of the nasal passage and severe neuralgic pains. When occurring, they usually develop about the age of puberty, but they are rare. Anatomical and Pathological Characteristics. — Osteomata are usually ovoid in form, and they vary in diameter from five millime- tres to five centimetres. They are distinctly bony formations, some- times exceedingly dense, yet at others cancellous; but they have little or no connection with the osseous structure of the nose, and are gener- ally attached to the soft tissues by a comparatively small pedicle. They are covered by periosteum and mucous membrane, which is freely sup- plied with blood vessels and of a pink or red color, and is occasionally ulcerated from pressure. Etiology. — The etiology is unknown. Symptomatology.— Early, the bony growth commonly causes intol- 573 DISEASES OF THE NASAL CAVITIES. erable itching of the nose, which is soon followed by symptoms of ob- struction, with impairment of the sense of smell, and frequent epistaxis. As it begins to press upon the surrounding parts, neuralgic pains some- times become extremely severe. In some instances, however, the nerves of sensation are paralyzed, and no suffering is experienced. As the growth enlarges, the nose may be distorted, the cheek may become prominent, and the eyeball crowded outward. In some cases con- tinued pressure causes ulceration and finally perforation of the exter- nal parts. Such tumors are usually attended by an offensive discharge. By inspection the tumor may be seen. Its densitv or immovability ran be ascertained with the needle or probe. Diagnosis. — The bony growths may be confounded with exostoses, rhinoliths, or cancer. They may be distinguished from exostoses at the outset by their movability, and later by their different form, larger size, and darker color. We can distinguish rhinoliths by an absence of mucous covering, and by the ease with which the surface is broken or crumbled by a strong nasal probe or forceps. It has been found that cancerous tumors grow much more rapidly and are usually very soft. In all cases they may be easily punctured by the needle. They, like osteomata, cause extreme pain and an offensive discharge. Prognosis. — If the tumor is seen early enough, it may be readily re- moved through the natural passages, but, when large, external incisions are necessary and scars remain, unless it can be destroyed by a dental burr. There is no tendency to recurrence. Treatment. — The softer forms may be crushed with strong forceps and the fragments easily removed, but in the hard variety, which is most frequent, this is difficult, if not impossible. If not too large, they may be ground down or drilled through with dental burrs or trephines, and subsequently broken, but, if very large, an external incision is usually necessary for their removal. NASAL MALIGN AS T TUMORS. Cancerous growths of the nose are characterized by rapid growth, obstruction of the nasal cavities, an offensive discharge, frequent epi- staxis, and usually by severe pain. Anatomical and Pathological Characteristics. — They com- monly grow from the septum, but sometimes from the outer wall or floor of the nasal cavity. They are usually sarcomatous, but sometimes carcinomatous. They tend to increase rapidly in size, and soon en- croach upon surrounding structures. They have a pale, slightly nodular or raspberry-like surface, are of soft consistence as a rule., and bleed freely when touched with the probe; their microscopic character- istics are the same as those of similar growths in other parts of the body. NASAL MALIGNANT TUMORS. 573 Etiology. — The etiology is unknown. Symptomatology. — At first there are alteration of the voice, impair- ment of the sense of smell, and sensations of stuffiness in the nose com- mon to all tumors in this locality. Other symptoms, however, rapidly develop. A greenish, offensive discharge is apt to soon occur, frequent epistaxis takes place, and great pain is often felt in the infra-orbital region. As the disease progresses, the bony structures are pushed in front of it or separated from each other, the eyeball protrudes, and the mass, perforating the base of the skull, may extend to the brain. Deafness, dysphagia, and dyspnoea are all symptoms which may occur in the progress of the case, and ere long constitutional symptoms appear indicated by loss of appetite, the development of fever, and a marked cachexia. Upon inspection, a tumor may be detected, usually of a light pink hue, but sometimes darker, even brown or black; highly vascular, bleeding easily when touched, and commonly soft and friable. Malig- nant growths ulcerate early; the ulcer presenting raised, ragged edges, and a sanious base. Diagnosis.— Malignant tumors of the nose are to be distinguished from rhinoliths, impacted foreign bodies, abscess, and benign growths. When the nasal cavity has been cleansed and well illuminated, we find the appearance of a rliinolitli or impacted foreign body, and the sensa- tion it communicates through the probe entirely different from that of a malignant tumor. An abscess may be developed rapidly or slowly, but it is almost universally located at the lower part of the septum, is apt to present upon both sides, is covered by normal mucous membrane, does not bleed, is elastic to the touch, and is not attended by the symp- toms so commonly found in malignant growths. We may distinguish benign tumors by their color, density, slow growth, and other symptoms already described. In malignant growths, after a short time there is an enlargement of the lymphatics, especially those below the angle of the jaw. This does not occur witb benign tumors. Prognosis. — The disease usually runs a rapid course, terminating within six or eight months in death. Sarcomata appear to have been eradicated in some cases where taken early, but carcinomata are always fatal. Treatment. — Astringents and sedatives may be applied as palliative measures, but thorough eradication, when practicable, is the only treat- ment that affords any chance of success. Partial removal only aggra- vates the disease and causes its more rapid growth. E. P. Lincoln reports a case of melano-sarcoma of the lower and middle turbinated bones and floor of the nostril which, returning after several operative procedures, was finally completely cured by the use of the galvano-cautery ecraseur with cauterization at the site of removal (Transactions of the American Laryngological Association, 1885). CHAPTEK XXXIV. DISEASES OF THE NASAL CAVITIES.— Continued. SYPHILIS OF THE NOSE. A local manifestation of constitutional syphilis in the nose may be primary, secondary, or tertiary, and may be congenital or acquired. It is characterized in mild cases by simple obstruction of the nares, and in the more severe by extensive ulceration and necrosis of the bones and cartilages. Anatomical and Pathological Characteristics. — The mucous membrane may be thickened in patches or may be ulcerated. Condylo- mata are sometimes observed, and if the perichondrium or periosteum beneath the thickened patches becomes the seat of suppuration, death of the cartilage or bone is the natural result. This necrosis may also fol- low extension of the ulceration from the surface. Sometimes the pro- cess is one of gradual molecular destruction or slow caries, entirely es- caping observation during life. In such cases the bone, gradually devitalized and absorbed, is replaced by exuberant granulations. Etiology. — The sole cause is the syphilitic virus, but the severity of the disease often appears to depend upon individual constitutional peculiarities other than syphilitic. According to Mackenzie, the stru- mous diathesis seems to render the subject particularly liable to severe forms of nasal syphilis; and in countries where the disease is imper- fectly treated, as, for example, in Egypt and Mexico, it becomes virulent. Primary syphilis of the nose is very rare. The secondary form is not ' infrequent in infants, in whom it is usually developed about the third or fourth month; but it is generally overlooked, and passes for what the nurse terms snuffles. Tertiary manifestations are seldom noticed until several years after the initial lesion; but the symptoms are some- times developed between the sixth and twelfth month, and it is stated that among the modern Arabs, where syphilis is peculiarly severe, the tertiary symptoms appear much earlier. In the secondary stage of the disease, the congestion of the mucous membrane causes profuse muco-purulent secretion and more or less obstruction of the nares. Mucous patches may occasionally be observed at the angle of the nostrils or upon the anterior portion of the mucous membrane. Evidences of the disease in the mouth and throat and upon the skin are usually present at the same time. In the tertiary stage, SYPHILIS OF THE NOSE. 575 there occurs necrosis of the cartilaginous or bony septum or of the tur- binated bodies, accompanied by a most offensive odor of decaying tissue. Extensive destruction of the nasal bones causes falling in of the bridge of the nose, and the oral cavity may be entered by perforation of the palate. Deep, foul ulcers, with ragged edges and a dirty, gray base, are usually present. Before extensive destruction has taken place, the turbinated bodies are often so swollen as nearly or quite to occlude the nares. The dead bone usually presents a blackish, uneven surface, though in some instances nothing can be seen except an offensive crust of dried and decaying secretion, which must be thoroughly washed away before satisfactory examination can be made; it can sometimes be de- tected with a probe, by the rough, grating sensation which it com- municates; occasionally the lesions are so situated that they cannot be discovered. In rare instances an offensive odor is constantly exhaled, even though the parts are apparently kept perfectly cleansed by fre- quent ablutions. Diagnosis. — The secondary stage of the disease is not common, and, when it does occur, is very apt to escape observation. It can be distinguished from chronic rhinitis by the history of its sudden onset with very pronounced symptoms; by its very obstinate course; by the discovery of mucous patches or condylomata when these exist; and by the acknowledgment of infection when this can be obtained from the patient. The tertiary affection may be confounded with lupus or simple atrophic rhinitis. We can distinguish lupus from syphilis by its occurring at an earlier age than any form of syphilis except the hereditary. Again, in the beginning, the peculiar reddish papules or tubercles of lupus are quite distinct from any syphilitic manifestations; and, later, the marked preference which lupus shows for the cartilage is characteristic. The offensive odor caused by atrophic rhinitis is quite different from the stench of tertiary syphilis. Upon cleansing the parts carefully, no necrosed tissue will be found in ozama, whereas it is very apt to be present in syphilis. In all doubtful cases, the history, the presence of old cicatrices, or induration of the tongue, pharynx, or larynx, or brown- ish scars upon the skin or periosteal nodes, and finally the beneficial action of potassium iodide usually enable us to make a diagnosis of syphilis. Pkognosis. — Syphilitic coryza in the adult usually terminates within two or three weeks. Secondary symptoms and those of the tertiary stage in mild cases, as a rule, speedily disappear under proper anti- syphilitic treatment. When caries has taken place, and is still pro- gressing, the prognosis is much less favorable, especially in debilitated subjects, in whom even life may be endangered. Teeatment. — Syphilitic coryza requires no other treatment than the internal administration of tonics, and the local use of mild alkaline r > 7 I '- DISEA SE8 OF THE XA SA L < 'A T 'ITIES. sprays or washes. Indeed, any secondary symptoms usually require only mild constitutional treatment, and touching of the condylomatous growths or mucous patches with tincture of iodine or silver nitrate. Tertiary syphilis, however, demands active constitutional and local treatment. It is well to begin with potassium iodide in moderate quantity, and steadily increase the doses until the reparative process is well established. To this end, 7iot infrequently the drug must be pushed to its physiological limit. In all cases it or other specific medication should be continued in larger or smaller doses until a complete cure is effected. Small doses of mercur}', or of gold and sodium chlcride, will sometimes be found especially bene- ficial. At the same time, bitter or ferruginous tonics are often de- manded, and cod-liver oil when well borne is useful. Good nutri- tious diet should be provided. Local treatment is extremely impor- tant. The nose should be thoroughly cleansed two or three times daily with the sodium salicylate wash (Form. 18?) or a similar alkaline Fig. 211.— Ingals' Nasal Dressing-Forceps (3-5 size). solution. Under this treatment superficial ulcers usually speedily heal; but where deep ulceration exists, in addition to cleansing, the sores must be touched with some stimulant or caustic. For this purpose the most commonly employed caustic is silver nitrate fused upon the end of an aluminium or silver applicator, but in the majority of cases ' prefer strong tincture of iodine to any other local remedy. The applications should be made daily for ten or fourteen days, until evidence of cica- trization appears, and then every other day for a week or more, and subsequently less often. Even large ulcers under this treatment usually heal- within three or four weeks. If dead bone is present, it must be carefully removed with forceps (Fig. 211), though it is unsafe to use much force. In the mean time the patient may advantageously insuf- flate into the nasal cavity twice daily a powder consisting of one part boric acid and two parts iodol or iodoform; or with this, in case there is much swelling, may be combined two or three per cent of cocaine, and five per cent of aristol to correct the offensive odor. Schuster specially recommends scraping the ulcers with a sharp spoon, and afterward de- stroying any indurated tissue that may remain with the galvano-cautery or silver nitrate (Viertetyahresschrift fur Dermatologie r. Syphilis, 1877). CONGENITAL SYPHILIS OF THE NOSE. 577 When the disease has been checked, if serious deformity exists, it may sometimes be remedied by an artificial nose, or in some cases by rhino- plastic operations, which are described in the textbooks of surgery. CONGENITAL SYPHILIS OF THE NOSE. Hereditary syphilis usually makes its appearance in children within the first two or three weeks after birth, and seldom later than the second month; but occasionally not until the child is eight or ten years of age, or at a later period, about puberty. Etiology. — The disease appears to be contracted, in many instances, at the time of birth, though commonly during intra-uterine life. Symptomatology. — Usually within a week or two after birth the child appears to have a bad cold in the head, the nares are stopped, and there appears a thin, irritating discharge, which soon becomes muco-purulent, causing redness, soreness, and erosion of the nostrils and upper lip. The child is said to have the snuffles. As the secretions become thicker, the nasal cavity is blocked with scabs, which exhale an offensive odor. In some instances caries of the cartilages and bones ensues, not infrequently causing disfigurement for life. Such children are usually small and feeble, suffer from marasmus, and frequently have a copper-colored, papular eruption upon the skin. Mucous patches are probably present in the nose in most cases, but it is hard to get a view of them; similar patches may often be found at the anus or at the angles of the mouth or eyelids. Diagnosis. — The diagnosis must depend upon the history, the symptoms, the obstinacy of the disease, and the effects of treatment. Prognosis.— The affection runs a chronic course, with little or no tendency to spontaneous recovery. Such children often die young; but under judicious treatment some may be apparently cured. In a con- siderable number the disorder may be checked, but it continues to re- appear at intervals for many years. Treatment. — Mercurials and potassium iodide are indicated inter- nally, and local treatment is generally desirable, though in young chil- dren it is very difficult to carry out. Mackenzie prefers mercury with chalk, which he administers in doses of from one to two grains twice daily, to which he adds, if this causes diarrhcea, one grain of Dover's powder or an additional grain of chalk (Diseases of the Throat and Nose, Vol. II). Eriehsen recommends the external applica- tion of mercury in the following manner proposed by Brodie (Science and Art of Surgery, London, 1872): a drachm of mercurial ointment is spread upon a flannel roller which is stretched around the child's thigh just above the knee, the ointment next to the skin. This is renewed daily for two or three weeks, after which potassium iodide is adminis- tered in milk, cod-liver oil, or malt. Milk and water are the best vehicles for the administration of the drug to either children or adults. 37 578 DISEASES OF THE NASAL CAVITIES TUBERCULOSIS OF THE NARES. Tuberculosis of the nares is a rare affection characterized by the for- mation of tubercles of varying size, with ulceration and a fetid discharge. It is usually secondary, though Tornwaldt has reported a case in which the nasal symptoms preceded any other; and I have seen one case in which no evidence of pulmonary lesion could be discovered for several months after the appearance of the tubercular ulcer in the nostril. Of thirty- eight cases of nasal tuberculosis collected by Michelson, of Konigsberg, nineteen showed no tuberculosis of any other organ (Internationale Minische Rundschau, Vienna, 1889), and F. Halm reports five primary cases (Deutsche medicinische Wochenschrift, Leipsic, 1889). Anatomical and Pathological Charactekistics. — The tuber- cular deposit may be observed either as thickening, with or without ulceration of the mucous membrane, or in the form of tumors varying from two to thirty millimetres in diameter. The disease may attack any part, but most frequently the septum is the seat of the trouble. The nodules are generally small and of a grayish white color; the ulcers, which may be single or multiple, have a grayish base and frequently raised edges. Etiology. — The bacillus tuberculosis is now generally accepted as the ultimate cause of the disease. Symptomatology. — The affection comes on insidiously, and gener- ally progresses slowly, causing all the symptoms of offensive catarrh. Tubercles or ulcers, as already described, may be detected by careful inspection. The ulcers are not generally painful und at first are not accompanied by constitutional symptoms; but sooner or later tubercu- losis of the lungs or larynx is developed, and runs its ordinary course. Diagnosis. — Tuberculosis may always be suspected when obstinate ulcers or tubercles are detected in the nose, especially in scrofulous pa- tients, or those with recognized tuberculosis of other organs providing syphilis has been carefully excluded. An accurate diagnosis can only be made by finding tuberculosis in other parts or by the detection of the bacillus tuberculosis in the discharges or scrapings from the ulcers. Prognosis. — The progress of the disease is generally slow, and may extend over many years; but it usually continues until other organs finally become involved, and then runs a more rapid course to a fatal termination. Treatment. — The nares should be kept clean. Tumors which by their size interfere with respiration should be removed, and ulcers should be thoroughly treated with lactic acid, in strength varying from thirty to one hundred per cent, with or withoujt previous scraping, according to the indications. Treatment of the ulcerated surface by carefully touching it from time to time with the galvano-cautery has been recom- EMPYEMA OF THE ANTRUM. 579 mended, and is advantageous in some cases. Insufflations of iodol or iodoform are also indicated; but whatever method is adopted, the ulcers are very difficult to heal, and in many cases the treatment does no appreciable good. When pain is present, soothing remedies are required. Of prime importance are all those means by which the system may be fortified against the spread of the disease. It would appear that these cases, if any, might be cured by the use of Koch's tuberculin; but in a single case of the kind in which I administered it, the results were most disastrous, and the progress of the disease was yery much accelerated by the presumed remedy. EMPYEMA OP THE ANTRUM. Empyema of the antrum, which was accurately described by John Hunter, consists of a collection of pus in the antrum of Highmore, characterized by a purulent discharge having an offensive odor, usually Fig. 213. — Cross Section of Head Looking prom Behind Forward about Half an Inch in Front •of the Opening of the N ares into the Naso-Pharynx. From a photograph of a frozen section prepared by C. H. Stowell, of Washington (4-5 natural size), a.a. Middle turbinated bodies; b,b, in- ferior turbinated bodies; c,c,c,c, ethmoid cells; d,d, antra of Highmore. from one nostril. It is more commonly found upon the left side, but frequently upon the right, and occasionally on both sides. The antrum, as shown by Giraldes, is sometimes divided by sejita of bone, so that in this disease two or more pockets of pus may exist (Des Maladies du Sinus Maxillaire, Paris, 1857). Delavan, in a paper read before the American Medical Association, Section of Laryngology, in 1889, showed that the antra are liable to various irregularities in formation, which accounts for some of the peculiarities presented in the symptoms and signs of the disease. The relations of these cavities to the nares and surrounding parts are accurately shown in Fig. 79, and Fig. 212. Etiology. — Disease of the teeth is the principal cause of the affec- tion ; but in many instances it originates in morbid changes in the nasal 580 DISEASES <>F THE NASAL CAVITIES. cavity or adjoining sinuses, such as caries, polypi or granulation tissue in the middle meatus, or suppurative inflammation of the ethmoid cells or middle meatus, the pus from which enters the antrum. Symptomatology. — The affection usually comes on insidiously and lasts for several months, or possibly years, before it is detected. When it has existed for some time, there may be found considerable disturb- ance of the general health. In most cases, pain in the cheek is com- plained of, sometimes radiating toward the ear and frequently attended by supra-orbital neuralgia. But comparatively few of the patients suf- fer from toothache or swelling of the face, the most common subjec- tive symptoms being more or less obstruction of the nose, a foul smell or taste seemingly from the throat, and discharge from one nos- tril. The fetor is often appreciated only by the patient himself, and is present in many instances only at certain hours of the day. The dis- charge also is usually periodical, occurring in considerable quantities two or three times a day, though in many instances there is a continual but slight flux. Sometimes this is only experienced upon assuming cer- tain positions, as when lying upon the affected side, or even upon the sound side, or, again, upon bending forward with the head low down. Sometimes the principal flow is into the naso-pharynx, where it may excite reflex cough, or even nausea and vomiting. Upon inspecting the nares, a jmrulent discharge is generally observed in the middle meatus, trickling down over the inferior turbinated body. Oftentimes this, on being wiped away, speedily reappears. Polypi or granulation tissue may be seen in a large percentage of cases, and with the probe caries may not infrequently be detected. By tapping over the malar prominence with the tip of the finger, pain or tenderness is usually caused, which is not experienced on the sound side. McBride, of Edinburgh, notes that generally there is marked redness of the gum corresponding to the diseased antrum (Edinburgh Medical Journal, April, 1S88). Diagnosis. — The essential points in the diagnosis are the pain, fetor, and discharge from one naris. The affection is liable to be mistaken for disease of the frontal sinus or of the anterior ethmoid cells, or for polypus, ozaena, foreign bodies, syphilis, caries, or disease of the sphenoidal sinus. A useful method of detecting pus in this locality consists of injecting, through the normal opening in the middle meatus, a solution of hydrogen peroxide, which, in case pus is present, will im- mediately cause a discharge of froth through the opening. Trans- illumination, as suggested by Voltolini, is often, though not universally, of great value in deciding obscure cases. It is practised by means of a small electric lamp placed in the mouth while the patient is in a dark room. The effect of this* is to cause a rosy-red suffusion of the face, cheeks, lips, and inferior eyelid in health, but the cheek and inferior eyelid will remain dark in case the antrum is tilled with pus. A three candle power lamp, five to eight volts according to the strength of the EMPYEMA OF THE ANTRUM. 581 battery used, is best for this purpose. It may be attached to some form of tongue depressor. That shown in Fig. 213, which is inserted into the ordinary galvano-cautery handle, I have found most convenient. The patient may be examined in a dark room, or more easily with the aid of an ordinary photographer's focusing-cloth thrown over the heads of both patient and physician. This method is of peculiar value in detecting cysts of the antrum, which are said to render the illumina- tion even more brilliant than in health, while solid tumors or pus prevent the transmission of light. Empyema, of the frontal sinus, unattended by closure of the duct, is so extremely rare that it may be excluded ; when the duct is occluded the external signs are so marked that the affection cannot be mistaken for disease of the antrum. We frequently find suppuration of the anterior ethmoid cells associated with empyema of the antrum; but when occurring by itself it is distin- guished from the latter by the position of the pus above instead of below the middle turbinated body, and by the absence of positive signs in the antrum. McDonald recommends as a means of diagnosis the introduc- tion into the antrum, immediately above the inferior turbinated bone, Fig. 213.— Ingals' Electric Lamp Q/c, size). For trans-illumination. of a strong, curved, hollow needle, to which is attached a small exhaust syringe (Diseases of the Nose, 1890). Empyema is distinguished from polypus by inspection of the nares, but it must be remembered that before any operation has been done, whenever polypi are attended with purulent secretion, pus will usually be found in the antrum at the same time. An extremely fetid breath, which is appreciated by every one except the patient, is continuously caused by ozama. The fetor in empyema of the antrum is usually noticed only by the patient, and is apt to be in- termittent in its occurrence. Inspection of the nares in these cases will readily determine the diagnosis. An offensive discharge from one nostril may arise • from foreign bodies in the nose, but they may be easily distinguished from disease of the antrum by inspection, and palpation with the probe. An offensive odor and excessive discharge from the nares may be caused by syphilis, but it nearly always affects both sides, and inspec- tion reveals ulceration, dead bone, or other evidence of disease of the cavity itself, instead of the comparatively healthy appearance found in empyema of the antrum. Caries is also usually detected in syphilis by inspection, and palpation with the probe. Disease of the sphenoidal sinus is very rare, and when it does occur 582 DISEASES OF THE NASAL CAVITIES. the discharge flows into the throat, but not from the nostrils. It would not cause pain in the cheek or interference with the transmission of light; therefore, it may readily be excluded. Prognosis. — Acute cases sometimes recover spontaneously within a short time, but the affection may extend over many years unless appro- priate treatment is adopted. Even under the most approved methods, with free drainage, it is sometimes impossible to check the forma- tion of pus. Treatment. — Some cases have been cured by washing out the an- trum through the natural opening with detergent solutions or with hydrogen peroxide, but usually free drainage must be established. For this purpose, Hunter's method of opening the antrum through the socket of one of the molars is still considered best, the only objection urged against it being the annoyance caused the patient by the offensive dis- cbarge into the mouth, and the possibility that particles of food may escape into the antrum. Christopher Heath recommends puncture of the antrum above the alveolus (Transactions Odontological Society, November, 1889). The main objection to this is the difficulty of keep- ing the opening patent. The antrum may be opened through the Fig. 214.— Brainard\s Bone Drill. inferior meatus by means of trephine, drill, knife, or a long, curved, strong trocar, as recommended by Krause (Berliner klinischc Wochen- schrift, 1889). The latter position obviates the objection to Hunter's method, but the opening is less easy of access, and is more difficult to maintain until healing has occurred. My own preference is for Hunter's method, a tooth or a root being extracted when necessary, or an opening being made through the space 4eft by a tooth which has been already lost. Various forms of trephines, drills and dental burrs have been used for making the opening, but in most instances too small an instrument is employed. I use Brainard's conical bone-drill (Fig. 214), which makes an opening nearly a quarter of an inch in diameter. Notwithstanding statements to the contrary, the operation is extremely painful unless an anaesthetic has been used. General anaesthesia may be induced by chloroform, ether, or nitrous oxide gas — the effects of the latter are usually too evanescent — but in most instances the parts may be sufficiently benumbed by injecting into the gum, in two or three places on each side of the alveolus, a solution of cocaine, already recommended (Form. 143). The opening having been made, the antrum should be washed out and a gold or rubber tube introduced to maintain its patency. If this precaution is neglected, the opening is almost sure to close before the disease has been cured. Any good dentist can make a suitable gold tube which can be EMPYEMA OF THE SPHENOIDAL SINUSES. 583 fastened with clamps to the adjoining teeth. I have recently used with great satisfaction rubber tubes (Fig. 215) of six millimetres diameter, nineteen to thirty-five millimetres length, and four millimetres calibre, with flanges at each end. With a wire, the end of which has been bent to a right angle, the distance through the alveolus may be measured and a tube of proper length selected. The flange at the upper end of the tube is thinned, by cutting away its upper surface, until it may be squeezed into a gelatin capsule of proper size. This is then oiled and readily passed through the opening into the antrum. A probe is then Fig. 215. — In-gals' Drainage Tube for Antrum. Full diameter; three different lengths. passed through the tube, the gelatin capsule forced off, the flange opens out, and the tube is thoroughly secure. These tubes are inexpensive and very much more comfortable to the patient than gold. The sub- sequent treatment consists of keeping the cavity clean, and stimulating the healing process by injections of iodine, zinc, copper, or hydrogen peroxide in watery solution; or by insufflations of boric acid, iodol, iodoform, or aristol; or by solutions, in liquid albolene, of carbolic acid, oil of cloves, oil of cinnamon, or terebene. If septa prevent thorough cleansing of the cavity, it may be necessary to enlarge the opening and break them down. The patient should always stop the opening with a pledget of cotton while eating. EMPYEMA OF THE SPHENOIDAL SINUSES. Empyema of the sphenoidal sinuses is so extremely rare that no defi- nite rules for diagnosis or treatment can be formulated. These sinuses, which occupy a position at the upper back part of the nasal cavity, just at its opening into the naso-pharynx, vary in number, size, and form in different individuals (Fig. 216). Symptomatology. — Purulent inflammation of these cavities gives rise to a persistent discharge of pus into the nares and naso-pharynx, and not infrequently causes severe headache, with more or less disturbance of the senses of smell and sight. The anterior wall of the sphenoidal sinus, as shown in Fig. 216, is thin, and in cases of long-continued empyema a spontaneous opening through it might be effected. The finding of pus uniformly in this position, or trickling from it down the sides into the posterior nares, may suggest the true nature of the disease. Treatment. — Other affections being excluded, and the diagnosis established, the anterior wall of the sinus should be carefully perforated, and the cavity drained and treated ou the same principles as empyema 584 DISEASES OF THE NASAL CAVITIES. of the antrum. Opening has also been successfully effected through the inner wall of the orbit in extreme cases. INFLAMMATION OF THE FRONTAL SINUS. Inflammation of the frontal sinus is a comparatively frequent affec- tion, but owing to the dependent position of the duct in most cases the products of inflammation readily escape and spontaneous recovery speed- ily follows. Sometimes, however, swelling obstructs the duct, and the secretions may be pent up. Such cases I have seen readily relieved by ff^^^Sm^^^^ Fig. 216.— Cross Section of Head. From photograph of frozen section prepared by C. H. Stolen (4-5 natural size), a. Middle turbinated body; b. inferior turbinated body; c, superior turbinated body; d, sphenoid cells; e, frontal sinus; /, Eustachian orifice; g, naso-pharynx as closed in deglutition. the local use of cocaine, which reduced the swelling sufficiently to allow free discharge, and, this condition being maintained for two or three weeks, recovery ensued. In some instances, permanent obstruction of the duct occurs, and then empyema of the frontal sinus follows. ^\ hen this results, the pent-up secretions eventually cause a tumor at the upper inner angle of the orbit, disfiguring the patient, and displacing the globe of the eye. The occurrence of suppuration will be indicated by rigors, exces- sive headaches, swelling, redness, and some local oedema and throb- bing pain. Violent pain in the course of the supra-orbital and nasal CHRONIC SUPPURATIVE ETH2I0IDITI8. 585 nerves is a common symptom. In suppuration caused by simple catar- rhal inflammation, a small opening made with a drill from the nasal cavity, is usually sufficient to allow the confined secretions to escape; but when it results from syphilis, energetic measures are demanded, otherwise fatal involvement of the brain is likely to ensue. Then the frontal bone should be laid bare, and the cavity opened with a tre- phine in its most dependent part. Afterward provision should be made for free drainage into the nasal cavity, a drainage tube introduced, and the external wound allowed to heal. Finally, as recovery takes place, the drainage tube is removed through the nose. Other diseases of the frontal sinus come more properly within the domain of general surgery. CHRONIC SUPPURATIVE ETHMOIDITIS. A chronic suppurative inflammation of the ethmoid bone and mem- brane lining its cells is characterized by a persistent, somewhat offen- sive discharge, and obstinate neuralgic pains in the temples and forehead. Etiology. — The causes are unknown. In two cases which have come under my observation, I am satisfied that the disease was the direct result of inflammation of the antrum, and not the cause of the latter, as it is believed often to be by McDonald (Diseases of the Nose, 1890). The suppuration results from abscess of the antrum in consequence of the occlusion of the opening from the latter into the nasal cavity, so that it becomes filled with pus which crowds upward and finally flows from the openings which are frequently present between the antrum and the ethmoid cells; by pressure this pus causes necrosis and perforation of the thin bones which separate the two cavities. The relation of parts will be readily understood by reference to Fig. 212. Symptomatology. — Patients frequently suffer from neuralgic pains in the temple or over the orbit, which are more or less intermittent, and sometimes paroxysmal. Indeed, the symptoms closely resemble some of those attributed to empyema of the antrum; but there may be reasonable doubt whether these symptoms would occur in the latter affection were it not for coexisting disease of the ethmoid cells. There is usually purulent or muco-purulent discharge from the nose, which is often fetid, but not so offensive as in ozasna. This flux may be scanty or very profuse, is generally continuous, and usually comes from one side only. Upon inspection it may be seen filling the middle meatus and running over the middle turbinated body. Often inflam- matory thickening of the external wall of the middle meatus is seen, which sometimes communicates through the probe a sensation of bony hardness, but usually it appears and -feels more like a polypoid for- mation or fungous granulation. Diagnosis. — The affection is to be distinguished from mucous polypi, atrophic rhinitis with ozama, from suppuration of the antrum, and from 5b»; DISEASES OF THE NASAL CAVITIES. empyema of the sphenoidal and frontal sinuses. It may ordinarily he distinguished from mucous polypi by the presence of pus; this must he wiped away, and carious hone which often exists, or fungous granu- lations are to he carefully sought with the probe. Not infrequenly small polypi are associated with this affection. Suppurative ethmoiditis must be distinguished from suppuration of the antrum by careful inquiry into the history and symptoms and by persistence of the discharge after the latter cavity is known to be healed. TVe readily distinguish atrophic rhinitis by the abnormal size of the nasal cavities, the peculiar stench, and collections of decaying crusts of mu co- pus. From empyema of the sphenoidal and frontal sinuses this affection is distinguished according to Max Schaeffer {Deutsche Medinische Wo- chenschrift, Leipzig, No. 41, 1890), largely by the position of the pus, which in disease of the frontal sinus covers the more or less swollen mucous membrane of the septum in the superior meatus, and in disease of the sphenoid cells passes down the pharynx, while in ethmoiditis it spreads out in the middle meatus. Prognosis and Treatment. — It is probable that some of the cases recover spontaneously, but most of them continue for many months, and even years, in spite of the best-directed treatment. The indications are to remove any obstruction which prevents free exit of pus; to keep the parts cleansed, and as nearly aseptic as possible; and by judicious stimu- FlG. 217.— Holbrook Curtis' Wash Bottle C% size). Used for the ethmoid cells. lation to encourage healing. If disease of the antrum exists, it must be remedied before we can hope to cure the disease of the ethmoid cells. Polypoid growths or fungous granulations may he best removed by snare or sharp spoon, or small masses may be touched with the galvano-cautery or with monochloracetic acid. Dead bone must be carefully scraped away, and with the drill, trephine, or forceps the partitions of the eth- moid cells may be broken down to give free exit to the pus; hut care must be taken not to excite undue inflammation, which might extend to the brain. I have found the most satisfactory results from injecting into the ethmoid cells, with a long, slender silver canula attached to a hypodermic syringe, about fifty per cent solutions of the hydrogen peroxide, and subsequently oily solutions containing oil of gaultheria LUPUS OF THE If ARES. 587 TTi I, oil of caryophyllum Til v., terebene TT[ x., ad 3 i. of liquid albolene, the strength being slightly increased or diminished according to its effect. It should not cause pain for more than half an hour after- ward. At the same time the nasal cavity should be washed two or three times daily, by means of the nasal syringe or Curtis' wash-bottle (Fig. 217), with a detergent solution, and a similar oily preparation, or one somewhat weaker may be used as a spray by the patient morning and evening. A powder containing five per cent of aristol, two per cent of cocaine, twenty per cent of boric acid, forty per cent of iodol, with sugar of milk for an excipient, may be advantageously used by the patient once or twice daily as an insufflation. LUPUS OF THE NARES. Lupus of the nares is a chronic affection of the mucous membrane usually secondary to lupus of the external surface of the nose, and characterized by the formation of small, irritable nodules which sub- sequently are the seat of iudolent ulceration, followed frequently by a process of slow repair and cicatrization. It generally occurs in young persons of strumous habit, and is most liable to affect girls. Anatomical and Pathological Characteristics. — Two varie- ties of the affection are recognized; one known as lupus non-exedens, in which atrophy of the affected tissues, including bone and cartilage, occurs without ulceration ; the other as lupus exedens, which usually begins on the cartilaginous septum in the form of small, red, irritable nodules; these gradually coalesce, forming raised, uneven patches, which ere long become the seat of deep ulceration. This process extends slowly, destroying the soft tissues, cartilages, and even the bones, though repair is often inaugurated before the latter perish. The ulcers are covered with crusts under which the destructive process is going on in some places, while healing may be taking place in others. Etiology. — Pathologists now generally recognize lupus as a tuber- cular disease, but the clinical history of the affection still leaves much doubt as to its true nature, and a large part of the profession is still unwilling to accept any dictum concerning it. Symptomatology. — The disease occurs in young subjects, progresses slowly, causing the physical appearance already described, and it is at- tended by a discharge more or less profuse and offensive. The ulcers are not usually painful. As a rule, the disease first attacks the skin upon the cheek or nose, but it occasionally commences in the mucous membrane. Diagnosis. — Lupus is liable to be mistaken for syphilitic affections of the nose, epithelioma, and true tubercular disease. The essential points in the diagnosis are the history, the development of red, irritable nodules, the progressive ulceration, and the slow process of repair. 588 DISEASES OF THE NASAL CAVITIES. There is usually a specific history in syphilis, which may be obtained by the adroit physician ; thickening of the mucous membrane in patches or extensive swelling of the turbinated bodies comes on rapidly and is quite unlike the slowly developing, small, red tubercles seen in lupus. Syphilitic ulceration, though rapid, may usually be soon checked by ap- propriate local and internal remedies, which make no impression upon lupus. We cannot always distinguish epithelioma from lupus in the be- ginning, but after a short time the characteristic features of the two diseases render the diagnosis easy. The small red nodules found in lupus do not precede true tuber- cular ulceration, in which the ulcers are of a lighter color and present few if any of the bright red granulations usually seen in lupus, and show no tendency to repair. The presence of pulmonary tuberculosis would lie a valuable point in the diagnosis. Prognosis. — The disease continues for several years, but can some- times be checked by appropriate treatment, though even when the ulceration has healed there is great tendency to recurrence, especially if the cicatrices remain red and indurated. With advancing age there is sometimes spontaneous recovery. In some instances it extends to the pharynx and larynx; in these, recovery is not likely to take place. 4 Treatment. — Arsenious acid and other tonics, with cod-liver oil, sometimes prove beneficial. The local treatment consists in removing or destroying the diseased tissues by the knife, curette, caustic, or the galvano-cautery. The treatment generally recommended consists of scraping the ulcers thoroughly with the curette, and then applying lactic acid, which should be repeatedly used until the process of repair is thoroughly established; other powerful caustics such as nitric acid, caustic potash, and zinc chloride have been recommended, but they are more severe and seem no more effective than lactic acid. The galvano-cautery has also been efficiently used for the same purpose. Koch's tuberculin has a wonderful effect on the disease, and has proven curative in some cases. Complete removal by the knife is sometimes practised. RHIXOSCLEROMA. Rhinoscleroma is a rare affection, most cases of which have been ob- served in Austria, Hungary, and Italy, but a few have been seen in Germany. As described it is characterized by the formation about the nostrils or upper lip of smooth, flat, slightly raised, and extremely hard patches. The integument over these is either natural or of a reddish hue, and the spots are tender on pressure, but not otherwise painful. Xo con- stitutional symptoms are developed. The disease may appear in two or more places simultaneously; it progresses slowly, and may involve the alae of the nose and septum, and may pass backward to the throat, GLANDERS. 58 9 larynx, and even the trachea, causing extensive swelling of the mucous membrane and symptoms due to mechanical interference with the func- tions of the parts. Etiology. — Ehinoscleroma is probably due to local infection, but the specific cause has not yet been identified, though micro-organisms are always to be found in the cells and lymphatic spaces of the affected part, and some of these have been specially studied. Diagnosis. — Ehinoscleroma is to be distinguished from syphilis, epithelioma, and keloid. It is differentiated from syphilis by its chronic course, the absence of softening and ulceration, and the fruitlessness of specific medication. Epithelioma is softer, it soon ulcerates and bleeds, which does not occur in the affection under consideration and it is much shorter in duration. Ehinoscleroma must be distinguished from keloid by the location and progress of the case. Keloid usually occurs on the front of the chest as an irregular, corrugated, cicatrix-like ex- crescence, of slow growth. Prognosis. — There is no tendency to spontaneous recovery, and if extirpated or destroyed it is sure to recur, but it does not shorten life. Treatment. — Treatment is of no avail except as a palliative meas- ure; obstructing masses should be removed from the air passages, and. in case the larynx becomes involved, tracheotomy should be performed to prevent suffocation. Injection of Koch's tuberculin produces no re- action in these cases. GLANDERS. Glanders is a contagious disease derived directly by inoculation usually from a horse suffering from the affection. It is characterized by the formation of nodules, which soon become pustular and ulcerated, with symptoms of septicaemia and thick, muco-purulent, or sanious, offensive discharge. The affection is rare and is hardly observed except among veterinary surgeons, grooms, coachmen, and others whose occupation brings them in contact with horses. The disease may extend to the skin and various parts of the body, causing inflammation of the lym- phatics, and it is then termed farcy. It may be either acute or chronic; the chronic form frequently precedes the acute. Anatomical and Pathological Characteristics. — There is usu- ally but little swelling and redness of the mucous membrane, which is covered by scabs, beneath which ulcers will be found in several places; it extends in less degree to the mouth, throat, and larynx. Etiology. — Glanders in the human subject is always caused by direct inoculation from a horse suffering from the disease, and is due to the bacillus malei. Symptomatology. — The acute form is marked at its outset by chills, high fever, and erysipelatous rash on the nose and face, soon followed by vesicles which burst and discharge a thin, serous fluid. These pustules 590 DISEASES OF THE NASAL CAVITIES. appear on the face associated with blebs. The secretion soon dries and forms a crust, under which a deep and rapidly spreading nicer is found. Obstruction in the nose and throat is caused by the pustules. The chronic affection is characterized by similar symptoms, coming on more slowly, but it is likely to be merged suddenly into the acute form. When the disease becomes fairly developed, the muscles and tendons are often tender and the seat of rheumatic pain. The voice be- comes husky or even lost, and some dyspnoea may develop ; frequently there is slight cough. The discharge from the nose and throat is always extremely offensive, and usually profuse and thin at first, but later thick and glutinous, and sometimes streaked with blood. Nausea, diarrhoea, and abdominal pains are sometimes experienced. As the dis- ease progresses, the patient passes into a typhoid condition, which, in the acute form soon terminates in coma and death. In the chronic form the patient may remain ill for several years, and he seldom fully regains his health. Diagnosis. — Glanders is liable to be mistaken for rheumatism, py- aemia, typhoid fever, syphilis, and scrofulous eruptions. The essential points in the diagnosis are : the history of infection, the marked consti- tutional symptoms, nasal obstruction and offensive discharge, pains in the limbs, and abscesses in various parts of the body. It will be distinguished from rheumatism by the history, the presence of pustules and ulcera- tion, and the occurrence of pain in the muscles and tendons, instead of in the articulations. It will be distinguished from pyaemia by less pronounced rigors, and by the pustules, ulceration, and offensive nasal discharge. It will be differentiated from typhoid fever by the history, the pustules, ulceration, and discharge. There should be no difficulty in distinguishing glanders from syphilis, if the history, marked consti- tutional symptoms, and failure of specific medicines to give relief are considered. It is readily distinguished from scrofulous eruptions by the marked constitutional symptoms. Prognosis. — The chronic disease usually runs from four to eight months or even longer. Bollinger (Ziemssen's Cyclopaedia of Medicine) mentions a case in which the symptoms lasted for eleven years. The acute affection usually lasts for about three weeks when coming on independently; but when following the chronic disease, it generally terminates fatally within a week. The acute disease is almost always fatal, probably always if the nose is. attacked. The symptoms preceding a fatal termination are protracted fever, night sweats, diarrhoea, delirium, and great exhaustion. Treatment. — No form of treatment seems to be of any avail, but the case should be managed on general principles, and an attempt made to relieve suffering and sustain the vital powers. PERVERTED SENSE OF SMELL. 591 NASAL AFFECTIONS IN ACUTE DISEASES. Acute coryza is one of the earliest symptoms of measles and it is oc- casionally followed by severe inflammation, with epistaxis and muco- purulent secretions. Atrophic rhinitis and ulceration of the septum sometimes result. Slight or severe acute rhinitis, with profuse serous or muco-purulent discharge and sometimes epistaxis, may attend scarlet fever. An eruption in the nares, with obstruction of the passages, and sub- sequently epistaxis, is sometimes caused by small-pox, and cases are not very uncommon where the nostrils have become occluded by healing of the ulcerated surfaces. Very distressing catarrhal symptoms, due to collection of secretions and formation of large crusts, sometimes attend typhoid fever. Under the crusts, ulceration may possibly take place, and sometimes the sep- tum is partially destroyed. Severe rhinitis sometimes attends rlieumatism, but more frequently will be observed rheumatic or neuralgic pains, associated with but little if any evidence of inflammation. In all of these cases the diagnosis is comparatively easy, and the local treatment is that suitable for acute catarrhal rhinitis. PERVERTED SENSE OF SMELL. Parosmia. Parosmia indicates a perversion of the sense of smell by which the patient experiences sensations of odors, usually disagreeable, which are not really present. It is said to be comparatively common in epileptics' and among the insane, but is also observed in those who are otherwise perfectly healthy. The condition is analogous to neuralgia of a nerve of common sensation. In some it is constantly present, in others in- termittent. In some patients the sensation occurs without an exciting cause, whereas in others agreeable odors smell offensive. Diagnosis. — The diagnosis is made from the subjective features of the disease. Treatment. — No rules for treatment can be formulated. Anosmia. Anosmia or loss of the sense of smell is dependent upon obstructions in the nares or disease of the olfactory nerves or lobes, or of their cere- bral centres. Etiology. — Anosmia is caused by obstruction of the nares from an acute cold, polypi, hypertrophy of the mucous membrane, or presence DISEASES OF THE NASAL CAVITIES. of foreign bodies; also by disease of the olfactory nerves, either distal, or along the trunk, or at the centres. The most frequent cause is obstruction from mucous polypi, or swelling of the middle turbinated body, or of the mucous membrane covering the septum directly opposite. In these cases it is usually intermittent. It not infrequently results from injury to the head, as from blows or falls, and cases are on record in which it has been caused by prolonged exposure of the olfactory nerve to some pungent or extremely disagreeable odor. It has been caused by inhalation of irritating vapors, snuff-taking and local use of solutions of alum, or other nasal washes. It sometimes follows prolonged rhinitis especially of the dry variety, frontal neuralgia, or long-continued paral- ysis of the fifth or seventh nerve, and it is occasionally congenital. Symptomatology. — In addition to the loss of smell, the patient is usually deprived of the sense of taste for all substances with a dis- tinct flavor, but bitter, sweet, sour, salt, and acids are usually recognized. The loss of the sense of smell may be unilateral or bilateral, and is often intermittent, returning for a few minutes or even days, after ex- ertion or without evident cause; but disappearing again without the slightest known provocation. Diagnosis. — The diagnosis is made from the subjective symptoms and the exclusion by inspection of conditions causing obstruction of the nares. Prognosis. — When due to mechanical obstruction, most cases are relieved when the obstruction has been removed. Cases dependent upon catarrhal inflammation of the Schneiderian membrane usually re- cover unless they have already existed for two or three years, in which case a favorable termination cannot be expected. When due to cerebral disease, the sense of smell is seldom restored. Treatment. — The condition causing the affection should be sought and, if possible, removed When this cannot be found, Mackenzie rec- ommends the insufflation of a powder containing one twenty-fourth of a grain of strychnine with two grains of starch twice a da}', and if it does not succeed he increases the strychnine to one-sixteenth or even one-twelfth of a grain (Diseases of the Throat and Xose). CHAPTER XXXV. DISEASES OF THE NASAL CAVITIES.— Continued. CONGENITAL DEFORMITY OF THE NOSE. The principal nasal deformities which have been observed are : ab- sence of the septum, double septum, narrowness of one naris as compared with the other, and occlusion of the posterior nares by membranous or bony tissues. Cases have also been recorded of complete absence of the nose, and of double nose. Closure of the posterior nares seriously inter- feres with respiration, especially in infants, and in them may be a seri- ous menace to life. Treatment. — Various plastic operations have been performed to correct these deformities. Congenital closure of the posterior nares, which principally concerns us, demands prompt attention, for infants will not thrive unless they can breathe through the nose. A passage must be forced through the obstruction by a strong probe, blunt for- ceps, or other instrument, and the opening thus made must be dilated and kept open until healing occurs. FRACTURES OF THE NOSE. Fractures of the nose are usually caused by falls upon the sharp edge of a step or the corner of a table, blows from the fist, a baseball bat, or flying missile, or the kick of a horse. Symptomatology. — The injuries vary from a slight fracture to com- plete crushing of the nose with great displacement and more or less in- jury to the surface. There is usually much swelling and ecchymosis of the parts and frequently subcutaneous emphysema. Profuse bleeding is likely to occur at the time of the accident, and to recur from time to time on sneezing or blowing of the nose. The sense of smell is often lost at first, and sometimes it is permanently destroyed. Diagnosis. — In order to make an accurate examination, it is some- times only necessary to inspect the part with the aid of the speculum and rhinoscope; but if much contusion has occurred, complete anaes- thesia should be induced, to allow of careful manipulation, but even then crepitus is not often detected. Prognosis. — Great deformity may result if the injury be not prop- erly attended to at the time, and it must not be forgotten that a blow -8 o'J4 DISEASES OF THE NASAL CAVITIES. may have also caused fracture of the base of the skull and serious injury to the brain. Treatment. — With the patient under an anaesthetic, the fragments should be replaced, as nearly as possible in their normal position, by the finger and forceps; and if there has been much displacement, the part should be retained by plugging the nares lightly with antiseptic wool or by the introduction of plugs or tubes of gutta-percha or other sub- stances, or by a spring, as practised by Roe (New York Medical Record, July, 1891). At the same time a plaster of Paris dressing may be ap- plied with benefit externally. Sometimes it will be necessary first to reduce the swelling by cold applications, and wait from twenty-four to forty-eight hours before an attempt is made to replace the fragments; but it must be remembered that healing in this location takes place very rapidly, and it is desirable, therefore, to correct the deformity be- fore union has occurred. DISLOCATION OF THE NASAL BONES. Dislocation of the nasal bones is a rare accident, which in the few reported cases has resulted from a blow on the side of the nose by which the bones at the upper third of the organ have been laterally displaced. Reduction is accomplished by means of combined internal and external manipulation while the patient is fully anaesthetized. DEFLECTION OF THE NASAL SEPTUM. Uncomplicated deflection of the septum does not often exist, but, associated with thickening of the cartilage and bone or enchondroma and exostosis, it is one of the most common deformities of the nose. In- deed, Mackenzie found a deflection of from half a millimetre to nine millimetres in over seventy-six per cent of 2,152 crania examined in the museum of the Royal College of Surgeons (Diseases of the Throat and Nose). Delavan has found among European races well marked deflection in fifty per cent of several thousand crania examined (Trans- actions of the American Laryngological Association, 1887). Anatomical and Pathological Characteristics. — The cartilagi- nous or the bony septum, or both portions, are simply bent to one side, the cartilaginous portion usually being most involved. The deformity cause enlargement of one nasal chamber, at the expense of its fellow. Simple bending of the septum is uncommon, for in most instances of deflection there is also thickening, especially at the lower part of the convex surface. Etiology. — The causes of the affection are obscure. It was at one time thought to be often congenital, but Znckerkandl, as reported by Mackenzie and Delavan, states that it is never found before the seventh DEFLECTION OF THE NASAL SEPTUM. 595 year; this, however, is a mistake, for I have operated upon several cases in children under four years of age, and I observed it in a child less than eighteen months old. Delavan believes that it is generally due to injury, especially when situated anteriorly, and that otherwise it is due to hypernutrition, particularly when located posteriorly (op. cit.). Chas- saignac attributes it to hypernutrition (Bulletin de la Societe de clii- rurgie, 1851 to 1852, Tome II). My own observation is in accord with that of Delavan, excepting that I have found comparatively few cases that could be clearly traced to an injury; and the evidence in support of some of the older views, as suggested by Mackenzie, is, to say the least, insufficient. It is probable that not infrequently trauma is the starting-point, but undoubtedly chronic catarrhal congestion, by deter- mining an increased flow of blood to the part, gives rise to hyperplasia. Symptomatology. — When the deflection is great, the most promi- nent symptom is twisting of the nose to one side, usually opposite the convexity of the septum. This deformity is sometimes very marked from bending to the side of the anterior edge of the cartilage, even though there is but little deflection farther back. More or less difficulty in nasal respiration is experienced according to the amount of obstruc- tion. Interference with the free passage of air through the obstructed side causes the secretion to collect behind the convex portion and in the naso-pharynx, giving rise to postnasal catarrh. Pressure upon the external wall, especially when this is associated with exostosis, often in- duces atrophy of the turbinated body of that side, whereas the inferior turbinated body of the other side is usually hypertrophied ; and thus it frequently happens that patients find respiration easier through the cavity which upon inspection seems most obstructed. As further conse- quences of the obstruction, the voice acquires a nasal twang, and mouth- breathing becomes necessary, with all its attendant evils. Diagnosis. — There is no disease with which deflection of the septum is liable to be confounded if a careful rhinoscopic examination is made. Pkognosis. — Most of the evil results of the obstruction can be reme- died by a suitable operation, and the external deformity may be largely removed if the nasal bones have not been crushed so as to cause depres- sion of the bridge of the nose. Tkeatment. — The simplest treatment that has been recommended is for the patient to push the nose or the septum firmly over to the op- posite side several times daily ; but unfortunately this is seldom capable of accomplishing any good. In 1851 Chassaignac recommended a form of treatment especially applicable to deviations with thickening of the cartilaginous septum. This consisted in dissecting up the mucous membrane and paring off the superfluous tissue. It is not always easy of accomplishment, but in certain cases no better operation could be devised. Blanden first ad- vocated punching out a portion of the septum and establishing free con- 596 DISEASES .OF THE NASAL CAVITIES. nection between the two nares (Compendium de Chirurgie Pratique, Tome III), but tbis does not afford the desired relief and cannot be recommended. Walsham proposes forcible replacement of the bent septum (Nelaton: Pathologie Chirurgicale, seconde edition, Tome III), its resiliency having first been overcome by stellate incisions. This practice has been effectual in moderate deviations of the septum without thickening. Where the deviation is marked, the redundant tissue must be removed in order to obtain perfect results. In slight Fig. 318.— Ingals' Septum Forceps G*a size;. deviations most excellent results may be attained by making a crucial incision through the cartilage, the cut being made obliquely so that the bevelled edges will easily slide past each other. The septum is then forced into its normal position by forceps (Fig. 218), the vomer being fractured if necessary, and a gutta-percha plug of sufficient size is kept in the obstructed nostril until union has taken place. Where the stellate incisions are made either by knife or punch, the plug, or Adam's clamp, must be worn in a similar manner; the plug is simpler and quite as effective. In most instances it will be found necessary to remove the re- dundant tissue before a good result can be obtained. In cases where the cartilage is bent, almost at right angles, across the nostrils, I have found it most satisfactory (as I stated in Transactions American Laryngological Association, 1880) to dissect up the mu cous. membrane, remove a triangu- lar piece from the cartilage of sufficient size, incise the cartilage farther Fig. 219.— Ixgals' Septum Knife (2-5 size). back to destroy its resiliency, and then place a plug in the obstructed nos- tril to maintain the septum in position until union has taken place. When the obstruction is less complete, and there is simple deviation of the sep- tum, I have frequently operated by making three or four horizontal inci- sions through the cartilage from the front backward, the cut being made obliquely from above downward^ and outward; sometimes across these near the middle is made an oblique vertical incision; the whole is then pushed over and retained by a plug or tube of gutta-percha until union has occurred. The main objection to this, and to other operations in which no tissue is removed, is that certain parts remain thickened and ECCHONDROMA AND EA r 08T0SIS. 597 the resiliency of the cartilage is seldom perfectly destroyed; the plug then has to be worn for several weeks, and when removed, in many in- stances, the cartilage will again return so far toward its old position as to prevent a satisfactory result. During the past two years I have fre- quently operated on these cases by cutting through from the front backward, in three or four places, and as much as possible beneath the mucous membrane, with a small trephine about two and one-half millimetres in diameter (Fig. 202). The removal of these cores de- stroys the resiliency of the cartilage so that it may be readily carried back and retained in its proper position. Whatever operation is adopted it is undesirable to perforate the cartilaginous septum because of the subsequent tendency of the secretions to dry about the edges of the opening and form obstructive crusts which are a constant annoyance to the patient. Perforations of the bony septum give rise to little or no inconvenience, provided they are as far as an inch back of the nostril, in which position the edges are kept moistened by the secretions, and scabs do not collect. When deformity of the nose and obstruction to respiration result from protrusion to one side of the anterior edge of the triangular carti- Fig. 520.— Ingals 1 Right-Angle Cutting-Forceps Q/§ size). lage, the most satisfactory operation consists of incising the mucous membrane, over the edge of the cartilage, dissecting it back upon both surfaces, and then cutting off with a right-angle cutting-forceps (Fig. 220) all of the cartilage that projects beyond the normal plane of the septum into the obstructed nostril. This operation not only relieves obstructed respiration, but largely remedies the external deformity or twisting of the nose. In order to secure sufficient anesthesia for this operation with co- caine, it will be necessary to inject a few drops of a weak solution (Form. 140) under the integument on the outer surface of the cartilage; the mucous membrane on its posterior surface being anaesthetized in the usual manner. ECCHONDROMA AND EXOSTOSIS OF THE NASAL SEPTUM. Ecchondroma and exostosis of the nasal septum consist of thicken- ing of the cartilaginous and bony parts of the septum with a more or less prominent outgrowth or spur in most cases, and usually some deflection. They are present in nearly all cases of deflected septum, and the etiology and symptomatology are practically the same in both. The project- ing spur is usually directed from below upward and backward along DISEASES OF THE NASAL CAVITIES. the Hue of articulation between the vomer and the perpendicular plate of the ethmoid. This may be small, or so large as to impinge against outer wall of the nasal cavity. The spur is covered by mucous membrane, its anterior portion is cartilaginous, the posterior bony, ami the inferior part immedi- ately back of the cartilaginous septum is made up of bone of extreme hardness. These forma- tions, because larger and exerting more pressure against the outer wall, are more liable than simple deviations of the septum to excite neuralgic pain and various other nervous symptoms. They are frequently found in cases of hypertrophic rhinitis, Fig. 221. — Ecchondroma ] iav f PVer , as tlima, and persistent supra-orbital or and Exostosis of Right - . , x Side of Septum. Hypertro- Occipital neuralgia, phy of inferior turbinated Diagxosis.— The diagnosis is easilv made by body of left si. In. . ... , . ,. ,. , inspection of the nares and the application of a probe, which detects the difference in the density of simple thickening of the soft tissue, and that of bony or cartilaginous tissue. Prognosis. — The obstruction may be completely removed by suita- ble operation, and many of the symptoms will be relieved accordingly; but the surgeon should not be too confident of the result, for in a con- siderable number of cases, some of the symptoms will remain. Treatment. — The excessive tissue must be removed by operation, during which an effort should be made to save as much of the mucous membrane as possible. Before commencing the operation, the septum, both upon the affected side and upon the opposite side, and all other portions of the walls of the cavity liable to be touched during the operation should be thoroughly anaesthetized by cocaine. It will be found impossible to produce complete anaesthesia by applying cocaine to the sur- face near the nostrils, therefore when the operation is to extend far for- ward a few drops of the solution (Form. 140) should be injected beneath the mucous membrane where it joins the integument, Ecchondroma near the nostril may be removed by dissecting up the mucous membrane and paring away the cartilage with a knife, or cutting it with saws, trephines, or drills. Jarvis has devised a drill for cutting cartilage beneath the mucous membrane, but I have not seen its work. C. H. Wright, a den- tist of Chicago, had made for me a burr which cuts cartilage very well in adults, but it will not cut mucous membrane except under firm pres- sure, and unfortunately does not accomplish much on cartilage in chil- dren. This, or other drills or trephines (Fig. 202) I use with an electric motor. The burr may be made to penetrate the mucous membrane by firm pressure while it is in motion; and then, by moving it slowly about, the excess of cartilaginous or bony tissue may be cut away without injuring the mucous covering. Any of the debris which is not extruded during the drilling process is washed away with a two per cent solution of car- ECCHONDROMA AND EXOSTOSIS. 599 bolic acid, applied by a small syringe. Ordinary dental burrs will not cut cartilage. Trephines may be run directly through from the front Fig. 222.— Sajous 1 Knife (]4 size). backward, and with care most of the mucous membrane may be preserved, but more of it is destroyed than when a burr is employed. For re- Fig. 223. — Nasal Spud (}/ 2 size). moval of ecchondroma or exostosis situated farther back, I cut the mucous membrane along the lower edge of the spur with Sajous' knife Fig. 224. — Ingals' Nasal, Saw (J^size). (Fig. 222), and bring the incision, in a curved line, forward and upward to the anterior and upper portion of the mass to be removed. The Fig. 225. — Ingals' Flat Nasal Saw (2-5 size). mucous membrane is then lifted from the subjacent tissues by the back of the same instrument or a spud (Fig. 223) ; a saw is passed beneath Fig. 226.— Sajous' Nasal Saw Q4 size). Form used for downward cutting. Fig, 227 Sajous' Nasal Saw (^ size), Form used for upward cutting. the loosened flap at the upper part of the spur, and a cut made down- ward on the normal plane of the septum until it reaches nearly to the tJOO DISEASES OF THE NASAL CAVITIES. lower part of the nasal fossa; a narrow saw is then passed beneath the spur, and a cut made directly upward to meet the one from above. After the bone is cut through, it may be held by soft tissues, and these are cut by scissors (Fig. 200), to allow removal of the fragment. Sometimes stronger scissors, as shown (Fig. 228), will be needed. Subsequently with Fig. 228.— Ingals 1 Heavy-Bone Scissors (V^size). bone forceps (Fig. 229) any sharp spicule are cut off. In some instances I find it preferable to cut through the lower portion of the spur with a good-sized trephine. In others where the spur is not large, I use the trephine, only removing one or more cores as seems desirable. This latter operation is usually made without first having removed the mucous membrane, and the cut is made as much as possible beneath it. After Fig. 229.— Ingals' Nasal-Bone Forceps (% size). the bone is removed, the loose flap of mucous membrane, which may have been saved above, is pressed down smoothly against the septum. The patient then blows out the blood; the cavity is freely dusted with a powder of equal parts of iodoform and boric acid, and, while the flap is held in position with the nasal spatula (Fig. 230), the naris is packed, as recommended in the treatment of epistaxis, either with a Fig. 230.— Ingals' Nasal Spatcla (V2 size). Sets of three varying in width, angle of 45°. Made of steel. strip of haemostatic gauze or pledgets of lint. This tampon the patient is directed to remove at the end of sixteen to twenty-four hours, but sometimes it is allowed to remain two or three days provided there is no offensive odor or pain. Subsequently the wound is kept clean and as nearly antiseptic as possible, and the patient is directed to use two or three times a day a powder containing from twenty to fifty per cent of iodol. PERFORATION OF THE NASAL SEPTUM. 0U1 Healing usually takes place in from one to six weeks, according to the size of the wound produced, and it is often remarkable that after a few months, even when large spurs have been removed, the membrane over the wound appears normal with no cicatrix that can be seen. H. Holbrook Curtis prefers to remove these spurs with the trephine alone; Bosworth usually employs saws; others are in favor of dentrJ burrs. By using a trephine to cut the lower portion, where the bone is very hard, and a saw for the upper part of the incision when the spur is large, I am enabled to make the most complete and expeditious opera- tion. The main objection to operating with the trephine alone is that after making two or three cuts it will be found that sufficient tissue has not been removed, and the parts are so obscured by bleeding that it is difficult to complete the operation accurately; it therefore requires much more time than with the saw; in the mean time the effects of the cocaine are liable to pass away, and much pain will be caused. Perfora- tion of the cartilaginous septum should always be avoided, and an open- ing should not be made in the bony septum if sufficient room can be obtained without it; but often when there is a sharp deflection, together with the exostosis, it is impossible to free the nostril without opening through to the other side. There is, however, no serious objection to this, providing it is more than an inch back from the nostril, and the opening in such cases is certainly preferable to a cavity only one- third or one-half its normal size. Cartilage may be removed by electrolysis, preferably performed with both needles introduced into the tissue near each other. A current is used of from 5 to 15 M.A. , continued when the patient can bear it, for ten or fifteen minutes at each sitting. The operation is not repeated until the eschar is thrown off. James E. Newcomb, of New York {Medical Record, August 5, 1893), who has recently gone over this entire subject thoroughly, concludes that the method is worthy of a further trial, but that " whatever can be done by electrolysis can be, by other means, accomplished more quickly." In most instances cauteriza- tion of the inferior turbinated body of the opposite side will subsequently be found necessary, and sometimes it is desirable to remove during the operation a part of the inferior turbinated body of the same side. When the operation is finished, the cavity should be perfectly free and about one- third larger than normal, to allow for the partial closure which is sure to take place during cicatrization. PERFORATION OF THE NASAL SEPTUM. Perforation of the septum is often found as a result of syphilis, but it also not infrequently occurs, in persons of low vitality, as a result of constant picking at the nose; or it may happen during an exhausting disease, as typhoid fever, pneumonia, and phthisis. I have known quite 602 DISEASES OF THE NASAL CAVITIES. a large piece of the cartilaginous septum to be expelled, without warn- ing, in a person apparently in perfect health; and I have even seen such openings independent of any of the causes already mentioned, which have occurred without the patient's knowledge. Treatment. — The treatment consists in making suitable applica- tions to heal any ulceration which may be present. It is not worth while to try to close the opening, an attempt which even at best could give little benefit, and which would usually result in failure. HEMATOMA OF THE NASAL SEPTUM. Hematoma is a collection of blood in the septum indicated by the formation of a tumor usually at the lower anterior part, and projecting alike upon both sides; it results from an effusion of blood between the deep layer of the mucous membrane and the underlying cartilage. Etiology. — Bare cases of spontaneous hematoma have been ob- served, but it is usually due to fracture of the bony or cartilaginous septum by violent blows on the nose. Symptomatology. — The blood collects immediately or within a few hours after the causative accident, and causes a smooth, uniform tumor of purple color, which hue sometimes extends to a considerable portion of the mucous membrane of the nose. These tumors are situated just within the nostril, are soft and fluctuating, usually symmetrical upon both sides, and may be so large as to protrude from the nostrils. More commonly they cause simply an extremely thickened appearance of the cartilaginous septum. Diagnosis. — The tumors are liable to be mistaken for mucous polypi, hypertrophy of the turbinated body, ecchondroma, or abscess of the septum. The essential points in the diagnosis are the' symmetrical character of the swelling, the color, and the fluctuation. These tumors are distinguished from cartilaginous tumors by their softness and symmetrical appearance; from mucous polypi by their uni- form character, broad base, and color ; from extreme hypertrophy of the anterior end of the inferior turbinated body, by their location in the sep- tum, as demonstrated by the probe; from abscess by their color and by the result of exploratory puncture. Prognosis. — The enlargements sometimes exist for a long time, but usually, within a few days, they eventuate in abscess, the patient rarely recovering without a permanent aperture in the septum. Treatment.— Cold applications to reduce the swelling and inflam- mation should be made at first; if the blood does not become absorbed, as sometimes happens, within three or four days, it is apt to become purulent, and the swelling must then be opened upon one side at its most dependent part. Usually a single opening will drain both sides, but an incision on each side may be necessary. FOREIGN BODIES IN THE NOSE. 603 ABSCESSES OF THE NASAL SEPTUM. ' Abscesses of the nasal septum may be acute or chronic. They are found in the same position as the haematoma just described. They may result from the latter, or follow from simple inflammation of the parts. The symptoms, diagnosis, prognosis, and treatment are essen- tially the same as those of haematoma of the septum. FOREIGN BODIES IN THE NOSE. Foreign bodies of great variety have been found in the nose where they are most commonly placed by children in play. Beans, peas, buttons, or pebbles, are most common. Insane people frequently insert things into the nares. Occasionally some of the contents of the stomach are lodged in the nose during the act of vomiting. I have seen one in- stance where a child, during the act of deglutition, choked and coughed, thus lodging in the posterior naris a cervical vertebra of a chicken, which remained there several months. Symptomatology. — foreign bodies sometimes remain in the nose for a long time without exciting any symptoms. Substances which absorb moisture soon swell and obstruct the nostril, and beans, peas, and other seeds may germinate. Irregular bodies may excite acute and severe inflammation. Headache, often assuming a neuralgic form, is occasionally present at an early period. The most characteristic symptom is a more or less profuse discharge from one nostril, which becomes exceedingly offensive when the body is one which will take up moisture and decompose. Upon inspection, the nasal fossa usually appears filled with secretion, .but when this is wiped away the foreign body may be seen, or felt with the probe. Diagnosis. — The presence of a foreign body is to be distinguished from exostosis, rhinoliths, other causes of nasal obstruction, and from simple catarrh, by the history, which may oftentimes be obtained from the child or its playmates ; by the occurrence of the discharge from one side only, which does not occur in simple catarrhal inflammation of the nasal mucous membrane; by the offensive nature of the discharge in many instances; and by careful inspection or palpation with the probe. As an illustration of the difficulty which sometimes attends the diagnosis, I recall an instance in which a long match had been inserted into the nose and had been sought unsuccessfully by a phy- sician. The mucous membrane was so swollen and the naris so filled with secretion that the object was found only after carefully wiping this away, and feeling backward with the probe along the floor of the nasal fossa. Since the discovery of the properties of cocaine, it is much easier to make a diagnosis in these cases, for by the injection of a small 604 DISEASES OF THE NASAL CAVITIES. quantity of this drug the swelling is removed and the mucous membrane is benumbed so that a careful exploration can be made. A good light is always essential to a satisfactory examination. Foreign bodies are distinguished f rom polypi by their color, consist- ence, and mobility; from exostosis in the same way. Prognosis. — Small bodies may remain for a long time, even many years, without attracting attention. By the accretion of chalky de- posits they may become the nuclei of rhinoliths. They are not danger- ous, but in most instances sooner or later provoke an extremely offensive discharge. Treatment. — The nasal cavity should be anaesthetized with cocaine, and the substance removed with forceps, catheter, probe, hooks, screws, posterior nasal douche, or the snare; the latter I have found more use- Fig. 231. — Gross' 1 Instruments for Removing Foreign Bodies from the Nasal Cavities and Ears. ful than other instruments. The loop is easily passed by the sides of the foreign body, and when tightened upon it the object is firmly held so that it can be withdrawn. In one instance I extracted by this means a wild tooth from the floor of the naris which had caused a catarrhal discharge for several years. RHINOLITHS. Rhinoliths are cretaceous masses of comparatively rare occurrence which usually owe their origin to the lodgment in the naris of some foreign substance upon which phosphate of lime is gradually deposited from the secretions. They are generally hard on the surface, but softer toward the centre. Symptomatology. — The symptoms are similar to those described as due to the presence of foreign bodies, the most characteristic being ob- struction and a fetid discharge from one nostril. "When situated in the upper and anterior portion of the nasal fossa, they sometimes cause swelling of the face. The symptoms come on more slowly than those re- sulting from a foreign body; but as the calculus continually enlarges, the obstruction finally becomes greater. The calculus is usually single, but more than one may occasionally be found. It is generally of a grayish or blackish color, with a rough, and more or less uneven though sometimes smooth surface. Sometimes it becomes partially imbedded in the mucous membrane, which then is apt to ulcerate and bleed. The size of the calculus varies greatly. TV. X. Browne records a case (Edin- burgh Medical Journal, 1859) in which the stone measured one inch and three-quarters in length, one inch in breadth, and nearly half an inch in thickness. MYASI8 NARIUM. 605 Diagnosis. — A rhinolith may be confounded with osteoma or can- cer. It is distinguished from osteoma in that it is movable and can be penetrated by a sharp probe or needle. Owing to the fungoid, bleed- ing granulations which sometimes spring up from the edges of the mucous membrane, where ulceration has occurred, and also to the offen- sive discharge, it may be mistaken for cancer, from which it is dis- tinguished by its slow growth, the comparative absence of pain, and by inspection and palpation with the probe. Prognosis. — Ehinoliths may remain many years, causing much an- noyance, but they are not dangerous to life. Treatment. — Iihinoliths may usually be removed with joolypus forceps or the snare, or they may sometimes be crowded back into the naso-pharynx, when they will be expelled by the patient. If too large to be readily removed, they should be broken down with the nasal bone forceps (Fig. 229). MTASIS NARIUM. Synonym. — Maggots in the nose. Myasis narium is a condition very rare excepting in the tropics. It is characterized by destruction of the soft tissues and occasionally of the bone, with offensive discharge, formication, severe pain, insomnia, and sometimes convulsions. It has been frequently observed in British India, South America, and Mexico, but in those countries it is said not to be found in the cooler atmosphere of high altitudes. Very few cases have been recorded either in Europe or the United States. A case is recorded by D. N. Eankin (Transactions of the American Laryngological Association, 1883). Etiology. — Usually the worms owe their presence to the hatching of eggs deposited in or near the nostril by flies, which are attracted by the odor of an already existing discharge or foul breath. Symptomatology. — Soon after deposit of the eggs, the mucous mem- brane becomes irritable, tickling sensations, with attacks of sneezing, soon follow, and subsequently troublesome crawling sensations are experi- enced. There is a sanious or bloody discharge from the nostrils, and oedema of the face and eyelids may also appear; severe and sometimes ex- cessive, unceasing, pain is felt at the root of the nose and over the frontal region. In this affection the mucous membrane, and even the carti- lages and bones, may be destroyed, and the resulting inflammation may extend to the brain, causing convulsions and death. As many as two or three hundred maggots have been ejected from the nose in a single case. Upon inspection, the horrible condition may be readily detected. Diagnosis. — All the symptoms may be caused by other affections, therefore the diagnosis must depend upon finding maggots in the nasal cavity. Prognosis. — If neglected, a considerable proportion of cases will eventually prove fatal. 606 DISEASES OF THE NASAL CAVITIES. Treatment.— Chloroform has been found most efficient for destruc- tion of the parasites. In some instances inhalation only, of chloroform is sufficient to effect a cure. When this does not succeed, the patient should be fully anaesthetized, and the nasal cavities thoroughly syringed with pure chloroform. This does not seem to affect the mucous mem- brane deleteriously, but it would cause extreme pain if the patient were conscious. CHAPTER XXXYI. DISEASES OF THE NASO-PHARYNX. RHINO-PHARYNGITIS. Synonyms. — Post-nasal catarrh, retro-nasal catarrh, follicular disease of the naso-pharynx. Rhino-pharyngitis consists of chronic inflammation of the mucous membrane of the naso-pharynx, characterized by collection of viscid or drying secretion, and a tendency to hawk frequently and clear the throat, especially in the early morning or after eating. It is a very common and widespread affection, but seems especially prevalent in America, where it is found in all regions and among patients of differ- ing age, sex, and condition; it is less frequent in warm and equable cli- mates. Etiology. — Beverley Robinson justly attributes it largely to cold and damp atmosphere subject to sudden and great changes of tempera- ture, but believes that it is also due to a special diathesis which he terms catarrhal (Nasal Catarrh, 1880). Mackenzie believes it is mainly due to dust, and frequently to dyspepsia. I am satisfied that a cold, damp climate, and an excessive amount of irritating dust in the atmosphere, are the chief of its predisposing causes, and that disturbance of the digestive organs is a pronounced etiological factor in many instances; but I am equally satisfied that obstruction of the nares, as in hyper- trophic rhinitis, is the exciting cause in a large proportion of cases; while in certain others the affection is due to extension of inflammation from the nares or oro-pharynx. Hypertrophy of Luschka's tonsil or even of the faucial tonsils undoubtedly causes the disease in some cases; but the catarrhal symptoms caused by hypertrophy of Luschka's tonsil, or excessive adenoid growths in the naso-pharynx, should not be confounded with the result of simple inflammation. Tornwaldt contends that it is often due to catarrhal inflammation of the pharyngeal bursa (Ueber die Bedeutung der Bursa pharyngea, u. s. w., Wiesbaden, 1885); this is undoubtedly true of some cases, but not of a large percentage. Many cases are apparently caused by sub- mucous thickening at the sides of the posterior part of the vomer. I am unable to explain the direct relation of this thickening to the dis- charge and chronic inflammation, but I am satisfied of its etiological relation from the fact that its reduction will often greatly benefit, if not 608 DISEASES OF THE NASOPHARYNX. completely cure, the post-nasal catarrh. Tobacco-smoking is a com- paratively frequent cause, and the excessive use of alcoholic stimulants may produce congestion and inflammation of the mucous membrane here as in other localities. Symptomatology. — In slight cases the patient is merely troubled with a sensation as of something sticking in the naso-pharynx, but usually the secretion is tenacious or dry, and difficult to dislodge, and gives the patient great discomfort, causing him to hawk and make frequent efforts at its removal. Distinct articulation is fre- quently prevented, partially from obstruction of the naso-pharynx and partially from a mild form of chronic laryngitis which often coexists. These conditions are most annoying early in the morning or after eating, when the patient's efforts to dislodge the secretion may produce nausea or even vomiting. The symptoms are especially troublesome in damp or chilly weather, or after catching cold. Dull aching in the upper part of the throat, and sometimes weight and pain in the occipital region, are experienced by some of these patients, but the latter is apparently due to the rhinitis rather than to the pharyngitis. The sense of hearing is often obtunded, in consequence of extension of the inflammation through the Eustachian tube. Upon examining the pharynx, tenacious secretion will usually be observed coming down from the naso-pharynx, upon the vault of wdiich similar secretion or adherent crusts may be found. The mu- ous membrane is more or less congested and usually has a relaxed appearance, often exhibiting one or more enlarged follicles, especially just back of the posterior pillars of the fauces; indeed, in many in- stances this affection appears to be simply a chronic follicular inflam- mation of the upper part of the pharynx associated with a similar condi- tion in the oropharynx. The diseased follicles referred to appear as small, oval or round, reddish granulations, usually raised about two millimetres, and from four to eight millimetres in diameter. Small ero- sions or ecchymotic spots are sometimes seen, and in 3*oung subjects adenoid growths in the vault are frequently present. The Eustachian orifices are often congested and swollen and sometimes blocked with secretion. Varicose veins are often observed in the pharynx, and the pillars of the fauces are usually congested and thickened. In ad- vanced cases, atrophy occurs, with accompanying dryness and irritation of the parts. Whatever the condition, there is apt to be a similar affec- tion of the oro-pharynx. Diagnosis. — The disease may be confounded with adenoid growths or other tumors, or syphilitic disease of the parts. We can distinguish adenoid and other growths by inspection and palpation, and syphilitic disease by a consideration of the history, and by inspection, which is liable to reveal mucous patches, condylomata, ulcers, or cicatrices. Prognosis. — The disease may extend over a period of many years, RHINOPHARYNGITIS. 609 but is not dangerous to life, and, contrary to the popular belief, which is fostered among the laity by designing charlatans, there appears to be no tendency for it to extend downward and eventuate in pulmonary tuber- culosis. When the affection has lasted for many years it is doubtful whether it is often cured, but in the majority of cases removal of the nasal obstruction will greatly relieve, if not cure, the disease in the naso-pharynx. Tkeatmekt. — As a means of prophylaxis the patient should be pro- tected so far as possible from sudden changes of weather; he should avoid dampness and chills; summer and winter constantly wear woollen underclothes; keep the skin and digestive organs vigorous by the ob- servance of proper hygienic rules, and when exposed to an excessive amount of dust in the atmosphere, protect the nares and pharynx by wearing loose pledgets of wool in the nostrils, or by some form of respirator. The treatment of this disease resolves itself in the main into curing the nasal disease which has caused it. Constitutional treatment is indi- Fig. 232.— Post-nasal Syringe (2-5 size). cated for debility, and faulty digestion must be corrected by appropri- ate treatment, as has been so judiciously insisted upon by Beverley Eobinson (Transactions of the American Laryngological Association, Vol. X). In the direct treatment of the naso-pharynx, cleanliness is of first importance. This may be accomplished by means of the nasal douche, nasal insufflation, the post-nasal syringe (Fig. 232), or the free use of nasal or post-nasal atomizers. The salicylate wash (Form. 187) is an excellent detergent application; but any alkaline wash, as, for example, sodium bicarbonate or equal parts of sodium bicarbonate with sodium chloride 3 i. ad i. of water, or Dobell's solution may be used instead. It should always be borne in mind that with the nasal douche, and to a less extent even with the other methods of cleansing just recommended, there is some danger that fluid may pass through the Eustachian tube to the middle ear. This may generally be avoided by causing the patient to keep the mouth open, not to use too much force, and to be careful not to swallow while the application is being made. The solution should always be used lukewarm. The parts having been cleansed, Mackenzie specially recommends the insufflation of astringent powders. The old-time application of a solution of silver nitrate, varying in strength from ten to sixty grains to the ounce, will be found beneficial in many cases; and astringent or stimulating sprays, either aqueous or oleaginous, are often desirable. 39 €10 DISEASES OF THE NASOPHARYNX. When there are enlarged follicles without great congestion, and where the parts remain moist, I have seen great benefit from the insufflation, two or three times per week, of two or three grains of a powder con- sisting of berberine muriate one part and sugar of milk or acacia two parts. For excessive secretion, either here or in the nares, I have found terebene beneficial in the proportion of about ten minims to the ounce of liquid albolene, combined or not with other substances as seems de- sirable. If the parts have a tendency to dryness, after they have been thoroughly cleansed the application of an oily spray containing from two to six grains of carbolic acid to the ounce may be made by the patient twice daily back of the palate, or in case he cannot do this a weaker spray may be thrown through the nose while the head is held backward so that it will run gradually down over the pharyngeal wall. Indeed, the same remedies are applicable here as to the nasal cavities, it being remembered that the naso-pharynx will tolerate advantageously applications from fifty per cent to one hundred per cent stronger than the nasal cavities. THROAT DEAFNESS. Morbid changes in the naso-pharynx, particularly when near the orifice of the Eustachian tube, frequently involve the latter and extend to the middle ear, affecting more or less the sense of hearing. Probably most cases of deafness are of this nature. Etiology. — The disease may depend upon a paretic condition of the Eustachian tube, or chronic inflammatory thickening of its lining mem- brane, or any morbid state of the naso-pharynx which gives rise to ob- struction of the Eustachian orifice. Edward Woakes considers this, or motor paralysis, the fundamental cause (Diseases of the Nose). He also attributes the deafness to exaggerated folds of mucous membrane at the orifice of the Eustachian tube, and to folds projecting from the sides of the pharynx, and to partial obstruction of the nasal cavity by exostosis, or hypertrophy of the turbinated bodies; whereby during inspiration, but especially deglutition, the air is rarefied in the tym- panic cavity, producing depression of the drumhead. Persistence of this condition eventuates in permanent collapse of the membrane and resulting deafness. One of the most frequent .causes of throat deafness is enlargement of Luschka's tonsil. Atrophic rhinitis is also a cause; the affection has also been attributed to syphilis, diphtheria, rheuma- tism, progressive muscular atrophy, chlorosis, and extreme anaemia. ' Symptomatology. — According to Weber-Liel, the chief feature of the complaint is paralysis of the tensor palati muscle (Mackenzie: Diseases of the Throat and Nose, Vol. II). In severe cases there is col- lapse of the Eustachian tube, the air in the tympanic cavity becomes rarefied and the tympanic membrane yielding to the pressure of the THROAT DEAFNESS. 611 denser air on its external surface becomes abnormally concave (drawn in) and as this movement of the drumhead is necessarily transmitted to the chain of ossicles, the foot-plate of the stapes is abnormally pressed into tHe oval fenestra. Secondary changes soon follow, passive conges- tion of the tympanic cavity leads to trophic changes of a more or less cirrhotic character, consisting at first in the growth of a low form of con- nective tissue, with subsequent atrophy. Adhesion takes place, the stapes becomes fixed in the fenestra ovalis, and the labyrinth becomes the seat of disease. The patient often complains of tickling or scratch- ing sensations in the throat; of snapping sounds heard during mastica- -rion or deglutition; of fatigue in listening, and difficulty in hearing during general conversation, though he may readily understand one person talking alone; and often of noises in the head and giddiness. Diagnosis. — In the mildest form, according to E. C. Hotz, pro- fessor of ophthalmology, Chicago Polyclinic, the tympanic membrane is of normal color and brightness, but abnormally concave (personal letter from F. G. Hotz, July, 1891). In the medium variety, attended by acute inflammation of the middle ear, the membrane is congested ac- cording to the degree of inflammation, and the injection may be limited to a small streak along the malleus or may occupy the upper flaccid portion only, or it may spread over the whole membrane. The Eusta- chian tube is obstructed, and the tympanic cavity contains more or less secretion, the presence of which is indicated by characteristic rales heard through the auscultating tube while insufflation is made through the Eustachian catheter. In the most serious variety, the drum mem- brane may be bright and clear or dull and opaque, its movements may be impeded indicating sclerosis or anchylosis, or they may be excessive, indicating atrophy, and the Eustachian tubes may be either closed or unusually patent. The drum cavity may be either dry and empty or it may contain inspissated mucus, and we must distinguish by the tuning- fork test whether the deafness is due to changes in the middle ear or to lesions of the internal ear. If the patient hears the sounding-fork bet- ter when placed near the external ear than when touched to his fore- head or held between the teeth, we must assume that the internal ear is involved; but if the fork is heard better against the forehead or between the teeth, we conclude that the chief cause of deafness is located in the middle ear. Prognosis. — In the mild variety the prognosis is favorable provided the congestion and swelling of the pharynx and Eustachian tube can be removed by occasional insufflation. In the second variety, also, the prog- nosis is good if proper treatment is adopted early; but if neglected, per- manent damage to the structure and sense of hearing is likely to ensue. In the most severe or chronic form, the chances for cure or even relief are poor, especially when the tuning-fork test shows that the internal ear is affected : but even in these cases the prognosis is somewhat more 012 DISEASES OF THE NASO-PHARYNX. favorable if there are rales, indicating the presence of mucus in the tympanic cavity, or if, as sometimes happens, there is marked and fre- quent variation in the hearing power. In the majority of cases no im- provement can be expected, and we are fortunate if by treatment we can check the onward progress of the disease and save the patient from ab- solute deafness. Treatment. — Our first effort should be directed to removing the cause of the disease. Obstruction of the naso-pharynx, or of the nares by the various forms of inflammation or exostosis or tumors, should be removed and the inflammation subdued by the methods already sug- gested. For the chronic thickening and congestion of the rhino- pharynx, with extension to the Eustachian tubes, the frequent applica- tion of strong solutions of silver nitrate, varying in strength from forty to one hundred and twenty grains to the ounce, have been most highly recommended, and the various alteratives, astringents, and stimulants already recommended may be tried. In a considerable number of cases Fig. 233.— CCR"!'^ Vaporizer. For inflation of the Eustachian tubes and middle ear. The bottle should be held in the hand with the thumb alongside the glass bulb. When applied to the nostrils, the thumb completely covers one and the glass bulb snugly fits the other orifice. The right hand grasps the rubber ball, and simultaneously with the rapid enunciation of the letter K or the guttural G, a number of pressures upon the bulb will inflate the middle ear without the trouble of taking a swallow of water. This method of treatment of the Eustachian tubes by the vapor of iodine, ether, chloroform, etc., dropped upon the sponge of the vaporizer, is reported to be very efficacious by H. Holbrook Curtis. By removing the sponge, the instrument may be used as a powder blower. I have obtained much benefit from spraying into the naso-pharynx and 'Eustachian tubes, while the nostrils are held, a solution of two to five grains of menthol to the ounce of liquid albolene. This may be readily done by the Davidson atomizer No. GG with the long tip (Fig. 106), and there is no danger in using fifteen to twenty pounds pressure, for the palate will yield before injury will be done to the drum membrane. As stated by Hotz, in addition to the treatment of the pharynx, in mild cases, when the chief trouble is the insufficient ventilation of the tym- panic cavity on account of the catarrhal swelling in the Eustachian tube, it is only necessary every two or three days to supply the drum cavity with fresh air by means of Politzer's method. But when the tympanic cavity itself is the seat of catarrhal changes the use of the Eustachian catheter is indispensable for the efficient introduction of suitable reme- HYPERTROPHY OF THE PHARYNGEAL TONSIL. 613 dies. When the auscultating tube reveals the presence of mucus in the Eustachian tube and tympanic chamber, warm solutions of boric acid (gr. x. ad 3 i.) are very serviceable. Two or three drops of this are put into the catheter and blown into the cavity by means of the air-bag. In the atrophic forms of otitis media, stimulating vapors are recommended, as of ammonium muriate, eucalyptol, or benzol In cases of severer grade with acute inflammation, he specially recommends hot solutions of cocaine four per cent, frequently dropped into the external meatus, and warm compresses covering the ear and mastoid region, together with careful insufflations through the Eus- tachian catheter to ventilate the drum chamber and clear it of accumu- lated mucous secretions, and at the same time spraying this cavity through the catheter with solutions of boric acid, eucalyptus, or other suitable remedies. In this variety, rapid and copious secretion into the cavity is liable to take place, indicated by intense pain and bulging of the membrane, for which paracentesis should be done at once. In the severer forms of the disease the local applications recommended may be tried, but not much can be accomplished. Mackenzie recommends constitutional treatment by the use of iron, strychnine, and phos- phorus, and suggests that in the later stages nothing remains but the doubtful operation of paracentesis of the tympanum or tenotomy of the tensor tympani (Diseases of the Throat, Vol. II). These cases are most unpromising, and it is only by carefully adapt- ing the treatment to the requirements and the peculiarities of each individual patient that we can hope to jnevent even absolute deafness. The details of treatment are more properly set forth in works on diseases of the ear, and the treatment itself should be carried out by an experi- enced aurist. HYPERTROPHY OF THE PHARYNGEAL TONSIL. Synonyms. — Hypertrophy of Luschka's' tonsil, adenoid growths in the vault of the pharynx. An abnormal enlargement of the glandular tissue normally found in the vault and walls of the pharynx, is characterized by obstruction of nasal respiration, alterations in the voice, and in many cases partial deafness, with catarrhal symptoms and more or less deterioration of the general health. It is particularly observed in damp climates. It com- monly occurs in 'children, but is not infrequently observed in young adults. Anatomical and Pathological Characteristics. — The changes in the glandular tissue closely resemble those which are frequently wit- nessed in the faucial tonsil. The gland is of a grayish or pinkish color, though sometimes even of a bright red hue, and the surface often has a lobulated appearance. Enlarged blood vessels are not present upon the surface, as in many other forms of abnormal growth. The tissue 614 DISEASES OF THE NA80-PHARYNX. may be soft and friable (Fig. 234) or exceeding]}' firm. It consists of lymphoid structure and increased connective tissue similar to that found in hypertrophy of the faucial tonsil. The effect upon respiration and the general health depends upon the size and the amount of ob- struction. ETIOLOGY. — Heredity evidently bears some part in the etiology of the affection, although statistics have not yet proven the point; fre- quently several children in the same family will be found affected. It appears to be due in most - to the same causes as enlargement of the faucial tonsil. The exanthematous diseases and diphtheria are common causes, and frequent colds, as well as the strumous and rheumatic diatheses, appear to be predisposing factors. McDonald ( Diseases of the Xose, 1890) attributes the majority of cases to obstruction of the nasal fig. 3W.-RHINO8C0PIC view passages, and consequent rarefaction of the air of veoetati .xs in the vault in the naso-pharynx during respiration. This of the pharynx (Cohen). theory, however, would seem to be opposed to the fact that nearly all cases of cleft palate are also affected by the dis- ease; it certainly does not correspond with my own observations, al- though it is true that in many cases anterior nasal stenosis does exist. Symptomatology. — There is usually a history of mouth-breathing, which has lasted for several months or years, with all its attendant svmptoms. During this time the parents have been continually dis- turbed at night by the loud snoring of the patient. The child is usually very restless, and often wakens from troubled dreams during the early part of the night, but later sinks into a heavy sleep, from which it wakens in the morning with headache or a feeling of malaise that does not wear off for several hours. Spasmodic croup is sometimes apparently caused by this condition. Xasal or post-nasal catarrh and partial deaf- ness are not infrequently present, and it is common to find that these have come on after diphtheria or one of the exanthematous diseases. The deafness appears to be due to obstruction of the Eustachian tube by the hypertrophied gland, and in some cases to gradual extension of inflammation to the middle ear. Acute earaches are frequently caused by this affection. The deafness is sometimes outgrown as the gland atrophies during advancing life, and it may often be cured by removal of the abnormal tissue, but if allowed to persist for a few years it is likely to become permanent. The voice is thick and indistinct in proportion to the interference with nasal resonance, and it becomes impossible for the patient to sound the letters m or n, especially when occurring before a vowel, I and d being sounded instead. In such cases the voice sounds as though the patient had a cold in the head. Wroblewski of Warsaw {Internationale Klinische Rundschau, Vienna, Annual of the Universal Medical Sciences, HYPERTROPHY OF THE PHARYNGEAL TONSIL. 615 1892) found adenoid growths in over fifty-seven per cent of one hundred and sixty deaf and dumb patients. Shortness of breath upon exertion is often noticed, and where children are trained to keep the mouth closed we may frequently observe catching or sighing respiration at intervals, an effort to compensate for the constant deficiency of air ; and it is often necessary for these patients to clear out the mucus from the naso-pharynx by the act of hawking. A barking, reflex cough is some- times present, and occasionally a spasmodic affection simulating whoop- ing-cough. Often a peculiarly disagreeable nasal screatus becomes a fixed habit. Occasionally, though not in the majority of cases, rhinor- rhcea is present. The mucous membrane of the nostrils and anterior nasal cavi- ties is found abnormally swollen in some cases, and in the majority the faucial tonsils are also enlarged. The uvula, pillars of the fauces, and edge of the palate are generally slightly congested, and frothy or muco-purulent secretion is found upon the pharyngeal wall dropping down from the naso-pharynx. In many cases the pharynx is relaxed and the follicles are swollen, as in advanced cases of follicular pharyn- gitis. The follicles, which are liable to be paler than the surrounding mucous membrane, usually increase in size toward the upper part of the pharynx, until just above the edge of the palate they become con- tinuous with the glandular enlargement. In posterior rhinoscopic ex- amination we should observe especially the posterior pharyngeal wall, the vault of the pharynx, and the choanse. Irregularity of the upper outlines of the latter are among the most easily recognized signs of the disease. Upon the pharynx the growth has a cushion-like appearance, more or less nodular upon its surface, but in rare instances it hangs from the vault in soft, pendulous masses resembling condylomatous warts. In color it is usually pale pink or grayish, though it may have any shade from this to a deep red. Its surface is not traversed by blood vessels. In adults, where atrophy has taken place, the remains of the gland may sometimes be seen as small excrescences. Palpation is often desirable in adults to determine the consistency of the growth, and it is frequently essential in children because of the difficulty of rhinoscopic examination. In performing it, a gag having been placed between the teeth, the fore- finger of the right hand should be carried back to the pharyngeal wall and then turned upward behind the palate, where it at once detects the abnormal growth. Those unfamiliar with the normal feeling of the part should at first search for the septum and carry the examination from this backward and upward along both sides. Slight bleeding usually follows, though the examination is not specially painful to the patient. Chronic pharyngitis, rhinitis, or laryngitis will be found present in some cases, and occasionally deformity of the thorax will have resulted, as shown in the pyriform chest or pigeon-breast already referred to in speaking of hypertrophy of the tonsils. 616 * DISEASES OF THE NASO-PHARYNX. Diagnosis. — The affection is to be distinguished from nasal mucous polypi and fibroid tumors by inspection and palpation. We seldom find mucous polypi at so early an age as hypertrophy of the pharyngeal tonsil; they are of a lighter color, semi-translucent, and usually have coursing across their surface blood vessels, which are not seen in this disease. They usually spring from the nasal cavities and may be readily detected by anterior rhinoscopy. We find fibroid tumors much harder than the hypertrophied glandular tissue; they are frequently attended by severe epistaxis, and, upon being touched, bleed easily and profusely. They are usually of a bright red color with blood vessels apparent upon the surface. When large, they cause distortion of the neighboring parts. None of these signs are ob- served in hypertrophy of the pharyngeal tonsil. Prognosis. — Probably in seventy-five per cent of the cases the gland, if left to itself, would atrophy at about the twelfth or fourteenth year of the patient's age; but in the mean time irreparable mischief to the ear, the voice, or the general health may result. In the re- maining cases the gland gradually diminishes in size, and disappears before middle life. When the affection has existed for a long time, the hearing may be permanently impaired, but usually removal of the gland greatly benefits this condition. The voice is not always perfectly re- stored, because a person having learned to talk with an obstruction in the naso-pharynx may require a considerable time to overcome the mus- cular habit, and in adults it may never be entirely remedied. The results of operative procedure, if not too long delayed, are most satis- factory. Treatment. — Internally, particularly for anaemic children, I have occasionally found the syrup of iodide of iron of value. Sometimes other preparations of the iodides will prove beneficial and probably calcium chloride might cause some reduction of the gland in some in- stances. As a rule, however, medicinal treatment is of little value. Locally, astringents have been recommended, and seem to be useful in a few cases. The most satisfactory results follow removal of the gland by surgical measures, and there are no contra-indications to operating even on young children. In a few patients where friends have objected to an operation I have employed chromic acid successfully. In using this caustic I fuse a few crystals on the end of a flat aluminium probe and pass this through the nostril to the enlarged pharyngeal tonsil, where it is held for two or three seconds. Previously the nares may be oiled to prevent the possible contact of any of the acid with its mucous membrane, and a small amount of cocaine may have been applied to the nares and naso-pharynx by means of powder or spray. The acid applied in this way usually causes a moderate amount of pain at the time, and some soreness for several hours afterward, but it is not severe. The applications may be repeated HYPERTROPHY OF THE PHARYNGEAL TONSIL. 617 once in from three to five days, being made through the opposite nostrils alternately. The galvano-cautery may be used to destroy the growth, a bent electrode being passed up behind the palate, but the method is painful, tedious, and altogether not very satisfactory. Scraping off the gland by means of a long finger-nail or various forms of curettes is in favor with some operators and may in certain cases answer an excellent purpose; but usually the operation is less complete than when performed by Loewenberg's forceps, and therefore recurrence is more likely to take place. Ecrasement by means of a bent snare is practised satisfactorily in some cases where the growth is very soft. Some operators prefer scissors or punch-like forceps, but they are both open to some objections. The scissors -like instruments which I have seen may be satisfactory for cutting out a portion of the mass, when it is soft, but they are not well adapted to a complete extirpation of the growth, so that other instruments must generally be used to make a complete operation. The punch-like forceps are not open to the same objection, but it is asserted that unnecessary bleeding results from their use. By far the most satisfactory instrument to me for extirpation of the gland is Loewenberg's forceps, or some one of its modifications, espe- cially that suggested by. John N. Mackenzie. I have had a similar in- strument made with shorter blades, for operating upon young children. In performing the operation upon adults, it is often sufficient to an- aesthetize the parts by cocaine, which may be applied by spray, syringe, or swab, or by the hypodermic syringe with a bent needle, by which it may be injected directly into the gland. My own custom has been to apply a ten per cent solution by spray behind the palate, and a similar solution by means of a syringe with a long blunt nozzle, to the upper part of the gland through the nares. The application should be re- peated about once a minute until the part is fairly anaesthetized, which Fig. 235. — Mackenzie's Modification of Loewenberg's Forceps. will take about ten minutes. A self-retaining palate retractor should then be adjusted and the patient may hold the tongue with a depressor. The forceps are then inserted with the aid of the rhinoscopic mirror, and thus one or two bites may be made accurately, but subsequently the blood obstructs the view and the remainder of the operation may be postponed to another sitting or completed by the sense of touch if the patient will permit. Usually, even with cocaine, after two or three 618 DISEASES OF THE NA80-PHARYNJT. bites have been made, patients prefer to have the remainder of the op- eration done at another time. Two or three sittings, however, will be sufficient in the majority of these eases. When an anaesthetic is objected to, or if for any reason a complete operation will not be permitted, a single, large excision may be recommended when the gland is soft. This, in the case of either children or adults, will generally give much relief. In children chloroform or ether should lie administered, chloro- form being preferable. When anaesthesia is complete, the child should be turned upon its abdomen and face, the month coming over the side of the table. A gag should then be inserted to hold the teeth apart. Henrotin's gag is the simplest one that I have seen for this purpose, but sometimes Alliugham's will be fouud preferable, especiallj' for large children (Fig. 113). The surgeon standing at the right side of the table, facing the patient's head, passes the index linger of his left hand behind the palate into the naso-pharynx, where it is retained as a guide for the forceps. The forceps may then be passed along the dorsal aspect of the finger and applied accurately to the growth. Thus piece by piece the gland is extracted, the forceps being guided each time by the finger until every part has been extirpated. Care should be taken to avoid seizing the posterior edge of the vomer or the projecting end of the Eusta- chian tubes. The latter often feel to the uneducated finger like ab- normal growths. If care is taken not to turn the forceps sideways, there is but little danger of doing damage, providing the operator is familiar with the normal condition of the parts. Sometimes masses, located just back of the Eustachian orifice, are liable to be overlooked, but the most common difficulty arises from small pendent masses which hang just back of the choanee aud are liable to be crowded for- ward by the finger into the posterior nares. It is sometimes quite diffi- cult to get the finger in front of this mass and push it back where it may be caught with the forceps. Some operators attempt to scrape this portion of the growth away with the finger-nail, but this effort can only be partially successful. When I find difficulty in removing this part with the post-nasal forceps, I employ a straight nasal forceps with cutting edge (Fig. 229), which I pass through the nostril, and guide to the proper point in the vault of the pharynx with my finger still retained behind the palate. In this manner a piece which might otherwise be difficult to catch is very readily removed. This procedure also enables us to determine whether the nasal fossa? are free, or if they are not to break down any adhesions or slight bony obstruction. With the patient in the position just recommended, there is no necessity for care in swabbing out the throat, as the blood cannot run up the trachea. With the patient on his back ami the head thrown far backward, as recommended by some English surgeons, it is necessary to swab out the throat and HYPERTROPHY OF THE PHARYNGEAL TONSIL. 619 naso-pharynx frequently to prevent blood from getting into the air pas- sages. There is usually considerable bleeding, but this stops as soon as the operation is completed. If undue hemorrhage should occur, the vault of the pharynx may be packed in the usual way or, as I prefer, with a long strip of gauze which is passed through the nares. This strip is saturated with a thick solution of tannic and gallic acids, as recom- mended for checking hemorrhage from the nares. This should be pushed back through the nares, and packed up behind the palate with the finger, which is inserted through the mouth. The nares should also be packed, and the gauze brought forward to the nostril to prevent the packing from falling into the throat. This packing should be removed within from twelve to twenty-four hours, to avoid the danger of exciting inflammation of the middle ear. When the operation is completed, the mouth should be wiped out and the nostrils squeezed to press out what blood is possible, but it is neither necessary nor desirable to wash out the parts. The patient should then be placed in bed, and it is well for the nurse to keep him as much as possible upon the face till he has thoroughly recovered from the chloroform. This latter suggestion, however, is not very important, and it is seldom followed. The patient should be kept in bed for a few hours, and in the house for from two days to a week according to the weather. During this time I usually have insufflations made through the nostrils two or three times during the day, of a powder of two per cent of cocaine, fifty per cent of iodol, and sufficient sugar of milk to make one hundred parts. A simple detergent alkaline spray is not objectionable, but washes should be avoided for fear of injury to the middle ear; even sprays will sometimes find their way up the Eustachian tube, and there- fore, unless by the odor there seems to be a special indication for them, I prefer to use the powder in connection with an antiseptic oily spray containing thymol gr. -|-, oleum caryophylli TTliij., toliquid albolene 3 i. As a result of the operation there is usually a little soreness of the parts for a day or two, but not sufficient to interfere with swal- lowing. There is sometimes slight elevation of temperature; the im- provement in breathing is marked and immediate in many cases; very often the friends become alarmed during the first night because the child breathes so quietly. Where partial deafness exists, consider- able improvement may be expected within a few days or weeks, but recovery from alterations of the voice is sometimes less rapid. Some danger of otitis media exists from the liability of blood or other fluids passing into the Eustachian tube, but thus far no permanently bad results have been observed from it. In case it should occur, the con- tinuous use of hot water in the ear, or hot water with glycerin and opium and dry heat externally, are the best remedies that can be employed. In some cases nasal obstruction will be found to exist after the opera- 620 DISEASED OF THE N4S0-PHABTNX. tion, and it must receive appropriate treatment subsequently. The final results of removing the hypertrophied pharyngeal tonsil are the most satisfactory of any with which I am acquainted in the domain of special surgery. The operation should not be recommended unless the dis- eased gland is large enough to interfere with nasal respiration, at least when the patient has a cold, or unless it affects the sense of hearing by pressure on the orifice of the Eustachian tube. In cases suitable for the operation, the patient's general condition undergoes a revolution for the better, which often astonishes even the physician, and gives the friends most unbounded satisfaction. In a child of from three to six years of age it is not unusual for a gain in weight of from twenty to twenty-five per cent to occur within five or six months after the gland has been removed. I have never seen any ill results follow the opera- tion, and I think it safe to tell the friends that when properly done it is no more dangerous than the removal of a finger. RETRO NASAL FIBROUS TUMORS. Fibrous tumors of the naso-pharynx are characterized by obstruc- tion of the nose and dyspnoea, frequent epistaxis, and, when large, by great disfigurement known as frog face. They usually occur in young adults, sometimes in infants, but seldom after the twenty-fifth year of age, and they are much more common in men than in women. The affection is so rare that in over five thousand records of private patients suffering from disease of the throat and nose Tfind but six cases. AXATOMICAL AND PATHOLOGICAL CHARACTERISTICS. — The growths are generally smooth, hard, and unyielding, red or purplish in color, and sometimes ulcerated or bathed in a sanious secretion. They may spring from the periosteum of any portion of the roof or lateral walls of the naso-pharyngeal cavity, but they usually originate from the basilar process of the occipital bone and the body of the sphenoid, or from the upper cervical vertebrae. In character they are like fibromata in other localities, but occasionally are composed quite largely of erectile tissue. They are exceedingly dense, destitute of elastic fibres, and the blood vessels in their interior are small, while those in the investing membrane are larger, and have brittle walls which render them pecul- iarly liable to bleed. The tumor is usually single and attached by a broad pedicle. Etiology. — The etiology is unknown. Symptomatolqgy. — The patient first experiences a sense of obstruc- tion in the naso-pharynx, and finally one or both nasal passages become occluded. Many complain much of fatigue and drowsiness, probably due to imperfect aeration of the blood. Later, the symptoms depend upon the direction which the tumor may take in its development. If it extends toward the throat, it interferes with deglutition ; by pressure RETRO-NASAL FIBROUS TUMORS. 621 upon the Eustachian tube, it may excite inflammation of the middle ear, with more or less pain and deafness. When it projects forward, the nasal bones may be separated, the eyes pushed apart, and the bridge of the nose flattened, giving the characteristic deformity already mentioned as frog face. Pressure upon the lachrymal ducts causes epiphora. Sometimes the tumor extends into the antrum of Highmore and gives rise to swelling of the cheek. It may perforate and fill the sphenoid cells, and sometimes, as in one instance I have seen, it may cause absorption of the base of the skull, pressure upon the brain, and fatal meningitis. The filling up of the naso-pharynx interferes with articu- lation, giving a nasal twang to the voice, and, if the tumor is large and extends downward, great dyspnoea may occur. There is usually profuse purulent or muco-purulent secretion, sometimes offensive in character; and epistaxis, frequent and sometimes dangerous, is a common symptom. Dysphagia may be present. By inspection of the anterior and posterior nares, and palpation with the finger, the characteristics already pointed out may be readily detected. Diagnosis. — The growths are liable to be mistaken for mucous or fibroy-mucous polypi and sarcomata. From the latter they can only be distinguished by a microscopic examination. The essential points in the diagnosis are the age, sex, smoothness and density of the growth, and frequent epistaxis. They are distinguished from mucous polypi by their color, density, and tendency to bleed. Fibromata are distinguished from fihro-mucous polypi or tumors, the latter being less dense, having less tendency to bleed, und by microscopic examination. We might pos- sibly mistake hypertrophy of Lusclilca' 1 s tonsil for fibromata, from which it will be differentiated by the age of the patient, its slower growth, lack of tendency to bleed, and by its having a lighter color, more irreg- ular surface, and less density. Adenoid vegetations in the vault of the pharynx bleed easily, are soft, irregular, and occur at an earlier age than fibrous tumors. Prognosis. — The growths tend steadily to increase in size, and, unless recognized and removed, will prove fatal in most cases, in the course of four or five years. Even when removed, there yet remains a strong tendency to recurrence, but fortunately, if they can be kept in check until the patient has attained the age of twenty-five, there is a tendency to sjDontaneous arrest of development. Treatment. — If possible, the tumor should be removed through the natural passages by the ecraseur, galvano-cautery, or by electrolysis. When large, it may be necessary to adopt the more severe measures recommended by Dupuytren, Eouge, Eangenbeck, Chassaignac, Oilier, Lawrence, Palasciano, or Eampolla, which consist of various operations for exposure and removal of the tumor through the face that are fully described in the textbooks on surgery. I have never seen cases in which these methods were necessary, and the experience of Lincoln 622 DISEASES OF THE NASOPHARYNX. (Transactions of the American Laryngological Association, 1883), as well as my own experience in two cases, show that even large tumors may be extirpated through the nares and naso-pharynx with even better results than are obtained by external operations. The sim- plest operation, and one which is sometimes attended by success, consists of electrolysis, which is performed by passing one or more needles connected with the negative pole into the tumor from behind the palate or through the nares, a single needle connected with the positive pole being introduced in a similar manner. A continuous current as strong as the patient can tolerate should be used, and the operation continued ten or fifteen minutes, and repeated about once a week or less frequently according to circumstances, until the growth has been dissipated. Ligatures have been employed for the removal of these growths, but they are less satisfactory than the ecraseur or galvano-cautery. In all cases when ligation is practised, a thread should be passed through the neoplasm and brought out at the mouth so that upon separation the mass may be removed before it falls deep into the throat and causes strangulation. « When a strong ecraseur of sufficient power can be passed about the tumor, it may be readily and safely removed by this instrument, but the chances of recurrence are greater than if the galvano-cautery snare is used. Evulsion by strong forceps has been practised in some cases, but this method is not generally applicable. The tumor may be cut away with a curved, blunt-pointed bistoury, curved scissors, or strong cutting-forceps; or it may be removed by the gouge. Any of these methods are applicable in some instances, but they are apt to be at- tended by profuse hemorrhage, and if much force is used the resulting inflammation may prove fatal by extension to the brain, as in two of Ollier's cases (Spillmann: Dictioimaire Encyclopedic des Sciences medi- cates, fig., seconde serie, Tome XIII). When the tumor is jDedunculated, it may sometimes be secured in the loop of an ecraseur, but more easily in a loop of steel wire used with the ordinary snare; usually the tissue is so firm that it cannot be cut with the cold-wire snare in common use. The Xo. 5 piano wire used for mucous polypi is liable to break, and wire of larger size cuts the tissue much less easily, so that it cannot be drawn through the pedicle excepting with a stronger and much more powerful instrument. The galvano-cautery snare (Fig. 207) is the best instrument for the removal of these tumors whenever they are sufficiently pedun- culated to allow of its employment. In performing the operation, I pass two soft catheters through the naris, endeavoring to carry one on either side of the growth, and bring them out of the mouth. Into the ends that are brought out of the mouth the ends of a piece of platinum wire about three feet in length are introduced and pushed on until they RETRO-NASAL FIBROUS TUMORS. 623 come out of the nostril. I attach a thread to the wire loop to enable me to draw it backward in case of failure on the first attempt to place it about the tumor. The catheters with the wires protruding from the nostril are now drawn upon and the loop, passing back into the mouth, is carried with the finger or with the aid of a post-nasal snare-appli- cator (Fig. 236) up about the tumor, where it is drawn firmly into place. The catheters are then withdrawn, and the wires intrusted to an assistant, who holds them carefully, to prevent their becoming crossed in the naris. The ends of the wire are then slipped through the tubes of the galvano-cautery ecraseur and fastened to the ratchet on the handle. It is desirable to have the distal ends of this electrode separated about a quarter of an inch or even more, so that it may be the more readily passed upon either side of the tumor. As the instrument is pushed into the nose, the ratchet is turned to tighten the loop, which is drawn Fig. 236.— Ingals' Post-Nasal Snare Applicator Q4 size) . For tumors in naso-pharynx. The wire loop is held in notches at D by the slides B, C, which are held firmly by the cam A. As the loop is carried behind the palate, the blades are opened so that the wire incloses the tumor ; it is then tightened, the cam is loosened, the slides B, C are drawn slightly backward, and the wire is re- leased and left in position while the applicator is withdrawn. tight upon the pedicle of the tumor before the electric current is turned on. As it is very difficult to adjust the platinum loop properly with the patient under ether or chloroform, I have in recent cases relied upon the anaesthetic effects of cocaine ; but its benumbing effect in this locality is not sufficient to prevent considerable pain during the burning off of the growth; therefore, when everything is in readiness, I tell the patient to bear the burning as long as possible, and that I will stop the current as soon as he requests it. The current is then turned on and the ratchet tightened at the same time. The patient will endure the pain two or three seconds, then the circuit is broken and he is allowed to wait two or three minutes; as soon as he is again ready, the circuit is again closed and thus the process is continued until the pedicle is burned through. The tumor is then seized with a pair of post-nasal forceps and withdrawn through the mouth. There is little or no hemorrhage from this operation. Whenever as the result of an operation hemorrhage ensues, it may be necessary to plug the posterior nares. For this purpose I have 624 DlsEAs£s OF THE NASO-PHARYNX. found most satisfaction in passing through the naris a long strip of gauze, rendered styptic by saturation with tannic and gallic acid-, us ..mended in the treatment of epistaxis. The gauze is pushed hack with the probe through the naris to the naso-pharynx, and there it is packed into the vault, with the finger carried up behind the palate. Finally, the naris itself is completely filled to prevent the plug from fall- ing into the throat if it should become loosened. The tampon should be removed within from twelve to twenty-lour hours, by traction upon the end protruding from the nostril, by which the strip is gradually unfolded. In case clotting of blood has rendered the tampon hard, and bound its folds together, it should be softened by gently injecting into the nostril a warm solution of sodium bicarbonate. Should recurrence of the tumor take place, it should be treated while it is yet small by the galvano-cautery or by electrolysis. RETRONASAL FIBRO-MUCOUS TUMORS. Retro-nasal fibro-mucous polypi are smooth, more or less ovoid tumors, varying from two to ten centimetres in diameter. They cause obstruction of the posterior nares, especially in expiration, with conse- quent inability to blow the nose. They are less frequent than the fibrous tumors. Anatomical and Pathological Characteristics. — The growths originate near the posterior opening of the nasal fossa? and are more or less fibrous or mucous according to their position. Those growing Fir. VST. — Retro-Nasal Fibro-Mucous Tcmor. largely from the retro- nasal space are mostly fibrous, those from the nares, as a rule, are chiefly mucous, in character. They do not cause so much pressure as fibrous tumors, and do not displace the bony structures like the latter. Etiology. — The etiology is unknown. Symptomatology. — The growths develop slowly, and are attended by the well known symptoms of nasal obstruction. Diagnosis. — The retro-nasal fibro-mucous polypi are to be distin- guished from fibrous and mucous polypi and malignant growths. They differ from fibrous tumors in that They are less dense, they do not de- MALIGNANT TUMORS OF THE NASO-PHARYNX. 625 stroy the bony structures, and they are not attended by frequent epi- staxis. They are distinguished from mivcous polypi by their greater density, their darker color, and by their size and position. They are distinguished from malignant growths by the history, absence of pain and hemorrhage, smooth surface, and less degree of density. Prognosis. — The tumors grow slowly, and when removed have lit- tle tendency to recur. Treatment. — If not too firm, the tumors may be safely torn away with post-nasal forceps, but they are best removed with the steel wire ecraseur or galvano-cautery applied as recommended in speaking of fibromata. RETRO-NASAL CARTILAGINOUS TUMORS. True cartilaginous tumors of the retro-nasal locality are so rare as to barely need mention. Only three or four cases are on record. MALIGNANT TUMORS OP THE NASO-PHARYNX. Malignant tumors of the naso-pharynx are comparatively rare ; they are characterized by symptoms of nasal obstruction, with abundant dis- charge, frequent epistaxis, and often by severe pain. Anatomical and Pathological Characteristics. — The growths are usually more or less pedunculated, somewhat pyriform in shape, and they have a nodular or lobulated surface covered by mucous membrane. They appear to be mostly of a sarcomatous nature, and often contain mucous or fibrous % elements to a considerable extent. Microscopically they are found to contain the usual round or spindle- shaped cells and sometimes cartilaginous cells. In common with malig- nant tumors elsewhere, they are characterized by rapid growth, speedy recurrence after removal, and tendency to form new deposits in other organs. Etiology. — The etiology is unknown. Symptomatology. — The tumors cause the common symptoms of nasal obstruction, with more or less" discharge and bleeding, and often, but not invariably, severe lancinating pain shooting toward the ear and most troublesome at night. As the tumor increases in size, dyspnoea and dysphagia may become j)ronounced. It may be readily seen upon rhinoscopic inspection. Diagnosis. — The malignant tumor is to be distinguished from other retro-nasal growths by the features mentioned in speaking of fibrous and fibro-mucous polypi, and by microscopic examination. Prognosis. — The tumors grow rapidly and terminate fatally, usually within from four to six months. Eecurrence is the almost constant rule. Treatment. — When seen in the early stage, if possible, the growths should be thoroughly removed by the steel wire or galvano-cautery snare; but more serious operations cannot be advised. 40 626 DISEASES OF THE NASOPHARYNX. CYSTIC TUMORS OF THE NASOPHARYNX. Cystic tumors of the naso-pharynx are of rare formation; only a few cases have been reported in this country, by Lefferts, Clinton Wagner, and myself. They are characterized by the usual signs and symptoms of nasal obstruction. They are most readily removed by evulsion with strong post-nasal forceps, and show little or no tendency to recur- rence. Diseases of the Thyroid Gland and cesophagus. CHAPTER XXXVII. DISEASES OF THE THYROID GLAND. GOITRE. Synonyms. — Bronchocele, Derbyshire neck, struma. Goitre consists of an enlargement of the thyroid gland, which may be vascular, parenchymatous, or cystic. Anatomical and Pathological Characteristics. — In the vas- cular variety in some cases the veins, in others the arteries, and in still others all the blood vessels are enlarged, elongated, and tortuous, and the walls may be greatly thickened, so that the vessels themselves make up a large part of the increased size of the gland. In the parenchym- atous variety the glandular structure itself is increased, sometimes the alveoli are much enlarged, and the tumor is made up in great part of colloid material, while in other cases the alveoli are smaller and the tumor is composed largely of the solid stroma. In many instances the goitre consists mainly of true adenoid growth. In cystic goitre there may be one or more large or small cysts, usually combined with hypertrophy of the parenchyma to a greater or less extent. As a rule, these cysts contain tenacious, ropy, albuminous fluid, often more or less tinged with blood from rupture of varicose veins into them, and of various shades of color in consequence of the amount or condition of the blood which has been thrown out. Sometimes their contents are entirely serous and in other cases entirely hemorrhagic in character. These growths sometimes attain enormous size. They are more frequent in women than in men, and are most apt to occur at about the age of puberty. The disease is most common in the Italian and Swiss Alps, the Pyrenees in France, in the Himalayas, in Derbyshire and Notting- hamshire, England, and in certain limited but not well denned areas in the United States. Etiology. — The cause cannot be definitely determined; but the com- mencement can frequently be traced to repeated congestion of the thyroid body occurring at the time of menstruation, or due to violent efforts. Goitre is sometimes hereditary. It is often attributed to the drinking of snow and glacial water, water impregnated with chalk, or to bad air and bad surroundings and deficient sunlight; but the preva- lence of the disease in places differing from each other widely in atmo- 630 DISEASES OF THE THYROID GLAND. sphere, temperature, and surroundings, and in some of which the drink- ing-water cannot possibly account for it, shows that we are still in the dark regarding the etiology. Symptomatology. — The symptoms depend upon the amount of pres- sure exerted upon surrounding structures. The extent of pressure is not necessarily commensurate with the size of the tumor, which, though small, may send prolongations downward and backward that press upon the trachea or the pneumogastric or recurrent laryngeal nerves and cause alteration of the voice, and dyspnoea, which may be slight or severe. "When dyspnoea is severe, it often comes on in parox- ysms due to acute congestion and swelling of the already narrowed tube. These attacks are sometimes speedily fatal, and though the patient may recover from one attack he is liable to others during which the danger is great. Pressure upon the brachial plexus may cause pain, numbness, or even paralysis of the arm ; but there is seldom any pain referred to the enlarged thyroid gland. Diagnosis. — There is usually no difficulty in the diagnosis excepting in rare cases, where small goitres press posteriorly, causing difficulty in respiration, while the external growth may be hardly perceptible. Pressure upon the veins causes turgescence and lividity of the face, with promi- nence of the superficial veins over the tumor, and passive hyperemia of the brain. There is occasionally, though not often, pressure upon the oesophagus, which then causes difficult deglutition. The gland, which is connected with the trachea, rises and falls during deglutition unless too large; the skin over it is freely movable, and the tumor is not attached to the jaw and does not involve the surrounding parts. The size varies from slight fulness of the neck to an enormous growth. The surface is sometimes even, but often nodular, and in extreme cases lobu- lated. The fibro-cystic variety, which is most common, has an irregular surface, firm to the touch, with here and there soft spots over the cysts. It is distinguished from tumors of other portions of the neck by its position and movements during the act of swallowing. It is distinguished from exophthalmic goitre by absence of the ophthalmic and cardiac signs; and from malignant tumors by comparative absence of pain, and by not being adherent to other tissues and consequently moving beneath the skin and with the deglutitory movements of the larynx and trachea. Prognosis. — The tumor usually slowly increases for many years, but is always a source of danger, as, from sudden swelling or steady pressure, with acute inflammation of the lining membrane of the air passages, it is liable to cause strangulation. Treatment. — It is necessary to remember that endemic causes play a prominent part in the etiology of goitre, and therefore removal to some other locality may be the most important measure in effecting a cure. If the tumor is small or of medium size, it may often be dissi- pated by iodine in some form. The tincture of iodine may be applied GOITRE. 631 locally to the neck, and the remedy given internally in the form of potassium iodide in doses of from gr. v. to gr. xx., or the tincture of io- dine in doses of TT[ v. to xx. may he administered in capsules, which are taken with a large draught of water, three hours after each meal. The internal use of the remedy often fails, and then injections have been practised in some cases with excellent results. Here again iodine may be used, but it is important that the solution should be thoroughly aseptic ; for this purpose I would recommend the aqueous solution pre- pared by J. E. Clark of Detroit for the treatment of tuberculosis. Hypodermic injections into the tumor, of carbolic acid in doses of Ti[ xv. to lx. of a three to five per cent solution, are sometimes followed by excellent results. These should be given once or twice a week according to the irritation they produce. Injections of iodoform according to the Mosetig-Moorhof plan are said to be safe and efficacious. This method consists in injecting into the gland, with antiseptic precautions, about once a week, from one to four grains of iodoform dissolved in ether and olive oil seven parts each. Five to ten injections are said to be necessary for a cure. In the cystic variety, Mackenzie recommends puncturing the cyst, drawing off its contents and injecting the sac with a solution of perchlor- ide of iron, 3 ij. ad § i., which is to be left in for three days ; the canula being corked and held in place by a strip of tape passed about the neck. The cork is then removed and, if suppuration has occurred, the cyst should be thoroughly washed several times with an antiseptic solution {London Lancet, May 11th, 1872). Obliteration of the sac accompanies the healing process. If the first operation is not successful, it should be repeated until a sufficiently high grade of inflammation has been induced. Electrolysis is sometimes a very efficient means of curing these cystic growths. It may be practised by inserting into the tumor suita- ble needles at a distance of an inch or more from each other and passing through them a galvanic current as strong as can be borne by the patient for ten or fifteen minutes at each sitting; to be repeated at in- tervals of five or ten days until the cyst disappears. If the tumor presses upon the tracheia so as to interfere seriously with respiration, tracheot- omy should be done and a long, flexible canula introduced and worn while the danger remains. Owing to the success obtained during the last decade, partial extirpation of the gland is an operation which meets with considerable favor among general surgeons. Total extirpation is a dangerous operation, very liable, in those who survive the immediate effects, to be followed by cachexia, strumipriva or myxcedema, there- fore it cannot be recommended. The operation itself is fully described in recent works on surgery. 032 DISEASES OF THE THYROID GLAND. EXOPHTHALMIC OOITRE. Synonyms, — Graves' disease, Basedow's disease. Exophthalmic goitre is a disease of the sympathetic nervous system characterized by enlargement of the thyroid gland, prominence of the eyes, disturbance of the action of the heart, and deficient chest expan- sion, though one or two of these symptoms may be absent. It is fully described in textbooks on practice, and, as stated in the previous edition of this work, it belongs to the domain of the neurologist rather than to the specialist on diseases of the throat and chest. It is mentioned here because the laryngologist is sometimes consulted about it and to call attention to the remarkable effects sometimes exerted upon it by the administration of the tincture of strophanthus, which has proven cura- tive in several reported cases. Daniel R. Brower, of Chicago, has treated three cases by this agent successfully. I have cured two cases by the administration of ten-minim doses of tincture of strophanthus three times daily for a period of several months, combined with repeated injections into the gland of thirty minims of a three to five per cent solution of carbolic acid. In some cases it seems to be of no value. DISEASES OF THE OESOPHAGUS. CESOPHAGITIS. ACUTE OESOPHAGITIS. Acute oesophagitis is a comparatively rare affection of the mucous membrane lining the oesophagus, characterized by painful deglutition. The inflammation may be either circumscribed or diffused. Etiology. — Oesophagitis sometimes results from simple exposure to cold, in which case it is generally rheumatic; it may be induced by the use of extremely hot or irritating foods, or by iced drinks, particu- larly when the subject is warm; it may be caused by irritating medi- cines, foreign bodies, or the passage of surgical instruments; but most frequently it results from swallowing very hot or corrosive substances. It is sometimes associated with diphtheria, pneumonia, scarlet fever, small-pox, dysentery, cholera, tuberculosis, pyaemia, or cancer. Symptomatology. — In mild cases there may be simply a sense of constriction in the oesophagus; but in those more severe, pain, which in the acute disease may be increased by pressure, is felt deep beneath the sternum or in the back, between the scapulae. This pain is experi- enced upon deglutition even of saliva, and is much aggravated by swal- lowing solids. Dysphagia or aphagia results from swelling or spasm of the oesophagus during attempted deglutition which may cause OESOPHAGITIS. 633 regurgitation of food and vomiting. The vomited matter consists of glairy, sometimes blood-stained mucus, together with the food that has been swallowed. There is fever, with intense thirst, commonly accompanied in children by convulsions. Sometimes involvement of the larynx causes hoarseness, and cough may be produced by the act of swallowing. By auscultation while the patient is swallowing fluid, a peculiar gurgling sound may be heard at the seat of inflammation pro- vided it has caused narrowing of the tube. Diagnosis. — The diagnosis will depend upon the history, the seat of the pain, the time of its occurrence and the presence of dysphagia. Prognosis. — In mild cases the disease usually subsides within three or four days; in those more severe it may terminate favorably within a week or ten days, but where there is extensive inflammation the prog- nosis is grave. "When associated with diphtheria or small-pox, it is gen- erally fatal. Phlegmonous inflammation of the cesophagus may cause death within two or three days. Where recovery occurs, the walls of the tube usually remain more or less thickened, and if the inflammation has been severe a stricture results. Treatment. — In mild cases, demulcents should be employed, and frequent comparatively large doses of bismuth subnitrate are valuable, given in powder and with as little fluid as possible. The food should be liquid. When swallowing is impracticable, food should be given per rectum. In the early stage, the sucking of ice, and the application of cold compresses externally, are useful. In cases resulting from an im- pacted foreign body, the cause should be removed. In those resulting from the swallowing of acids or alkalies, weak chemical antidotes should be administered in the beginning. CHRONIC OESOPHAGITIS. A chronic inflammation of the mucous membrane of the cesophagus, with more or less thickening of the walls, is characterized chiefly by difficulty in deglutition. Etiology. — Chronic oesophagitis usually results from the acute dis- ease, from the excessive use of alcohol, from syphilis, or from impaction of foreign bodies; but it may be due to extension of inflammation from neighboring parts, to pressure of aneurismal or other tumors, or to pro- longed congestion occasioned by chronic pulmonary or cardiac affections. Symptomatology. — The symptoms resemble those of the acute dis- ease, though they are less pronounced. Diagnosis. — The diagnosis depends upon the history and symptoms. The sounds obtained upon auscultation while the patient is swallowing are apt to be more pronounced than in the acute affection. Prognosis. — The affection usually extends over a considerable time, and is liable to eventuate in stricture. Treatment. — The cause should be removed if possible, and any G34 DISEASES OF THE (ESOPHAGUS. associated disease should receive appropriate treatment. Locally the use of astringents or stimulants, applied by means of a soft sponge at- tached to a whalebone, has been found beneficial. For this purpose, solutions of alum, zinc sulphate, or tannin, varying in strength from gr. x. to xxx. ad 3 i., or silver nitrate gr. v. to x. ad 5 i., may be employed. Solutions of iodine are also recommended. Any of these in small quan- tity, not more than til xv. to xx. at a dose, and in weak solution, may be brought in contact with the parts by the act of deglutition. As the inflammation subsides, bougies should be passed at intervals of one or two weeks to prevent the formation of stricture, and iu some cases this procedure will be found beneficial for overcoming a persistent low grade of inflammation. STRICTURE OF THE (ESOPHAGUS. Stricture of the oesophagus consists in a narrowing of the tube, occa- sionally congenital, but generally as the resnlt of injury. It occurs most frequently in children or young adults. Anatomical and Pathological Characteristics. — The thick- ening usually involves the mucous membrane and connective tissue, and sometimes the muscular walls also. It occurs oftenest at the upper, narrowest portion of the tube, and next in frequency near the cardiac orifice of the stomach. It varies in degree from slight obstruction to almost complete closure, and rarely involves more than a few inches of the tube; it may be single or multiple, symmetrical or tortuous; the thickening may be uniform about the tube, leaving the opening in its centre, or it may involve only a portion of the walls, leaving the opening at one side. Atrophy of the wall is usually found below the seat of stricture if it is narrow. Collection of food above the stric- ture causes hypertrophy first, with subsequent fatty degeneration and dilatation. As a result of this weakening and dilatation of the wall and collection of food, not infrequently a large cul-de-sac may be formed above the obstruction. Etiology. — Stricture is sometimes congenital, but usually it results from acute or chronic inflammation most commonly excited by swallow- ing of hot water or lye, or the result of rheumatism, syphilis, or cancer. Symptomatology. — Except in traumatic cases, the symptoms usually come on gradually, the patient at first experiencing some difficulty in swallowing large boluses of solid food. As the obstruction increases and deglutition becomes more and more difficult, solids have to be taken in small boluses and washed down with liquid. Subsequently the diet is necessarily restricted to fluids; and eventually, in extreme cases, even these cannot be swallowed. Sometimes the bolus is regurgitated imme- diately after it has been taken, perhaps covered with mucus, pus, or blood. When dilatation of the oesophagus has occurred above the stric- ture the food may be retained for some hours, finally to be regurgitated STRICTURE OF THE (ESOPHAGUS. 635 more or less decomposed and softened. The patient is usually much depressed and very nervous, and this adds to the tendency to spasm of the oesophagus, which not infrequently takes place during deglutition. Pain at the seat of the stricture is sometimes experienced, and occasion- ally dyspnoea is complained of; this is especially likely to occur in can- cerous strictures involving the recurrent laryngeal nerve. Usually nothing can be discovered by laryngoscopy examination, but by care- fully passing oesophageal bougies the location and degree of stricture may be determined. Diagnosis. — Stricture of the oesophagus is to be distinguished from tubercular laryngitis, from tumors of the pharynx, larynx, or oesophagus, from spasms of the oesophagus, from paralysis of the pharynx and oesophagus, and from the presence of foreign bodies. The diagnosis is not usually difficult; the essential points are the history, and presence of dysphagia, and regurgitation of food. By auscultation the seat of the stricture may frequently be located when the patient is swallowing, owing to the sound caused by the ascent of bubbles of air just above the narrowest portion ; but the degree of stricture can only be accurately determined by the passage of the oesophageal bougie. For this purpose, graduated dilators made of the same material as flexible catheters are the safest instruments; but surgeons usually employ an olivary bougie firmly attached to a long whalebone rod. These olivary bougies should be of several sizes, about one and a half inches in length, and conical at both ends; and when the instrument has once passed the stricture, it should be carried down to the stomach to determine whether other strictures exist. Great care should always be used in its passage, for the walls of the oesophagus are often thin and friable or ulcerated, and there is liability of perforation with fatal results. Upon laryngoscopic exam- ination, stricture is readily distinguished from tubercular laryngitis and tumors in the pharynx. By passage of the bougie, it is distinguished from tumors of the oesophagus, spasm, paralysis or foreign bodies. It is sometimes difficult to determine whether the stricture is the result of simple chronic catarrhal inflammation, or whether it is of malignant origin, but in advanced life cancerous disease may always be suspected, and a differential diagnosis may usually be made by examination of the regurgitated matter. Prognosis. — Non-malignant strictures may continue for many years, but those of cancerous origin are always fatal, usually within from eight to eighteen months. Strictures due to simple inflammation, if not too narrow, may often be cured by persistent dilatation; if not relieved, they tend to interfere more and more with nutrition, and finally, sometimes after many years, they may cause death by inanition. Occasionally death is the result of abscess caused by the pressure of food in the dila- tation above the stricture, or of tubercular degeneration, or gangrene resulting from the reduced condition of the system. Pressure upon the 636 DISEASES OF THE (ESOPHAGUS recurrent nerve sometimes causes paralysis of the abductor muscles of the vocal cords, with dangerous or even fatal dyspnoea unless tracheot- omy is promptly performed. Ulceration may occur into the trachea, the bronchial tubes, or into one of the adjacent large vessels. Treatment. — "When resulting from chronic catarrhal inflammation, rheumatism, or syphilis, the administration of the iodides is occasionally followed by relief. In malignant cases, opiates must be given to relieve pain. When food in sufficient quantity cannot be taken, nutritive ene- mata must be employed. Dilatation is indicated in all suitable cases. In those of malignant nature it must be practised, if at all, with the greatest care, but as a rule it is inadvisable. Charters J. Symonds, of London, in seventeen cases of malignant stricture of the oesophagus, has successfully used, for keeping the stric- ture pervious, a gum elastic tube four to six inches long (London Lan- March, April. 1889). This is funnel-shaped above and closed at its lower end, but has an opening just above the closed extremity like an ordinary catheter. This tube is introduced through the stricture, upon a whalebone staff, and has attached to its upper end a strong silk thread which is fastened to the ear. It may be left in situ for weeks or months, allowing the passage of liquid food, without hast- t5*tLL.nnz»B0 e- co « f. A,\AVtA^^\J>X\y^A^AAl^\^^^^ to Fig. 238. — Sands' CEsopbagotome. > ening the inevitable progress of the disease. In other cases dilata- tion should be attempted by the graduated bougies already described, and the operation should be repeated every two, three, or four days according to the amount of irritation produced, time aiways being al- lowed for this to subside before the next operation. When an instru- ment has been passed, it should be allowed to remain for a few seconds, as long as the patient can tolerate it, and then withdrawn and folio wed by one of a size larger. Thus the largest instrument that can be passed without great force should be used at each sitting; at the next an instrument a size smaller than the one previously introduced should be first used followed by one or two larger sizes. If the dilatation proves successful, bougies should be introduced from time to time with diminishing frequency, and the patient should be taught to perform the operation himself, which must be repeated at intervals for several months or possibly years, the cure usually requiring a treatment for at least six to eighteen months. When the stricture is very narrow, an cesophagotome (Fig. ~2-)b) may be employed for incising the mucous SPASM OF THE (ESOPHAGUS. 637 membrane to allow of more rapid and permanent dilatation. The bulb is to be introduced beyond the stricture, the knife slightly protruded, and the instrument withdrawn. The operation is attended by great danger, and is liable to be a direct cause of death in about thirty-five per cent of the cases operated upon. If this operation is adopted, two or three slight incisions should be made at different parts of the stric- ture, gradual dilatation being practised subsequently. External cesoph- agotomy and gastrotomy are recommended in special cases, but they come more properly within the domain of general surgery. Electroly- sis has also been recommended in the treatment of stricture, but the close proximity of the oesophagus to the vagus nerve renders it hazard- ous. A. Fort, of Paris, has practised it successfully in several instances, and appears to have obtained considerable benefit even in malignant cases. COMPRESSION OF THE OESOPHAGUS. Compression of the oesophagus results from the pressure of mediasti- nal tumors, which may be carcinomatous, aneurismal, or purulent. It is sometimes caused by enlargement of the bronchial or thyroid glands, and may be occasioned by pressure of the fluid in pericarditis. It is to be distinguished from true stricture, by the process of exclusion. The prognosis and treatment will depend upon the etiology. SPASM OF THE OESOPHAGUS. Synonyms. — Cramp of the oesophagus, oesophagismus, spasmodic stricture. Spasmodic contraction of the oesophagus is sometimes associated with a similar condition of the pharynx. It is characterized by paroxysmal inability to swallow, which may come on suddenly and as speedily dis- appear; or it may continue for several hours or at irregular intervals for days or weeks. It is most frequently seen in nervous women, but is said to occur at all ages, and judging from my own experience it is not infrequent in men past middle life. It may be associated with disease of the oesophagus, but is usually independent of it. Etiology. — The attacks are sometimes caused by attempts to swal- low certain kinds of food, but they are often brought on by solid food of any kind, and not infrequently even by fluids. The affection is at- tributed by Cohen to rheumatism, to acute disease of the stomach, heart, lungs, uterus, brain, or spinal cord, and to hysteria and hydro- phobia (Diseases of the Throat). Symptomatology. — In many instances the spasm comes on suddenly and may as speedily disappear, but in others the constriction remains, or at least the patient supposes it to remain, for many hours or even days, so that he is afraid to swallow food. When sudden, it is usually 638 DISEASES OF THE (ESOPHAGUS. followed by prompt regurgitation of any food that the patient attempts to swallow, and sometimes by spasm of the air passages, palpitation of the heart or syncope. The difficulty is usually intermittent, but occa- sionally, as before mentioned, the constriction remains for many hours; indeed, when occurring in a low position, it sometimes continues so long that food may be regurgitated in a softened and decomposing condition some hours after it has been swallowed, owing to the occurrence of dila- tation in the oesophagus above the constriction. The seat of the diffi- culty may be referred by the patient to any portion of the oesophagus. Diagnosis. — The diagnosis is based upon the intermittent character of the dysphagia, and exploration with oesophageal bougies, the passage of which is not often greatly hindered by the spasmodic contrac- tion. It is most likely to be confounded with organic stricture or paralysis of the oesophagus. It is distinguished from organic stricture by the history and the ready passage of the bougie. It is distinguished from paralysis by the history, paralysis usually following diphtheria; by the sudden regurgitation of food, which often takes place in spasm but is not common in paralysis; by its intermittent character; and by the introduction of the bougie, which passes readily in paralysis, and is more or less obstructed in spasmodic stricture. Prognosis. — The spasm is usually transient, and the liability to re- currence may disapjoear after a few days or weeks; but in some in- stances it continues for a long time, and I have seen patients who have been unable to swallow satisfactorily for three or four years. Treatment. — Anti-spasmodics, as bromides, camphor, valerian, and asafcetida, are frequently of benefit, and in most instances such tonics as iron, quinine, strychnine, and arsenious acid are necessary; but the repeated passage of an oesophageal bougie will give more relief than any other measure. Usually it is necessary to repeat the operation only three or four times. Borgiotti reports a case of oesophageal spasm in a woman thirty -one years old, which continued uninterruptedly for five hundred and thirty days, rarely permitting the passage of the sound or liquid food. Cure was effected within a few days by the use of Verneuil's oesophageal dilator (Centralblatt fur klinische Medicin, 1888). PARALYSIS OF THE OESOPHAGUS. Paralysis of the oesophagus consists of loss of muscular power, char- acterized by difficulty in deglutition. It is said to be very common in the insane, and it is comparatively frequent in old age or in those broken down by poor health, and also as a sequel of diphtheria. Anatomical and Pathological Characteristics. — The lesions may consist of changes at the nerve centres, such as hemorrhage into the pons or the medulla, or tumors of these organs, bulbar pa- PARALYSIS OF THE (ESOPHAGUS. 639 ralysis, multiple sclerosis, cerebral atrophy, and progressive locomotor ataxia; or of pressure upon the nerve as in tubercular enlargement of the pharyngeal lymphatic glands, or syphilitic enlargement of the cer- vical vertebras; or there may be simple muscular weakness without ner- vous lesions, as observed in the feeble or aged. Etiology. — The most common causes are diphtheria, and simple muscular weakness from old age or ill health. The affection is occa- sionally caused by syphilis, tuberculosis, lead poisoning, acute fever, and hysteria. Inability to swallow is usually observed in approaching dis- solution some time before failure of respiration and circulation. Symptomatology. — The essential symptom is difficulty in Swallow- ing, which may develop quickly or slowly according to the cause. It is probable that complete aphagia is never present unless the pharynx is paralyzed at the same time. When due to hemorrhage into the nerve centres, it comes on suddenly, and is at once complete; but if resulting from tumors, it develops gradually. Following diphtheria, it usually appears within three or four weeks after the beginning of the attack, and may reach its full intensity in three or four days. As the result of nervous diseases it is a rare affection, and in any case seldom appears until late in their course. When of central origin, it is sometimes asso- ciated with more or less paralysis of the sensory or motor nerves of the i irynx. In local paralysis, the affection comes pn gradually; Macken- zie states that he has seen several instances in which the disease has iasted from ten to twenty years, that it apparently leads after a time to some stenosis of the gullet, and that in long-standing cases the isthmus faucium, and even the mouth, is often much contracted (Diseases of the Throat and Nose, Vol. II). Patients are commonly very weak, but emaciation is not usually a marked symptom excepting in cases of long duration. There is seldom any regurgitation of food, though in mild cases patients complain of its lodging in the oesophagus. The sound, which may be heard during deglutition over the normal oesophagus is greatly altered or may be sup- pressed by paralysis, so that, instead of being distinct as in health, only a trickling or dropping can be heard. A bougie may be passed easily and is less likely to cause nausea than in health, but occasionally, in cases of long standing, contraction of the gullet is said to occur, causing much difficulty in passing the instrument. Diagnosis. — Paralysis is to be distinguished from spasm and from malignant diseases. Paralysis is distinguished from spasm of the oesophagus as follows : Paralysis of the cesophagus. Spasm of the cesophagus. Most common in advanced life and Most frequent in the young and hys- in feeble patients. terical subjects. Dysphagia continuous. Dysphagia intermittent. 640 DISEASES OF THE (ESOPHAGUS. Paralysis of the oesophagus. Spasm of the ozsophagus. Seldom any regurgitation of food. Regurgitation of food common Bougie passed easily, except in rare At times impossible to pass bougie. cases of long standing. No distinct sound produced by svval- Sharp sound heard over oesophagus lowing. during deglutition. We find that malignant disease of the oesophagus causes difficulty in deglutition, and, like paralysis, generally occurs in advanced life, but it is attended by pain, regurgitation of food, and constant obstruction to the passage of the bougie. Prognosis. — When depending upon muscular weakness, diphtheria, or lead poisoning, the prognosis is very favorable, but if due to lesions of the nervous system it is grave. Treatment. — In the severe forms, little can be accomplished in the way of treatment. In any case where the cause can be found it should be removed if possible. Usually iron, quinine, and strychnine, especially the latter, are important agents, together with a stimulating diet. Mackenzie recommends faradization of the oesophagus once or twice daily, preferably before meals. The positive pole should be placed by means of the necklet in contact with the spinous processes of the upper cervical vertebra?, the negative attached to the oesophageal elec- trode, which should be introduced three or four times at each sitting, and retained for a few seconds. It is sometimes desirable to feed the patient through an oesophageal tube; especially is this necessary if the pharynx and larynx are also paralyzed. FOREIGN BODIES IN THE OESOPHAGUS. Foreign bodies, of great variety, may become impacted in the oesoph- agus, where they interfere with respiration and deglutition. They gen- erally lodge either in the lower portion of the pharynx or just below it or at the upper portion of the oesophagus directly behind the cricoid cartilage, but sometimes they pass lower and occlude the passage opposite the bifurcation of the trachea or just above the cardiac orifice of the stomach. The most common of these foreign bodies are large boluses of food, coins, pins, fragments of bone, and plates with false teeth. Symptomatology. — When foreign bodies are large and lodged in the lower part of the pharynx, they may depress the epiglottis so as to cause immediate suffocation. Large bodies may provoke retching or vomit- ing, and prevent swallowing either of solids or fluids. Smaller bodies usually cause actual pain or pricking sensations, sometimes slight bleed- % ing, and frequently interfere with the swallowing of solids, but not with swallowing of liquid. Sharp, irregular bodies cause pain and inflam- FOREIGN BODIES IN THE ESOPHAGUS. 641 mation. Large or irregular bodies may cause cough, spasm of the glottis, aphonia, or asphyxia. The respiration may be impeded by involution of the trachea or by spasm. Diagnosis. — The presence of foreign bodies is to be distinguished from globus hystericus and from paresthesia of the oesophagus. The essential features in the diagnosis are the history, laryngoscopic exami- nation, and exploration with the bougie. By inspection, affections of the pharynx and larynx may be excluded; and sometimes, in the case of irregular bodies, blood or pus may be detected at the oesophageal en- trance. Exploration with the finger will sometimes detect a foreign substance, and passage of the oesophageal bougie will usually locate the object unless small; but in some cases spasm of the oesophagus above or below the foreign substance seriously interferes with this examination. Care must be taken not to be misled by the dense pharyngo-epiglottic ligament and normal narrowing at the entrance of the oesophagus. Foreign bodies will be distinguished from globus hyster- icus by the history, by the presence of other symptoms of hysteria, by frequent change in location of the sensations in the nervous affection, and by exploration with the bougie. From paresthesia of the cescph- agus, where the patient's sensations indicate the presence of a foreign body, and where the history generally points to an accident of this kind, the diagnosis can only be made by careful exploration with the bougie and extractor. Peogxosis. — The lodgement of a foreign body often proves immedi- ately fatal from suffocation. Sometimes comparatively smooth objects have remained in the oesophagus for months or years and then been removed or spontaneously discharged, but as a rule there is danger so long as a foreign body remains impacted in the oesophagus, since it is apt to set up inflammation which may be followed by abscess; or the pressure may cause ulceratibn and opening into the mediastinum, the trachea, or the aorta. Impacted bodies sometimes work their way to Fig. 339. — Flexible (Esophageal Forceps (1-5 size;. the surface and may be discharged without immediate danger, but in this way they may give rise to a fistula. Sometimes they cause inflam- mation ana caries of the vertebra?, or secondary disease of the lungs, pericardium, or other organs. Perforation of the oesophagus usually leads to emphysema of the neck, and commonly proves fatal. Great injury is sometimes unavoidably inflicted in withdrawing these sub- stances. Kepetition of the accident is observed in some people in consequence of spasm of the constrictor muscles of the oesophagus or of partial paral- 4i 642 DISEASES OF THE (ESOPHAGUS. ysis ; but in such cases the obstructing bolus may generally be carried on by the swallowing of another bit of food or a drink of water. Treatment. — Prompt removal of the body is desirable in all in- stances. If not too large, it may be speedily removed by an emetic, for which purpose apomorphine, gr. y^, injected subcutaneously, may be effectually employed. If the foreign body can be seen or felt, it may sometimes be removed by the finger, blunt hook, or forceps. Even when lower, it may often be caught with flexible oesophageal forceps (Fig. 239) or with the bristle extractor (Fig. 240) or the coin-catcher. In several instances Crequy has succeeded in removing foreign bodies by having the patient swallow a well lubricated tangled skein of thread with a long stout thread tied to its centre; traction is made upon the thread when the bundle has had time to pass the obstruction (Gazette des Hopitaux, 1870, No. 56). SHARP &. S'HYTH Fig. 240.— Bristle Extractor (\& size). B. Polikier, of Warsaw (Revue mensuelle des maladies de Venfance, Paris, 1892), reports two cases in which he succeeded in removing foreign bodies from the oesophagus in children, by a sort of massage upward and backward with the finger pressed down between the trachea and sterno- cleido-mastoid muscle; while with the other hand he tickled the child's throat until it vomited and brought up the foreign body. When susceptible of digestion, there is no objection to pushing the foreign body into the stomach, care being used to avoid injuring the oesophagus: and if the offending object be lodged low in the passage, this is frequently the only operation that can be practiced. Fortunately many indigestible substances may pass into the stomach without harm to the patient. When substances are firmly lodged in the upper por- tion of the oesophagus, and cause distressing or dangerous symptoms, laryngotomy or oesophagotoray must be performed. These operations, which are fully described in textbooks on general surgery, not infre- quently give good results. PARESTHESIA OF THE (ESOPHAGUS. Parassthesia is a nervous affection in which the patient fancies some foreign body lodged in the pharynx or oesophagus. It usually occurs in women of enfeebled health, with nervous temperament, or in hysteri- PARESTHESIA OF THE (ESOPHAGUS. 643 cal subjects. There are no anatomical changes in the parts, but the patient fancies she is unable to swallow solids, or she is unwilling to at- tempt it perhaps from a Tague fear of choking. Etiology. — Some of the cases are neuralgic in character, others hysterical: some depend upon derangements of the digestive system or genito-urinary tract; others upon a small ulcer or fissure in the pharynx or oesophagus; but "most frequently the condition is due to something which has lodged for a time in the oesophagus, or, having inflicted in- jury, has subsequently passed on through the alimentary canal. Pins, tacks, fishbones, and other small, sharp objects are most likely to leave this sensation. Symptomatology. — There is usually a history of something swal- lowed, which has apparently lodged in some part of the throat or oesoph- agus, giving rise to pricking sensations, or soreness, fulness, pressure, or weight, which seems to the patient clearly to indicate the presence of a foreign body. The seat of the fancied object frequently changes by deglutition or efforts made by the patient or physician to remove it; and although in many instances the patient readily swallows large, solid morsels, she cannot be convinced that these would necessarily carry the object with them. Inspection of the pharynx and mouth of the oesophagus will sometimes disclose a small fissure or ulcer which gives rise to the sensation, but usually it only reveals to the physician a nor- mal condition of the parts. Diagnosis. — One of the most valuable points in the diagnosis is a changeableness of the fancied position of the object. The patient is often found to be anaemic, debilitated, and nervous, frequently able to swallow without much difficulty: but the diagnosis must finally be de- cided by passage of the oesophageal bougie, or an extractor, by which foreign bodies can be felt or removed. Prognosis. — The sensations often continue weeks or months, and in some cases it is impossible to convince the patient that the sensations are altogether nervous. Teeatmext. — Cases depending upon ulceration or fissure are usu- ally best relieved by the application of solutions of silver nitrate or the mineral acids. Those resulting from having swallowed some substance are often cured by the passage of the bougie or of the bristle ex- tractor, thus demonstrating to the patient that nothing can be lodged in the oesophagus. Those of purely nervous origin are best relieved by the same means, together with the internal administration of iron, quinine, strychnine, arsenious acid, and the bromides. APPEXDIX. FORMULAE FOR PRESCRIPTIONS. Seteral of the formulae relating to diseases of the throat and nasal pas- sages are taken from the Pharmacopoeia of the Hospital for Diseases of the Throat, London. The various mixtures, excepting Formula 3, which would not be prescribed in quantities of less than four ounces, have been reduced to the standard of one ounce ; prescriptions for drugs to be given in pill form contain quantities sufficient for one pill. 1. 5 Morphin* sulphatis gr. i. Antimonii et potass, tart gr. i. Ammonii chloridi 3 i. Ext. grindelire robust* fluidi fl. 3 iv. Syrupi pruni Virginian* et Mistur* glycyrrhiz* comp aa fl. 3 ij. M. S. Teaspoonful, for cough. Especially useful in acute bronchitis. 2. Pf. Morphinse sulphatis gr. i. Chloralis 3 i. Syrupi zingiberis . • 3 iv. Misturte glycyrrhiz* ad fl. § i. M. S. Teaspoonful every half-hour until relieved. For spasmodic asthma. 3. Emulsion of Cool-Liver Oil. B Olei morrhute 3 ij . Sacchari 3 vi. Acacige 3 iv. Olei gaultheri* tt[ xv. Aqua3 q.s. ad fl. § iv. Triturate the sugar and acacia thoroughly with one-half the amount of water until a uniform mucilage is formed; then add the oil slowly, with constant trituration, and subsequently add the remainder of the water. It requires about an hour to make the perfect emulsion, to which may be added lacto-phosphate of calcium or phosphoric acid, which will give it an agreeable acidulous taste. Chloride of calcium may be added when desired, but the lactophosphate of calcium is much more agreeable to the taste and answers a similar remedial purpose. 4. Pi, Potassii bromidi gr. xl. Syrupi lactucarii (Aubergier's) Syrupi acidi hydriodici aa 3 iv. M. S. Teaspoonful every four to six hours. A most useful cough medi- cine for protracted branch itis in ch ilclren. 646 APPENDIX. 5. IJ Morphinse sulphatis Ammonii carbonatis Syrupi pruni Virginian* Mistime glycyrrhizae coinp. . M. S. Teaspoonful in water, for cough. when opiates are not contra-indicated. . gr. 1. . gr. xxx. -xl, aa fl. 3 iv. A most useful cough syrup 6. Pil. Can. Ind., Hyoscyam., et Quinince Comp. (No. 1). B Ext, can. Ind. (Allen's) gft \ Ext. nucis vom. gr. £' Ext. hyoscyam. (alcoholic) gr. i Camphor* gr. i. Quininse muriate gr. iss. M. S. Before meals and at bed-time. Pil. Can. Ind., Hyoscyam., et Quinince Comp. (No. 2). 5 Ext. can. Ind. (Allen's) gr. £ Ext. nucis vom. gr. i Ext. hyoscyam. (alcoholic) gr. i. Creasoti mi. Dextro-quininsc gr. ij. M. S. Before meals and at bed-time. Pil. Capsicum, Hydrastine, Papain Comp. 5 Oleoresinae capsici . Ext. nucis vom. Hydrastine muriate Papain (Carica papaya) Acidi salicylici . M. S. After meals. gr. i gr. i gr. iij. gr. i. 9. lodol Ointment. 3 Acidi carbohci ^l vi. Olei rosse TT, v. Iodol gr. xxv. Lanolini § ss. M. S. A valuable ointment for healing abrasions of the nostril and upper lip and for healing erosions of the septum. 10. 5 Antimonii et potassii tartratis gr. xx. Cantharidis et Olei tiglii aa, gr. xl. Camphor* et Ext, stramonii (aqueous) aa gr. lxxx. Adipis 3 iiss. Cerati simplicis ad 1 i. M. S. Counter-irritant ointment. 11. 3 Tinctur* iodi 3ss.-3i. Potassii iodidi gr. x.-xx. Aqua: ad fl. 1 i. M. S. Use as an injection, which should be withdrawn in about five minutes. For chronic pleurisy. GARGLES— TROCHISCI OR LOZENGES. 647 GARGLES. Gargles are only useful in diseases of the fauces. They cannot affect the nasal passages, lower pharynx, or larynx. The preparations may be seda- tive, astringent, stimulant, or antiseptic. SEDATIVES. 12. 5 Potassii bromidi 13. 1$ Potassii nitratis .... Potassii chloratis .... Aqua? ferventis M. S. Use as hot as it can be borne. ASTRINGENTS. 14. 5 Acidi tannici .... 15. 1J Aluminis 16. $ Ferri et ammonii sulphatis 17. 5 Sodii boratis .... Glycerine Tincturse myrrhae Aquas M. 18. 5 M. 19. 5 20. F, 21. B 22. 5 23. 3 24. 5 gr. xxx. ad fl. § i. gr. xx. ad fl. 5 i. gr.xij.-3ij. adfl. |i. gr. viij. ad fl. % i. gr. viij. ad fl. 3 i. gr. xxv. Til XXV. TTL XXV. ad fl. I i. STIMULANTS. Acidi aeetici dil v\ xv. Glycerins! • . Tq, xviij. Aqua? ad fl. § i. Acidi carbolici Potassii chloratis ANTISEPTICS. Acidi carbolici vel. Potassii chloratis (see Stimulants 19 and 20). Potassii permanganatis Hydrargyri chloridi corrosivi . - . Aqua? cinnamomi . . gr. ij.-x. ad fl. |i. err. x.-xxv. ad fl. 5 i. gr. ij.-iv. ad fl. § i. gr. i-gr. ss. ad fl. 3 i. q.s. TROCHISCI OR LOZENGES. Each lozenge contains seventy to eighty per cent of red-currant fruit paste, one to two per cent of powdered tragacanth, four per cent of sugar, and a varying quantity of the medicament according to the following formulae : SEDATIVES. 25. Troch. morphine sulphatis . . . . gr. 3^ ad troch. 26. Troch. ext. opii gr. ^ " 27. Troch. sodii boratis gr. iij. " " 28. Troch. ammonii chloridi gr. ij. " 29. Troch. lactucarii (Aubergier's) S. One every half-hour or hour as needed. These are very pleasant to take and efficient in mild cases. G48 APPENDIX. 30. Troch. chlorodyne 31. Troch. Lobe I iir Compound B Aimnunii ehloridi . Ext. lobelia? . Ext. glycyrrhizae . Codeinse . ttj, v. ad troch. 33. gr. i. gr. tV gr. i. gr. ^ ad troch. Troch. Morphia. Antimony et Ipecac Compound. ll Morphinae hydrochloratis gr. ^ Antimonii sulph . • gr. to Pulv. ipecac E r - tu Olei sassafras Balsam tolu Ext. glycyr., acacia? et sacch. alb. . . . aa q.s. ad troch. Troch. Terpin Hydrate and Cannabis Compound. B Terpin hydrate Ext. can. ind. . Codeine 01. menth. pip. Sacch. gr. ij- gr. its gr. i gr- hj. 34. B Troch. Mist. Glycyrrhizce Compound. Same as mist, glycyrrhizae conip.. U. S. P. 35. Troch. Opii et Anisi Compound. B Pulv. opii gr- to Olei anisi, ext. glycyrrhi. a?, acacis, et sacch. alb. q.s. ad troch. DEMULCENTS. 36. Troch. Althece. B Althe«, acacia 3 , et sacch. alb. 37. Troch\ VI mi. ll Mueil. ulmi cort., albumen ovi. acacia? Sacch. alb., aa q.s. ad troch. ASTRINGENTS. 38. B Krameri* gr. iij. ad troch. 39. B Kino gr. ij. " 40. B Acidi tannici gr. iss. 41. Troch. Krameria Compound. E Pulv. cubebae gr. i Ext. krameri* gr. i. Potassii chloratis gr. ij. ad troch. STIMULANTS. 42. B Acidi benzoici gr. iij. ad troch. 43. B Cubebae gr. ss. 44. B Guaiaci gr. ij.-iij. ' 45. B Pyrethri gr. i. VAPOR INHALATIONS. 649 46. Troch. Acid Benzoic Compound. • gr- i Acidi benzoici ■ gr. i Potassii chloratis . gr. ij. ad troch. 47. Troch. Cubeb and Potassium Chlorate. I£ Cubebae • gr. i Potassii chloratis . gr. iij. ad troch. 48. Troch. Ammonium Compound. ~B, Ext. glycyrrhizse • gr. i Cubebge ■ gr. i Pulv. ulrui cort. ■ gr. i. Ammonii chloridi • gr. iij. Acaciee et sacch. alb. .... . q.s. ad troch. 49. Guaiac and Ammonium Compound. ~Bf Ammonii chloridi • gr. i. Guaiaci resinse • gr. i. Potassii chloratis . gr. ij. ad. troch Potassium chlorate is more pleasant and more efficacious in compressed pills than in troches. ANTISEPTICS. 50. J} Acidi carbolici 51. ty Potassii chloratis (see Stimulants 19, 20). gr. i. ad troch. VAPOR INHALATIONS. Mackenzie's eclectic inhaler is the most complete, but some of the cheaper instruments will answer the same purpose. An inhaler which is in common use consists of a glass flask holding about a quart. This has a perforated cork, through which two glass tubes are passed, one to the bottom of the flask to admit the air, and the other, through which the patient inhales the vapor, into its upper part. In the absence of an inhaler an earthen tea- pot may be employed. I sometimes place the medicine in a pint of water in a small tin pan which is then covered by a cone of paper from the top of which the patient inhales. The inhalations are prepared by adding a tea- spoonful of the medicated solution to a pint of water, at a temperature of about 150° F. or as indicated by the formula. They should be used morn- ing and evening for about five minutes each time, six respirations being taken per minute. The oleaginous or balsamic remedies should be rubbed up with light car- bonate of magnesium, in order to maintain their suspension in the water, as shown in the following formula : 52. I? Olei cajuputi ni viij. Mag. carb. lev. gr. v. Aqua ad fl. 3 i. M. S. A teaspoonful in a pint of water at 150° F., for each inhalation. The vapors may be sedative, antispasmodic, antiseptic, or gently or strongly stimulant. 050 APPENDIX. SEDATIVES. 53. 1$ iEtheris et alcoholis, 54. ~Bf Chloroformi et alcoholis 55. Bf Lupulinae . 56. 3} Ext. belladonnae vel Ext. strainonii . 57. 1$ Ext. opii . 58. 1$ Tinct. benzoini conip. 59. J} Tinct. opii camph. . ANTISPASMODICS 60. I? iEtheris vel chloroformi (as in 53, 54). 61. J$ Amyl nitritis aa aa . gr. xxx. gr. v. ad fl. 3 i. gr. v. ad fl. 3 i. fl. 3i. fl. 3i. tti viij. ad fl. 3 i. MILD STIMULANTS. 62. J^ Olei pini sylvestris 63. 1$ Olei cubebae 64. 1$ Olei cassiae Olei limonis M. 65. I? Olei anisi tii xl. ad fl. § i. 3 ss. ad fl. 3 i. nivi. tti x. ad fl. 3 i. tii vi. ad fl. § i. 66. 3 Olei myrti m vi. Camphoise gr. v. ad fl. \ i. M. 67. 1} Terebene 3 i. Alcoholis 1 i. M. 68. More stimulating than the above, and antiseptic. J^ Acidi carbolici gr. xx. ad fl. 3 i. 69. ~R, Creasoti tti xl. ad fl. 3 i. 70. I* Olei cari tti vi. ad fl. | i. 71. 1$ Olei juniperi tti xx. ad fl. 1 i. 72. ~Bt Acidi carbolici gr. xxx. Ammonii chloridi gr. xxx. Glycerin* 3 i. Aquae dest § i. M. 73. I? Tinct. iodi comp. Glycerin* . Aquae dest. M. 74. 3 Creasoti Glycerinae . Aquae dest. M. tti v. 3i. 3 vij. . 3 ss. . 3ij. q.s. ad f i. SPRAY INHALATIONS. 651 To. R Hydrargyri chloridi corrosiv xt^ •jlycerinje 3 ij. Aqua? dest. § i. M. STRONG- STIMULANTS. 76. R; Olei calami arom m v. ad fl. 3 i. 77. R Olei caryophylli m x. ad fl. 3 i. 78. R Tinct. iodi eornp ^l x. S. Repeat two or three times at each inhalation. 79. R Aquae ammonia et aquae aa fl. 3 iv. SPRAT INHALATIONS. Spray inhalations are to be used by the physician or patient in full strength, with the compressed-air atomizer ; the aqueous solutions may be used in about double strength by the steam atomizer. These applications are useful principally in treating diseases of the fauces and of the nasal cavities. It is almost impossible for the patient to draw them into the larynx. The inhalations maybe classified as sedatives, astringents and stim-. ulants. haemostatics, and antiseptics. SEDATIVES. 80. R Potassii bromidi gr. xx. ad fl. § i. 81. R Cocainse hydroehloratis . . . . gr. xl. to lx. ad fl. § i.. M. 82. R Ext. pinus canadensis dest 3 ss. Olei geranii t^L iv, Olei petroling vel liquid albolene . . q.s. adfl.fi. IT. 83. R Antipyrini gr. x. Zinei sulph gr. ij. Ext. hamamelidis 3 i. Aquae dest, q.s. adfi. M. 84. R Acidi carbolici gr. iiss, Mentholis gr. v. Liquid albolene 1 i. M. 85. R Acidi hydrocyanici dil. . . . \ . 3 ss. ad fl. 3 i. To be used only as a cold spray. 86. R Acidi carbolici gr. i. Sodii boratis Sodii bicarb aa gr. ij. Grlycerinae 3 i. Aquas dest. q.s. ad|i, M. 87. R^ Olei petrolinte vel liquid albolene. 652 APPENDIX. 88. K Acidi tannici 89. K Zinci sulphatis . 90. K Zinci ehloridi 91. $ Aluminis . 92. V Ferri perchloridi m. r M. 94. 3 M 95. 3 ASTRINGENTS AND STIMULANTS. gr. iij. ad fl. § i. gr. ij.-x. ad fl. § i. gr. ij.-x. ad fl. § i. gr. x. ad fl. I i. gr. iij. ad fl. § i. Morph. sulph gr. iv. Acidi tannici Acidi carbolici aa gr. xxx. Glycerin* Aqu« dest aa fl. § ss. Acidi tartarici gr. i. Acidi carbolici Zinci sulph • . . aft gr; ij. Aqua? dest. fl. 3 i. Acidi tartarici gr. ij. Zinci sulph. gr. xv. Aqua? dest. fl. 3 i. M. 96. I? Acidi tartarici Zinci sulph. Aqu« dest. M. 97. 1} Acidi tartarici Zinci ehloridi Aqua? dest. M. gr. iij . gr. xxx. fl. si- gr- ij. gr. xv. fl. I i. 98. ^ Acidi tartarici Zinci ehloridi Glycerinae . Aqua? dest. M. 99. Bf Ext. hamamelidis dest. 100. 1$ Acidi carbolici . Glycerin* . Aqua? dest. gr. ii J. gr. xxx, 3 iij. Mi- Cupri sulphatis Aquae dest. M. 101. 3 M. 102. 3 Cupri sulphatis Aqua- dest. M. 103. 3 M. Acidi carbolici . Ext. pinus canadensis dest Liquid albolene gr. xl. 3i. 5i. gr. x. fl. = i. gr. xx. fl.§i. gr. xxx. ni xx. q. s. ad fl. 3 i. SPRAY INHALATIONS. 104. 1$ Acidi carbolici . ....... gr. ijss. Mentholis . gr. v. Liquid albolene fl. 1 i. M. 105. I£ Acidi carbolici tti i. Mentholis gr. i. Olei gaultheriae . . . . . . . tu i. Liquid albolene fl. 3 i. M. 106. 3 Olei caryophyl . . tti v. Liquid albolene fl. 1 i. M. 107. I£ Olei caryophyl ^l viij. Terebene . . tti xx. Liquid albolene q.s. ad fl. § i. M. 108. IJ Fl. ext. thuja occidentalis. 109. I£ Aluminis pulv gr. xxx. Grlycerini 3 iv. Aquae dest q.s. ad fl„ S i. M. HEMOSTATICS. 110. I£ Ferri chloridi gr. v. ad fl. 3" i. 111. I£ Acidi tannici . gr. x. ad fl. § i. 112. IJ Liquor, ferri chloridi 3 ij. Aquse dest. q.s. ad fl. § i. 653 ANTISEPTICS. 113. 1$ Sodii benzoatis . 114. I£ Aquse calcis 115. 3$ Bromini 116. ~Rf Acidi lactici 117. ^ Potassii permanganatis 118. J$ Potassii chloratis 119. I£ Acidi borici 120. IJ Listerine 3 i. ad fl. § i. fl.§i. gr. ss. ad fl. § i. ttl. xx. ad fl. 3 i. gr. v. ad fl. 3 i. gr. xx. ad fl. § i. gr. x. ad fl. § i. 3 i.-ij. ad fl. § i. 121. 1$ Hydrogen perioxiduni. This is used in full strength as purchased at the drug store, or diluted with one or two parts of water, according to the amount of smarting produced. 122. 1$ Acidi tartarici Hydrarg. chlorid. corrosiv. Aquae dest. M. gr. iss. gr. ss. fl.!i. 654 APPENDIX DRY INHALATIONS. Dry inhalations are composed of substances which volatilize at ordinary temperatures, or simply by the heat of the hand. They may be used with any of the instruments which are ordinarily used for vapor inhalations, or they. may be easily inhaled from a small wide-mouthed bottle in the bottom of which the medicine has been placed on a sponge. One of the simplest and most efficacious inhalers for dry preparations consists of a glass tube about four or five inches in length, open at both ends, and holding a small sponge at its middle. The remedy is dropped on the sponge, and air is inspired through the tube. When the substances are used with the small glass-tube inhaler, the amount given for each inhalation should be divided into three or four parts which are to be used successively. If the effect is only needed in the throat and nose, the solution may be concentrated so that the same amount of medicine will be obtained without repeatedly charging the inhaler. In this case, the patient should not inspire deeply, and only two or three inhalations should be taken per minute. These inhalations may be sedative or stimulant. SEDATIVES. 123. R Acidi hydrocyanici diluti fl. 3 i. ad fl. % i. S. A teaspoonful at each inhalation. 124. R iEtheris. S. A half-teaspoonful at each inhalation. 125. R Amyl nitriti H i. Alcoholis HI xxx. M. S. Use at each inhalation. This is useful, especially in spasmodic affections. 126. R Olei santali albi mi. Alcoholis tti xxx. M. S. To be used at each inhalation in divided doses. 127. R Chloroformi fl. 3 ss. S. To be used at each inhalation ; to be breathed slowly. STIMULANTS. 128. R Tinct. iodi m x.-xxx. In this same category may be included the carbonate of ammonium and camphor, used as smelling-salts; and nascent chloride of ammonium, used by any of the inhalers constructed especially for that purpose. FUMING INHALATIONS. Fuming inhalations are prepared by saturating bibulous paper with a solution of the remedy of a given strength, drying the paper, and then cut- ting it into twenty equal parts, each of which will contain one twentieth of the amount of medicine used. These strips may be rolled into cigarettes, or they may be burned under a funnel which will conduct the smoke to the mouth. They are employed in asthma and spasm of the larynx. The prin- cipal medicines employed in this manner are : 129. R Potassii arseniatis gr. xv. 130. R Sodii arseniatis gr. xx.-xl. 131. R Potassii nitratis gr. xxx.-lx. Aqua? ad fl. 3 i. PIGMENTS. Coo The three latter may be modified, as recommended in the Throat Hospital Pharmacopoeia, by the addition of various volatile principles. These vola- tile substances are added by moistening the nitre paper in a tincture, or, in the case of volatile oils, in a solution, of one part of the oil to nine parts of alcohol, and then exposing the paper to the air a few minutes to allow the alcohol to evaporate. The papers must be freshly prepared and kept in tinfoil. The following are the preparations most useful: SEDATIVES. 132. Nitrated papers with tinct. benzoini comp. 133. Nitrated papers with tinct. hyoscyami vel stramonii. 134. Nitrated papers with oleum santali. 135. Nitrated papers with oleum sumbuli. STIMULANTS. 136. Nitrated papers with spts. camphors. 137. Nitrated papers with oleum cinnamomi. 138. Nitrated papers with oleum cassise. PIGMENTS. The name pigments is given to the various mixtures which are designed for topical application by means of a brush, a probang wound with cotton, or by the compressed-air atomizer ; the latter is now almost invariably employed in preference to the brush or probang. They may be prepared with water or with glycerin, but it should be remembered that the latter is irritating to some throats. The pigments may be anaesthetic, astringent, stimulant, or antiseptic in their effects. LOCAL ANiESTHETICS. 139. R Morphinae sulphatis : gr. iv. Acidi carbolici gr. xxx. Glycerini fl. 1 i. M. Thirty grains of tannin may be added, when a slightly astringent effect is desired. 140. I? Atrophias gr. ^ Strophanthin gr. A Olei caryophylli . lT l iij. Acidi carbolici . ... . . . gr. x. Cocainae hydrochloratis gr. xx. Aquae dest fl. 3 i. M. 141. R Chloral . . . 3 i. Aquae ad fl. 1 i. M. 142. R Morphinae sulphatis . . . . . . gr. xx. Chloroformi ad fl. % i. M. 143. R Sol. cocainae 10% to 25$ This solution is rarely used for any other purpose than that of produc- ing anaesthesia of the faucial surfaces — where the throat is hyper-sensitive — to facilitate an examination of the pharyngo-larynx. 656 APPENDIX. 144. 145. 146. 147. 148. 149. 150. 151. 152. 153. 154. 155. 156. 157. 158. 159. 160. ASTRINGENTS. ~B, Zinci ehloridi R Zinci sulphatis I£ Ferri et auimonii sulphatis ~B, Liquor ferri ehloridi . R Aeidi tannici Glyeerini .... M. STIMULANTS AND CAUSTICS K Zinci ehloridi ~R, Cupri sulphatis . ~B, Liquor ferri ehloridi . ~B, Argenti nitratis . ~B, Liquor hydrargyri nitratis I? Tinct. iodi .... n lodi Glyeerini .... M. 1$ Argenti nitratis . R Argenti nitratis . R Argenti nitratis . 3 Tinct, iodi. R Liquor iodi couip. ANTISEPTICS. 161. 1$ Aeidi carboliei gr. x. ad fl. 1 i. gr. x.-xxx. ad fl. % i. gr. xxx. ad fl. § i. tti xl. ad fl. 3 i. 3ij. ad fl. I i. gr. xxx. ad fl. 3 i. gr. xx. ad fl. 3 i. fl. l ij. ad fl. 3 i. 3 ss. to 3 i. ad fl. § i. Tq. xl. to 3 ij. ad fl. § i. ?i. gr. xxx. ad fl. 3 i. gr. lx. ad fl. 3 i. gr. xl. ad fl. 3 i. gr. x. ad fl. 3 i. gr. xxx. ad fl. 1 i. INSUFFLATIONS. Powders have been extensively used in the treatment of nasal and laryn- geal affections. I am accustomed to dilute most of the drugs which I em- ploy in powdered form with from one to four parts of sugar of milk, acacia, or starch. Of the following powders, two or three grains are used at each insufflation. SEDATIVES. 162. 'B, Bismuthi carbonatis. 163. R Morphine sulphatis gr. £-gr. i Bismuthi carbonatis gr. ij. M. Tannin or iodoform may be added. 164. R Morph. sulph gr. iv. Bismuthi subnit 3 iv. Amyli 3 i. M. 165. R Morphine gr. v. Iodol Bismuthi subnit. Sacch. lact. aa gr. xxx. M. INSUFFLATIONS. 657 166. ~R, Sodii biearbonatis Sodii boratis aa gr. iss. Amyli gr. i Cocainfe hydrochloratis gr. iv. Saech. lact. . . . . . . . q. s. ad gr. C. M. 167. ~Rf Cocaine hydrochloratis gr. x. Atropine . . gr. i Mag. earb. levis gr. xv. Sacch. lact. q. s. ad gr. D. M. 168. 1^ Cocaine hydrochloratis . . . . . gr. x. Atropine gr. -J- Morph. sulph. Mag. carb. levis aa gr. xv. Sacch. lact . . q. s. ad gr. D. M. ANTISEPTICS AJtD STIMULANTS. 169. I£ Acidi borici 170. 3 Iodol 171. 3 Iodoforrui Acidi borici . . „ , . , . aa gr. 1. M. 172. ^ Iodoforrni gr. 1. Bisrnuthi subnit. Benzoini res. . aa gr. xxv. M. 173. 3 Iodoforrni. ASTRINGENTS AND STIMULANTS. 174. I£ Hydrastum muriatis gr. xxv. Acaciae . q. s. ad gr. C. 175. I£ Pulv. res. myrrha3. 176. I£ Morph. sulph gr. v. Acidi tannici „ gr. xxv. Pulv. Andersonii . , . „ . . § i. M. 177. ^ Benzoini res. Bismuthi subnit. . aa gr. 1. M. 178. ^ Bismuthi subnit. 179. 3 Hyd. chlor. mitis. 180. 3 Aluminis Sacch. albi . . . , . , . „ aa gr. 1. M. 181. 3$ Antipyrin. Cocain* hydrochloratis . . . . . aa gr. x. Mag. carb. levis ...».,. gr. xv. Sacch. lact. . . . , . „ , q. s. ad gr. D. M. 42 658 APPENDIX. NASAL DOUCHES. The following preparations may be used as insufflations or by the anterior or posterior nasal douche or syringe, for detergent or antiseptic purposes. They should always be used warm, and may be followed by more potent remedies. The amount given below should be added to a pint of water at blood heat, and part or all of it used at each application. 182. 3 Sodii chloridi 183. ^ Sodii bicarbonatis 184. 1^ Potassii permanganatis 185. I£ Acidi carbolic! 186. ~S, Zinci sulpho-carbolatis 187. Salicylate Wash. 'St, Sodii salicylates Sodii biboratis Sodii bicarbonatis Sodii chloridi M. S. 3 i. ad aqu« tepidaj i. 3 i 3 i- gr. iii. £»•• XXV gr. XXV a a I vi. iia 3 x. INDEX. It has been deemed best to give a synopsis of the articles on each disease and its differentiations, using abbreviations that ivill need no explanation to the profession. Abdominal breathing, 11 Abscess, infraglottic, due to syphilis, 430 of the larynx, illus., 429, 430 symp. , 429 ; diag. , ■ prog. , treat. , 430 ; diff. fr. croup; fr. retro-pharyngeal abscess, fr. acute catarrhal inflamma- tion, fr. oedema. 430 of the lung, 129-131 symp. , 129 ; diag. , 130 ; prog. , treat. , 131 ; diff. fr. bronchitis, fr. pneumonia, fr. pleurisy, 130 of the nasal septum, 603 diff. fr. cancer, 573; fr. hasmatoma, 602 of the tonsils, syn. of phlegmonous ton- sillitis, 368 retropharyngeal, 383-386 Abscission of the uvula, 359 Accentuation of the heart-sounds, 192 Acute and subacute bronchitis, 89, 90 anat., path., etiol., symp., 89 catarrhal laryngitis, syn. of acute laryn- gitis, 394 cold in the head, syn. of acute rhinitis, 522 coryza, syn. of simple acute rhinitis, 522 endocarditis, 219-222 syn.. anat., path., 219; etiol., symp., diag., 220; prog., treat., 221 diff. fr. pericarditis, 220 follicular glossitis, symp., diag., prog. treat., 347 follicular pharyngitis, 339, 340 anat., path., etiol., symp., diag., 339; prog., treat., 340 diff. fr. simple acute sore throat, 339 follicular tonsillitis, diff. fr. mycosis, 376, 377 inflammation and oedema of the uvula, treat., 358 laryngitis, 394-397 syn., anat., path., etiol., symp., 394; diag., 395; prog., treat., 396 diff. fr. spasm of the glottis, fr. croup, fr. paralysis of the vocal cords, fr. foreign bodies, 395, 396; fr. croup, 414 ; fr. retropharyngeal abscess, 430 miliai - y tuberculosis, 165-167 [166 anat., path., etiol., 165; symp., diag., diff. fr. other forms, 166, 167 myocarditis, 231 nasal catarrh, syn. of simple acute rhini- tis, 522 Acute oesophagitis, 632, 633 etiol., symp., 632; diag., prog., treat., 633 pericarditis, 212 pleurisy, 61-72 etiol., symp., 62; diag., 68; prog., 71 ; treat. , 72 diff. fr. pleurodynia, fr. pericarditis, fr. pneumonia, fr. phthisis, fr. col- lapse of the lung", fr. cancer, fr. hy- pertrophy of the liver and spleen, 68- 71 : f r. abscess of the lung, 130 ; fr. angina pectoris, 251 pneumonia, syn. of lobar pneumonia, 113 rheumatic sore throat, 316, 317 anat., path., etiol., symp., 316; diag., prog., treat., 317 diff. fr. acute sore throat, 312, 323 rhinorrhea, syn. of simple rhinitis, 522 sore throat, 311-314 syn., anat., path., etiol., symp., 311; diag., 312; prog., treat., 313 diff. fr. scarlatina, fr. acute tonsil- litis, 312; fr. acute rheumatic sore throat, 312, 324; fr. sore throat of scarlet fever, 324 ; fr. acute follicular pharyngitis. 339 sthenic pneumonia, syn. of lobar pneu- monia, 113 tonsillitis, 362-367 syn., 362; anat., path., etiol., symp., 363: diag., 364; prog., treat., 366 diff. fr. acute sore throat, 312; fr. scarlatina, fr. diphtheria, fr. sup- purative tonsillitis, fr. syphilitic sore throat, 364-366 tubercular phthisis, diff. fr. lobular pneu- monia, 127 tubercular sore throat, 350-353 anat., path., etiol., symp., 350; diag., 351 ; prog. , treat. , 352 diff. fr. rheumatic sore throat, 320; fr. chronic follicular pharyngitis, 344; fr. syphilitic sore throat, 351, 352, 355; fr. scrofulous sore throat, 350, 351, 352 tuberculosis diff. fr. emphysema, 111 Adams' clamp, 596 Adenoid growths in the vault of the pharynx, syn. of hypertrophy of the pharyn- geal tonsil, 613 Adenomata, 467 660 INDEX. Adhesion in syphilitic sore throat, 355 of the inner surfaces of the arytenoid cartilages, diff. fr. bilateral paraly- sis, 513 Adirondacks for phthisis, the, 175 Adventitious sounds, 48-54 iEgophony, 55, 57 Aerial goitre, syn. of tracheocele, 486 Age modifies percussion sounds, 27 Aitken, membranous croup, 411 Albolene in inhalations or sprays for throat and nose, 95, 441, 530, 535, 538, 557, 568, 587 Alcoholic stimulation in bronchitis, 98; in pul- monary phthisis, 171 ; in acute endo- carditis, 221 ; in chronic endocar- ditis, 224; in angina pectoris, 252; in erysipelatous sore throat, 316; in diphtheria, 335; in syphilitic laryn- gitis, 448 Algiers for phthisis, 176 Allen, Harrison, inequality of the choanse, 309; galvano-cautery, 544 Allingham, mouth gag, illus., 419, 617 Allison, Scott, stethogoniometer, illus., 18; differential stethoscope, illus., 37 Alps, goitre in the, 629 Ambidexterity in examination of the larynx, 285 American Journal of Medical Sciences, con- tagious pneumonia, Wagner, 116; diphtheria, Prudden, 329; congenital syphilis, John N. Mackenzie, 449; lupus, G. M. Lefferts, 451 ; laryngec- tomy, George B. Fowler, 483 Laryngological Association, Transactions, Registers of male and female voices, Thomas R. French, 298; choanal un- equal, Allen, 309; acute tubercular sore throat, Delavan, 352; leucoplakia buccalis, Ingals, 362; chromic acid in trachoma, Charles E. Sajous, 408 ; tubercular laryngitis, Jarvis, 441 ; feeding in laryngitis, Beverly Rob- inson, 443; snare forceps, Jarvis, 473 ; thyrotomy, Joseph Leidy, 475 ; laryngotomy, Cohen, 482; chorea laryngis, George M. Lefferts, E. Holden, 501; same, F. I. Knight, 501. 502; falsetto voice, J. C. Mulhall, 503; laryngeal vertigo, F. I. Knight, 504; relation of hay fever and condi- tions in the nasal passages, William H. Daly, 553 ; nasal cancerous tumors, R. P. Lincoln, 573; deflection of tin' nasal septum, D. Bryson Delavan, 594; same, D. N. Rankin, 605; rhino- laryngitis, Beverly Robinson, 609; extirpation of nasal tumors, Lincoln, 622 Amphoric cough, 59; resonance defined, 30; respiration, 41, 46, 47; sound, 41; voice, 55, 57; whisper, 58 Amygdalitis, syn. of acute tonsillitis, 362 Amyl nitrite in chronic endocarditis, 229 Anaemia, diff. fr. endocarditis, 226; fr. tuber- cular laryngitis, 437 Anaemic, haemic or organic murmurs, 196, 204; diff. fr. atheroma, 256 Anaesthesia of the larynx, 499, 500; etiol., symp., diag., prog., treat., 499; of the pharynx, etiol., prog., treat., 388 produced generally, 495, 582, 606 produced in tubercular laryngitis, 442 produced locally, 74, 80, 266, 407, 409, 422, 457, 484, 495, 544, 568, 597, 598, 425, 442 Anaesthetics, pigment, 655 Anatomy and physiology of the heart, 177-180 Anchylosis of the arytenoid cartilages, 514, 515; diag., treat., 515 Anemone pratensis. unsatisfactory in per* tussis, 155 Aneurism, aortic or thoracic, 16, 256-266 of the aorta, diff. fr. acute pleurisy, 70; fr. solid tumors, 262; fr. aortic pul- sation, fr. pulsating empyema, 263; fr. dilated auricle, fr. consolidation of the lung, 264 ; f r. aneurism of the pulmonary artery, 265 of the arch of the aorta, 257 of the arteria innominata, 265, 266 of the ascending aorta, illus., 209 of the descending aorta, 257 of the heart, etiol., diag., prog., treat., 245 of the pulmonary artery, 264. 865 diff. fr. aneurism of the aorta, 265 of the sinuses of Valsalva, 257 Aneurismal murmur, diff. fr. mitral, 198 Aneurismatiscope, the, 261 Angina diphtheritica, syn. of diphtheria, 328 epiglottidea, syn. of acute laryngitis. 394 laryngea, syn. of acute laryngitis, 394 membranosa, syn. of diphtheria, 328 pectoris, 250-253 etiol., 250; symp., diag., prog., 251; treat. , 252 diff. fr. pseudo-angina, fr. intercostal neuralgia, fr. acute pleurisy, fr. myalgia, 251, 252 Angiomata, or vascular tumors, illus., 467, 468 of the nose, syn. of vascular nasal tumors, 570 Annales de Gynecologie et d'Obstetrique, diphtheria, Roux and Yersin, 336 des Maladies de TOreille, fractures of the larynx, Panas, 489 Annual of the Universal Medical Sciences, distoma pulmonale, 151 ; pseudo diphtheria, Smith and Warner, 329 diphtheria infectious through cloth ing or furniture, Grancher, 334 spasm of the glottis, Lubet-Barbon 496; rhinitis, Raulin, 532; nasal os seous cysts, Macdonald quoted by Charles E. Sajous, 570; adenoid growths in deaf-mutes, Wr6blewski, 614 Anomalous heart sounds, 205 Anorexia in tubercular laryngitis. 437 Anosmia, 591, 592 etiol., 591; symp., diag., prog., treat., 592 Anstie, F. E., value of sphygmograph, 211 INDEX. 661 Antipneumotoxin in pneumonia, blood seram or, 123 Antipyrine in whooping cough, 155; in rheu- matic sore throat, 317 Antiseptic gargles, formulae for, 647 lozenges, formulae for, 648 vapor sprays, formulae for, 653 and stimulant insufflations, formulas for, 657 pigments, formula? for, 656 Antispasmodic vapor inhalations, formula? for, 650 Antrum, empyema of the, 579-583 of Highmore, ilfus., 302, 579 Aorta, the, 179 aneurism of the (see aortic or thoracic aneurism) aneurism of the ascending, 209 aneurism of the descending, 257 atheroma of the, 254-256 coarctation of the, 266, 267 rupture of the, 255 Aortic aneurism, diff. fr. pulmonary cancer, 148 area, illus., 198, 199 endarteritis, syn. of atheroma of the aorta, 254 murmurs, 198-200 obstruction, illus., 209, 225, 230 or thoracic aneurism, 14, 256-266 anat., path., etiol., 256; symp., 258; diag. , 262; prog., treat., 265 diff. fr. chronic endocarditis, 226, 227; fr. eccentric cardiac hypertro- phy, 238; fr. solid tumors, fr. aortic pulsation, fr. pulsating empyema, fr. dilatation of the auricle, fr. aneurism of the pulmonary artery, fr. consoli- dation of the lung, 262-265 pulsation, diff. fr. aneurism, 263 regurgitant murmurs, 200 regurgitation, illus., 209, 225, 228, 230 semilunar valves, 178 valves, 7; disease of, 256 Aortitis, 254 Apex -beat of the heart, 10, 182, 184-185 Apex, pleurisy of the, 82 Aphonia, functional, hysterical, or nervous, syn. of bilateral paralysis of the lateral crico-arytenoid muscles, 508 Aphonic pectoriloquy, 58 Aphthous sore throat, syn. of simple mem- branous sore throat, 324 Apneumatosis, syn. of pulmonary collapse, 139 Apoplexy, pulmonary, 15, 137, 138 Applicator, chromic acid, 409; for intubation tubes, illus., 420; cotton, 568; post- nasal snare, 623 Arch of the aorta, aneurism of the, 257 Arching of the tongue an obstacle to laryn- goscopy, 290 Archives GSnerale de Medecine, erysipelatous sore throat, Cornil, 314: erysipela- tous laryngitis, Cornil, 428 Archives of Laryngology, trachoma of the vocal cords, Carlo Labus, 408; lupus of the larynx, F. I. Knight, 451 Archives of Pediatrics, influenza, Charles W. Earle, 520 Area of cardiac impulse, 185; of cardiac dul- ness, flatness, 189; of cardiac sounds, 191; valvular, 197: of endocardial murmurs, illus , 198 Argand lamp for laryngoscopy, 279, 281 Arizona for phthisis, 175 Arteria innominata, aneurism of the, 265 Arterial diseases, cardiac and, 212-268 Artificial light to illuminate the larynx, direct, indirect, 275 Ary-epiglottic folds, 296 muscles, paralysis of the thyro-epiglottic and, 505 Aryteno-epiglottidean folds, 296 Arytenoid cartilages, illus., 296 cartilages, anchylosis of the, 514, 515 muscle, paralysis of the, 511 Asch, Morris, lupus of the larynx, 451 Aspiration in acute pleurisy, 72; in subacute pleurisy, 73-75; in chronic pleurisy, 78; in abscess of the lung, 131; in pericarditis, 217 Aspirator, mode of using the, 73-75 Asthenia in diphtheria, 333; in acute tubercu- lar sore throat, 352 Asthma, 102-105 anat., path., 102; etiol., 103; symp., 104; diag., prog., 105; treat., 106 diff. fr. bronchitis, 92; fr. capillary bronchitis, fr. spasmodic laryngeal affections, fr. emphysema, fr. cardiac dyspnoea, 105; fr. stenosis of the larynx, 457; fr. hay fever, 554 Asthmatic hay fever, 554 Astringent and stimulant insufflations, form- ulae for, 657 and stimulant spray inhalations, formula? for, 652 gargles, formulas for, 649 lozenges, formulas for, 643 pigments, formulas for, 656 Asystolism, 241 Atelectasis, syn. of pulmonary collapse, 139 Atheroma of the aorta, 254-256 syn., anat., path., etiol., 254; symp., diag., 255; treat., 256 diff. fr. disease of the valves, fr. anaemic murmurs, 256 Atheromatous degeneration of the aorta, syn. of atheroma of the aorta, 254 Atomizer, 401, 402; for oil, 536 Atrophic follicular pharyngitis, 343 rhinitis, 528, 547-552 anat., path., 547; etiol., symp., 548; diag., prog., 549; treat., 550 diff. fr. lupus, fr. syphilis, fr. sup- puration, fr. rhinoliths, fr. foreign bodies, 549; fr. chronic suppurative ethmoiditis, 586 Atrophy of the heart, syn. diag., 242 of the vocal cords, 515 Auricles of the heart, 178 662 INDEX. Auricular systole. 182; illus.. 201 Auscultation. 9. 34-47: mediate, immediate. 34: rules for. 38; in health, 39-41; in disease. 41-47; over the heart. 189; in aneurism of the aorta, 261 Auscultatory percussion. 32-33 Austria, rhinosclerma in, 588 Austrian mountains for phthisis. 175 Autumnal catarrh, syn. of hay fever, 553 Avenbrugger. percussion. 21 Avery, laryngoscopy, 272 Axillary region, 4, 8 Babbingtox. laryngoscopy, 272 Bacilli, tubercle, 157; transmitted to foetus, 158; staining, 164. 165; in endocardi- tis, 222: in lupus of the larynx, 451 Bacillus, Klebs-Loffler, diph., 329 mallei, glanders, 589 tuberculosis. 578 Bacteria in pericarditis purosa, 212; in ulcer- ative pericarditis, 222; in hypertro- phy of the tonsils, 370 Balfour, G. W. . quality of murmurs of the heart, 200; heart disease, 247; brady- cardia. 250; mode of administering chloroform in angina pectoris, 252 Barker, Fordyce, turpeth mineral in croup, 417 Barrel -shaped chest, 12 Base of heart, to find, 188 Basedow's disease, syn. of exophthalmic goitre, 632 Battery, galvano-cautery, 345 Baumes, laryngoscopy, 272 Bazin, leucoplakia buccalis, 360 BelfieW, W. T. , guaiacol in phthisis. 173; iodine trichloride in surgery. 441 Bell sound in percussion. 31 Bellocq, laryngoscopy, 272; canula, 306 Benign growths in the larynx, illus., 466-476 synip.,466; diag.,467; prog. , treat.. 4C9 diff. fr. syphilis, fr. tubercular laryn- gitis, fr. lepra, lupus, outgrowths, fr. eversion of the ventricles, fr. malig- nant tumors, 467-469; fr. malignant tumors, 479, 573 Bennatti, laryngoscopy, 272 Berberine, identical with hydrastine, 95 muriate in chronic laryngitis, 407; in rhino-pharyngitis, 610 Berliner klinische Wochenschrift, tubercles in 1 in i jr. Yin -how. 107; sound in em- physema. Gerhardt, 109; pneumonia contagious. Kuhn, 116; blood serum or antipneumotoxin in pneumonia, Klemperer, 123; dislocation of the larynx, H. Braun.490; operations on the antrum. Krause, 582 Best, J. E.. furunculosis of the nose, 559 Biegauski, pleurisy, 66 Bilateral paralysis of the lateral crico-ary- tenoid muscles, illus., 508-510 syn., etiol. , symp., 508; diag., treat., 510 paralysis of the posterior crico-arytenoid muscle, illus., 511-513 Bilateral paralysis of the posterior crico-ary- tenoid muscle, anat., path., etiol., symp., 512; diag.. prog., treat., 513 diff. fr. adhesion of the inner surfaces of the arytenoid cartilages, fr. spasm, 513 Bilious pneumonia. 128, 129 Bilocular pleurisy, diff. fr. other forms. 83 Birch-Hirschfeld. F. V. , bacilli transmitted to fcetus. 158 Bird, hydatid cysts of the lungs, 149 Bizot, aortitis, 254 Black, G. V., cinnamon water antiseptic. 336 Blake, Clarence, snare for polypi. 567 Blanden, deflection of the nasa) septum, 595 Blood serum or antipneumotoxin in pneu- monia. 123 Blue disease, the, syn. of morbus cseruleus. 246 Bocelli, Guido, distinction between serum and pus. 77 Boileau, aortic regurgitation, illus., 209 Bokai, retropharyngeal abscess, 384 Bollinger, case of glanders eleven years, 590 Bone drill, 582 Bony tumors, nasal, 571, 572 Borgiotti. case of oesophageal spasm five hun- dred and thirty-one days. 638 Boric acid in cinnamon water highly effective in diphtheria, 336 Bosworth, tongue-depressor, illus., 271; tuber- cular laryngitis, 436; cancer in the larynx, 476; chronic rhinitis. 537. 545; mucous polypi in asthma, 565; saws. 601 Bougie, oesophageal. 390; olivary, 635 Boundaries of the heart, 188 Bouveret, L. . pleurisy, 76; tachycardia, 249 Bowditch. danger in washing pleural cavity, 78 Boyle, immediate auscultation, 34 Bozzini, laryngoscopy, 272 Bradycardia, treat.. 250 Brainard, bone drill, illus., 582 Braun, H., dislocation of the larynx, 490 Bristle extractor, illus., 642 British Medical Journal, cause of angina pec- toris, Douglas Powell. 250; diph- theritic bacilli, Armand Ruffer, 329 Broad condylomata, 353 Brodie, mode of applying mercury to infants, 577 Bronchial cough, 59 fremitus, 16 glands enlarged, 152, 153 respiration, 41, 45 tubes, fremitus in dilatation of the, 15 whisper, normal, exaggerated, cavernous, 58 Bronchiectasis or bronchicatasis, syn. of dila- tation of the bronchial tubes, 100; syn. of fibroid phthisis, 156 Bronchitis. 89-100; acute and subacute. 89, 90; chronic, 89, 90-95; capillary, 95-98; plastic, 99, 100 diff. fr. abscess of the lung, 130: fr. pulmonary gangrene, 145; fr. trach- eitis, 461 INDEX. 663 Broncho-cavernous respiration, 46 Bronchocele, syn. of goitre, 629 Bronchophony, 36; normal, 55; whispering, 58 Broncho-pneumonia, syn. of lobular pneu- monia, 123 Bronchorrhagia. 134 Bronchorrhcea, 92 Bronchotomy, 495 Broncho-vesicular or harsh respiration, 41, 44 Brooklyn Medical Journal, pneumonia con- tagious. Hatheson, 116 Brower, Daniel E., mode of ventilation in diphtheria, 334; exophthalmic goitre, 632 Brown induration, symp. , diag. , treat., 134 Browne, Lennox, diphtheria, 328, 334, 336; acute tubercular sore throat, 350, 351 ; hypertrophy of the tonsils, 373; spasm of the pharynx, 390; definition of croup. 411 ; syphilitic laryngitis, 443, 448. 449 : lupus of the larynx, 453 ; lepra of the larynx, 454; endo-laryn- geal cauterization in cancer, opera- tion of resection of the larynx, 481 Walton, epistaxis, 562 W. N. , large rhinolith, 604 Bruit de diable. syn. of venous murmur, 207 de pot fele, syn. of cracked-pot resonance, 31 Brans, Paul, pincette, illus. ,291; infra-thyroid laryngotomy, 476 Bulbar paralysis, progressive, 391 Bulletin de la Society de Chirurgie. deflection of the nasal septum, Chassaignac, 595 medicale des Vosges, cause of angina pec- toris, Liegeois, 250 Burns of the pharynx, scalds and, 392 Burrs, nasal. 546, 598 Bursa pharyngea, illus. , 309 Cabot, A. T.. pleurotomy. 76; drainage tubes, illus.. 79 Calculus of the tonsil, syn. of concretions of the tonsils, 375 California for bronchitis, 95; for phthisis. 175 Calomel in lobular pneumonia. 122: in acute sore throat, 313 ; in diphtheria, 33S Camman, stethoscope, illus., 32, 36 and Clark instituted auscultatory percus- sion. 32 Campbell, see Harries and Campbell Canadian Practitioner, siphon drainage in pleurisy. Powell, 79 Cancer (see also malignant) Cancer, diff. fr. leukoplakia buccalis. 362 of the larynx, diff. fr. chronic laryngitis. 403. 404; fr. syphilitic laryngitis. 447; fr. lupus, 453 of the pharynx, anat. . path., symp., 386; diag., treat., 387; diff. fr. chronic rheumatic sore throat, 320; fr. syph- ilis, fr. fibrous tumors, 387 of the tonsil, 380. 381 diag., 380; prog., treat.. 81 diff. fr. tubercular ulceration of the tonsils, 378; fr. hypertrophy, fr. syphilitic ulceration, 380, 381; fr. rhinoliths, 605 Cancer, pulmonary, 70. 146. 148 Cancerous growths, diff. fr. nasal mucous polypi. 566; fr. nasal bony tumors, 572 Capillary bronchitis, 95-98 anat., path., 95; etiol., symp., diag., 96; prog., treat., 98 diff. fr. phthisis, 98; fr. asthma, 97, 105; fr. lobar pneumonia, fr. lobular pneumonia, fr. pulmonary oedema, 97, 98 Carbon dioxide in asthma, 106 Cardiac and arterial diseases, 11, 183, 212-268 aneurism, 245 dilatation syn. of dilatation of the heart, 239 displacement, diff. fr. hypertrophy and dilatation of the heart, 238 dulness, 188-190 hypertrophy, 14 hypertrophy, eccentric. 236 hypertrophy, simple, 234-236 impulse, 185 murmurs. 195-211 origin of dropsy, indicated, 11 pulsation, 185, 187 region, form of the, 184 resonance, 25 sound, modified by disease, 185 Cardialgia, 247 Cardiectasis, syn. of dilatation of the heart, 239 Cardio-pleuritic friction murmurs, 196 Carious teeth, a soil for leptothrix buccalis, 376 Carroll, stethometer, illus., 17 Cartilages, arytenoid, 296, 514; of Santorini, of the larynx, of Wrisberg, 296 ; cricoid, tracheal, 299 Cartilaginous tumors, illus., 467 diff. fr. nasal mucous polypi, 566; fr. haematoma of the nasal septum, 602 Cary, Frank, mode of feeding after intuba- tion, 421 Caseous pneumonia, 156 Casselberry, Wni. E. , mode of feeding after intubation, 421 Catarrh, epidemic, 519; acute nasal, 522; chronic, 527; autumnal, 553 Catarrhal diathesis, 607 fever, epidemic, 519 hay fever, 554 laryngitis, illus., 399 diff. fr. diphtheria, 331; fr. croup, 413 pneumonia, syn. of lobular pneumonia, 123 sore throat, syn. of acute sore throat, 311 stage of croup, 412 Catarrhus aestivus, syn. of hay fever, 553 Caustics— pigments ; stimulants and, 656 Cautery electrodes, 346 in diseases of the throat, passim, 240-485; in diseases of the nose, passim, 530-637 Cavernous sound. 41 ; respiration, 46; whisper, 58; cough, 59 664 INDEX. Centralblatt fiir klinische Medicin, spasm of the fjesophagus, Borgiotti, 638 Cerebral croup, syn. of spasm of the glottis, 406 Chancre iu the throat, 353 Chassaignac, relation of generative organs and tonsils, 375; deflection of the nasal septum, 595; retro-nasal fibrous tumors, 621 Cheesy infiltration of the lung, 156 Chest, dimensions of the, 3-8; form of heal- thy, 9-12; pigeon breast, 10; barrel- shaped, 12; size of the, 17 Cheyne-Stokes respiration, 243 Chiari and Rield, lupus of the larynx, 451 Chicago Medical Journal and Examiner, tym- panitic resonance in pleurisy, Ingals, 66 Medical Record, resection of the ribs in pleurisy, A. B. Strong, 78 China, distoma pulmonale in, 150 Chloride of iron in erysipelatous sore throat, 316 Chlorine inhalation in phthisis, 172 Chloroform for angina pectoris, mode of ad- ministering, 252; a preferred anaes- thetic for children, 373. 495, 618; for chronic laryngitis, 407; for general anaesthesia, 422, 582; preferred to ether in tracheotomy, 425; for cough, 501; for myasis narium, 606 Choanae. the, illus.. 309 Chondritis and perichpndritis of the laryngeal cartilages, 433. 434 etiol.. symp. , 433; diag. , prog., treat., 434 Chorditis tuberosa, syn. of trachoma of the vocal cords, 408 Chorea laryngis, 501, 502 anat., path., etiol., symp., 501; diag., prog., treat., 502 diff. fr. hysteria, 502 Chromic acid applicator, 409 acid in trachoma of the vocal cords, 409; effect in rhinitis compared with that of galvano-cautery. 537. 541 ; in hy- pertrophy of the pharyngeal tonsil, 616 Chronic abscess of the nasal septum, diff. fr. mucous polypi, 565 bronchitis, 14, 89, 90-95 anat. , path. , 90 ; etiol. , symp. , 91 ; diag. , 92; prog., 93; treat., 94 catarrh, syn. of chronic rhinitis, 527; syn. of intumescent rhinitis, 531 catarrh of the larynx, syn. of chronic laryngitis, 398 coryza, syn. of chronic rhinitis, 527 endocarditis. 223-230 etiol., symp., 224; diag., 226; prog., 228; treat., 229 diff. fr. functional diseases of the heart, fr. pericarditis, fr. anaemia, fr. tho- racic aneurism, fr. fatty heart, fr. congenital deformity, 226. •_'.'; follicular glossitis, 347, 348 Chronic follicular glossitis, symp., diag., prog., treat., 348 diff. fr. rheumatic sore throat, 319 follicular pharyngitis, illus., 340-346 syn., 340; anat., path., etiol., 341; symp., 342; diag., prog., treat , 344 diff. fr. chronic rheumatic sore throat, 319; fr. syphilis, fr. tubercular sore throat, 344 follicular tonsillitis, syn. of hypertrophy of the tonsils, 370 inflammation and elongation of the uvula, 358-369 diag., treat., 359 laryngitis, illus., 398-408 syn., anat., path., 398; etiol., symp., 399: diag.. 402; prog., treat., 404 diff. fr. paralysis of the vocal cords, fr. cedema of the larynx, fr. tubercular or syphilitic laryngitis, fr. cancer, 402-404 myocarditis, 231 oesophagitis, 633, 634 etiol.. symp., diag., prog., treat., 633 pericarditis, 213 pharyngitis, syn. of chronic follicular pharyngitis. 340 pleurisy, 12, 76-82. 130 anat., path., etiol., symp., 76; diag., prog., 77; treat., 78 diff. fr. pneumothorax, fr. hydro-pneu- mothorax, 88; fr. pulmonary cancer, 147 pneumonia, syn. of lobular pneumonia, 123. 128; syn. of fibroid phthisis, 167 rheumatic laryngitis, syn. of chronic rheu- matic sore throat. 318 rheumatic sore throat, 318-321 syn., anat.. path., etiol., symp., 318; diag., 319; prog., 320; treat., 321 diff. fr. chronic follicular tonsillitis, glossitis or pharyngitis, fr. tubercu- losis, fr. cancer, fr. neuralgia, fr. tobacco sore throat, 319, 320 rhinitis. 527-552 syn.. 527 stenosis of the larynx, illus.. 456-459 anat.. path., etiol.. symp.. diag., 456; prog., treat., 457 diff. fr. asthma, fr. foreign bodies, fr. compression, fr. tumors, fr. paraly- sis of the abductors, 457 suppurative ethmoiditis. 585-587 etiol., symp., diag., 585; prog., treat., 586 diff. fr. mucous polypi, fr. atrophic rhiuitis with redema, fr. suppuration of the antrum, fr. emphysema of the sphenoidal and frontal sinuses, 585 tonsillitis, syn. of hypertrophy of the ton- sils. 370 tuberculosis, 156 diff. fr. other forms of phthisis, 166 Ciniselli, galvanic puncture in thoracic aneu- rism. 265 Circumscribed pleurisy, 82 INDEX. 665 Circumscribed pleurisy, diff. fr. hydatid cysts of the lungs, 150 Cirrhosis or scirrhus of the lungs, syn. of dilatation of the bronchial tubes, 100; syn. of fibroid phthisis, 156, 167 Clark, see Camman and Clark J. E., immunity to tubercular virus se- cured, 172; solution of iodine for goitre, 631 Clavicular region, 4 Clergyman's sore throat, syn. of chronic fol- licular pharyngitis, 340 Climatic treatment, subacute pleurisy, 75; bronchitis, 95, 100; asthma, 106; em- physema, 112; lobula rpneumonia, 128; pulmonary phthisis, 174-178; in- fluenza, 522; hay fever, 555, 558 Clinical Diagnosis, Jasch, bacilli in phthisis, 164 Closure of the post-palatine space obstructing rhinoscopy remedied, 305 Cloves in laryngitis, solution of, 442 Coarctation of the aorta, 266, 267 syn., 266; diag., treat., 267 Cocaine as an anaesthetic, 74, 80, 266, 290, 370, 374, 377, 407, 409, 422, 425, 457, 484, 491, 495, 537, 544, 568, 597, 598, 603, 616, 617, 655 as a sedative, 389, 501, 525, 527, 530, 538, 551, 556, 584, 587, 651, 657 caution in the use of, 352, 530, 556, 568 not to be used as a sedative in acute sore throat, 314 Cog-wheel respiration, 41, 43 Cohen, J. Solis, laryngeal illumination, 282; laryngeal examination, illus., 286; larynx of woman, illus., 295; simple membranous sore throat, 327; chronic follicular pharyngitis, illus., 343; scrofulous sore throat, 348; scalds and burns of the pharynx, 392; hy- pertrophy of the larynx, 455; benign laryngeal tumors, 463; malignant tumors on the larynx, 476 ; laryngec- tomy, 482; nervous cough, 499 ; laryn- geal paralysis, 509; spasm of the oesophagus, 637 Cohnheim, pulmonary thrombosis, 138 Coil of tubing to apply cold water in pneumo- nia, diphtheria, croup, 122, 335, 369, 416 (see Leiter coil) Cold applications in pneumonia, 122; in cer- tain diseases of the throat, 307, 329, 335, 361, 363, 369, 379, 386, 392, 408, 410, 416, 633; in nose bleeding, 552, 553 (see also Ice) Collapse of the jugular veins, 207 pulmonary, 139-142 Colorado for asthma, 106; for phthisis, 175; rhinitis in, 527 Compendium de Chirurgie Pratique, deflection of the nasal sectum. Blanden, 596 Complete extirpation of the larynx described, 482 Compression of the oesophagus, 637 Concretions in the tonsil, syn., etiol., symp., prog., treat., 375 Condylomata, syphilitic, 153, 468, 575 Congenital deformities of the heart diff. fr. chronic endocarditis, 226, 227 deformity of the nose, treat., 593 murmurs, 204, 246 syphilis of the nose, etiol., symp., diag., prog., treat., 577 Consolidation of the lung, diff. fr. hypertro- phy and dilatation of the heart, 237; fr. aortic aneurism. 264 Convulsive disorders diff. fr. retropharyngeal . abscess, 384, 385 Corea, distoma pulmonale in. 150 Corniculum laryngis, syn. of cartilage of San- torini, 296 Cornil, erysipelatous sore throat, 314; erysi- pelatous laryngitis, 428 Corvisart, syphilitic disease of the heart, 245 Coryza, acute, 522, 591; chronic, 527; syphi- litic, 567; in measles, 591 Cotton applicator, illus., 568 Cough, amphoric, bronchial, cavernous, 59; laryngeal, 59, 400; in hypertrophy of the tonsils, 371 ; irritative, nervous, 498 Cracked-pot resonance, 28. 31 Cramp of the oesophagus, syn. of spasm of the oesophagus, 637 Creaking or crumpling sounds, 53 Creasote for pulmonary phthisis, 173 Crepitant rales, 48, 51 rale redux, 118 Crequy, removal of foreign bodies in the oesophagus, 642 Crico-arytenoid muscles, paralysis of the, 508-514 Cricoid cartilage, illus., 299 Crico-thyroid muscles, paralysis of the, 506 Croup, membranous, 14, 411-426 tent, 416 Croupous bronchitis, syn. of plastic bronchi- tis, 99 pneumonia, syn. of lobar pneumonia, 113 Crumpling sounds, creaking or, 53 Crushing tumors with forceps, 474, 572 Csokor, transmission of bacilli to foetus, 158 Cuneiform cartilages, syn. of cartilages of Wrisberg, 296 Curable mitral regurgitant murmurs, 202 Curschmann, cause of asthma, 103 Curtis, H. Holbrook, chronic rhinitis, 537; wash -bottle, illus., 586; nasal trephin- ing, 601; vaporizer, illus., 612 Curved line of flatness in pleurisy, illus., 64, 65 Cutting forceps, right angle, 597 operations on laryngeal tumors, 474 Cyanosis, syn. of morbus cssruleus, 246 Cyclopedia of the Diseases of Children, pleu- rotomy, A. T. Cabot, 78; asthma among Hebrews, Saltmann, 103; double pneumonia, 115 Cyclopedia of Practical Medicine, rhinitis, C. J. D. Williams, 525 C3'nanche laryngea, syn. of acute laryngitis, 394 pharyngea, syn. of acute sore throat, 311 tonsillaris, syn. of acute tonsillitis, 362 666 INDEX. Cyrtometers, 17, is Cystic growths, illus. , 466; retro-nasal, 556 Cysts of the lungs, hydatid. 1-48-150 Czermak, laryngoscopy, 272 Da Costa, J. M., divisions of the chest, 3; tym- panitic resonance. 29, 30. 66; pneumo- pericardium. 018; irritable heart of soldiers. 049 Dakota for phthisis, 175 Daly, William H. . hay fever related to condi- tions in nasal passages. 553 Damoiseau, pleuritic symptoms. 64 Danforth. J. N., mixed sarcoma, 478 Davidson, atomizer, illus., 405, 406; oil atom- izer, illus.. 536 Deafness, throat. 610-613 De Cerenville. epilepsy following irritation of pleural surfaces, 78 Deferred expiration, 43 Deflection of the nasal septum, 594-597 anat., path., etiol., 594; syrup., diag., prog., treat., 595 Delafleld, pneumonia infective. 115 Delavan, D. Bryson, acute tubercular sore throat, 352; hemorrhage after ton- sillotomy. 375; leptothrix buccalis. 376; electricity in rhinitis, 552; em- pyema of the antrum, 579; deflection of the nasal septum, 594. 595 Demulcents, trochisci or lozenges, formula?, 648 Dennison, Charles, binaural stethoscope, 37 Dental Review, cinnamon- water antiseptic, G. V. Black, 336 Derbyshire neck, syn. of goitre, 629 Descending aorta, aneurism of the, 257, 258 Des Maladies du Sinus Maxillaire, multiple secretion of pus in the antrum, Gi- raldes, 579 Deutsche Chirurgie, tracheotomy, Max Schiil- ler, 486 Klinik, benign growths in the larynx. Lewin. 465 medicinische Zeitung, heredity in asthma, Lazarus, 100 medicinische Wochenschrift. pneumonia contagious, Mosler, 116; transmission of bacilli to foetus, F. v. Birch- Hirschfeld, 158; nasal tuberculosis, F. Halm. 578; differentiation of nasal affections, Max Schaeffer, 586 Medizinal-Zeitung. transmission of bacilli to foetus, Csokor. 158 Deutsches Archiv fin- klinische Medicin, dan- ger from heart in pleurisy, Leichten- stern, 71 Deviation of the septum, diff. fr. polypi, 565 Diagnosis, physical. 3 59 Diaphragmatic hernia, diff. fr. pneumotho- rax, 88 pleurisy. 71. 82 Diastole of the heart, 180 Diastolic murmurs. 203 Dicrotism, 210 Dictionnaire Encyclopedic des Sciences mgdi- cales, inflammation in removal of na- sal tumors. Oilier. 622 Diffuse abscess of the larynx, syn. of phleg- monous laryngitis. 427 aneurism, 256 pulmonary hemorrhage, syn. of pulmonary apoplexy. 137 Dilatation in laryngeal diseases, 449. 457. 459. 17-.'. 188,515; in stricture of the oeso- phagus, 635, 636 of the aorta, diff. fr. aortic aneurism. 204 of the bronchial tubes, 15, 100-102 syn., anat., path., etiol.. 100; symp., diag., 101; prog., treat., 102 diff. fr. phthisis. 101 ; fr. gangrene, 145 of the heart. 238-242 syn.. anat., path., etiol. 239: symp., ■.'in; diag. , prog.. 241 ; treat., 242 diff. fr. pericarditis, 241 : fr. myocar- ditis. 232; fr. eccentric cardiac hy- pertrophy. 237 hypertrophy and. 236-239 of the larynx. 457, 458 Dilated auricle, diff. fr. aneurism of the aorta, 364 Dilator, cutting, laryngeal, 458; for stricture of the oesophagus. 636 Diminished resonance, 55 Diphtheria, 328-338 syn.. anat., path., 328: etiol., 329; symp., 330; diag., 331; prog., 332; treat., &33 diff. f r. sore throat of scarlet fever, 323 ; fr. simple catarrhal or rheumatic pharyngitis, fr. tonsillitis, fr. ery- sipelas, fr. scarlatina, fr. simple membranous sore throat, fr. phleg- monous or erysipelatous sore throat, fr. phlegmonous or erysipelatous sore throat, 331, 332; fr. hypertrophy of the tonsils, 332; fr. acute tonsillitis, 365; fr. croup, 415; fr. phlegmonous laryngitis. 427 Diphtheritic laryngitis, 455 diff. fr. phlegmonous laryngitis, 427 Diphtheritis. syn. of diphtheria. 328 Diplococcus pneumoniae of Fraenkel. 115 Disease of the aortic valves, diff. fr. atheroma, 256 Disinfection in diphtheria, extreme, 334 Dislocation of the larynx, 490 of the nasal bones, treat.. 594 Dissecting aneurism, 256 Disseminated pneumonia, syn. of lobular pneu- monia, 123 Distoma pulmonale, 150. 151 symp., diag., treat., 151 Divisions of the chest, illus., 3-8 supra-clavicular. 4 ; clavicular. 4 ; infra- clavicular. 4, 5; mammary. 4, 5; in- fra-mammary, 4, 6; supra-sternal, 4, 6; sternal. 4, 6; superior sternal, 4, 16; inferior sternal. 4, 7: supra-scap- ular. scapular, inter-scapular, 7; in- fra-scapular, 8; axillary, 4, 8; infra- axillary, 4, 8 IXDEX. 667 Donaldson. F., treatment of nasal polypi, 566 Douches, nasal, instruments, 551 nasal, formula?, 658 Dover's powder in acute laryngitis. 396 Drainage tubes for chronic pleurisy, 79-81 ; in abscess of the lung, 131 ; for empy- ema of the antrum, 583 Drill, bone, 582: for cutting cartilage, 598 Dropsy, diseases indicated by. 11 Dry inhalations, formulae. 654 pleurisy, 61 rales, 48 Drzewiecki, J. , pleurisy. 72 Dulness. 25, 26, 28, 29; triangle of. 64; cardiac, 188-190 Dupuytren, retro-nasal fibrous tumors, 621 Duration of sound, 23, 39 Eaele, Charles Warrlsgton. influenza. 520 Eccentric cardiac hypertrophy, syn. of hyper- trophy and dilatation of the heart. 236 Ecchondroma and exostosis of the nasal sep- tum, illus., 597-601 diag. , prog., treat., 598 Ecchondroses, diff. fr. nasal cartilaginous tu- mors, 571 Eclectic inhaler, 649 Ecrasement in hypertrophy of the tonsils, mode of. 373. 374 Ecraseur, galvano-cautery, 567, 569, 571, 573, 622; guarded wheel. 474 Edinburgh Medical Journal, bradycardia. Bal- four, 250 ; anaesthesia of the larynx, McBride, 499; empyema of the an- trum. McBride, 580; large rhinolith, W. N. Browne, 604 Egypt for phthisis. 176: nasal syphilis in, 574 Electric lamp for transillumination, 581 light for laryngeal illumination, 281 Electricity in rhinitis. 552 Electrodes, cautery. 346; laryngeal, 509, 511 Electrolysis, 372. 601 : method of. in retronasal tumors and goitre, 622, 631 ; for stric- ture of the oesophagus, 637 Ellis, curved line of flatness in pleurisy, illus., 64, 65 Elongation of the uvula, chronic inflamma- tion and, 358 Elongated uvula, an obstruction to laryn- goscopy, 289; remedied, 305 Emballometer, 33 Embolism, pulmonary thrombosis and, 138, 139 Emphysema, subcutaneous, 11; pulmonary, 107-112; atrophous, 109 Empyema, chronic pleurisy or, 61, 76-82 of the antrum, illus., 579-584 etiol., 579: symp., diag., 580; prog., treat., 582 diff. fr. empyema of the frontal sinus, fr. suppuration of the anterior eth- moid cells, fr. polypus, fr. oza?na, fr. foreign bodies, fr. syphilis, fr. caries, fr. disease of the sphenoidal sinus, 580, 581 Empyema of the frontal sinus, diff. fr. empy- ema of the antrum, 581 of the sphenoidal sinuses, 583 symp., treat., 583 diff. f r. empyema of the antrum, 581 Encephaloid cancer of the larynx, 476 Endocardial murmurs. 195. 196, 198 Endocarditis, acute. 219-222 ulcerative, 222, 223 chronic, 223-230 Endocardium, the, 178 England, goitre in, 629 Engorgement, in lobular pneumonia. 113 Enlarged bronchial glands, 152, 153 anat., path,, etiol., symp , 152; diag., prog., treat.. 153 diff. fr. phthisis, 153 glands at the base of the tongue, diff. fr, chronic rheumatic sore throat, 319 tonsils, an obstacle to laryngoscopy, 290 Enlargement of the heart, syn. of simple car- diac hypertrophy, 234 or bulging of the precordial region, 184 Epidemic catarrh, syn. of influenza, 519 catarrhal fever, syn. of influenza, 519 Epigastric pulsation. 187 Epiglottis, large or pendent, obstructs laryn- goscopy, 291 ; illus. , 294, 295 ulceration of the, 395 Epistaxis, 559-563 syn., anat., path., etiol., symp., 559; diag., prog., treat., 560 diff. fr. pulmonary hemorrhage. 136 Epithelioma, 361. 480; diff. fr. lupus of the nares. 588; fr. rhinoscleroma, 589 Erichsen, nasal syphilis. 577 Erysipelatous laryngitis. 428, 429 etiol., symp., diag., prog., 428; treat., 429 sore throat. 314-316 etiol.. symp., diag., prog., treat., 315 diff. fr. diphtheria, 332 Erythematous sore throat, syn. of acute sore throat. 311 Ether for general anaesthesia, 582, 618 Ethmoiditis. chronic suppurative, 585-587 Eustachian orifice, 308 Eversion of the ventricle of Morgagni. diag., treat,, 483 of the ventricle of the larynx, diff. fr. benign tumors. 469 Evulsion of nasal mucous polypi, 566 of tumors, in the larynx. 473 Exaggerated bronchial whisper, 58 pulmonary resonance. 28 respiration, 42 Examination of the chest, physical, 3-59; of the fauces. 271-310 of the heart, physical. 183-194 of the trachea, illus.. 300 Exocardial friction sounds or murmurs, 195 Exophthalmic goitre, 632 syn., 632 Exostosis of the nasal septum, ecchondroma and. 597-601 Exostoses, diff. fr. nasal cartilaginous tumors, 668 INDEX. 571 : fr. bony tumors, GTS; fr. foreign bodies, 603 Expiratory power greater than inspiratory, 20 Extirpation of the larynx, partial, complete, 481, 482 Extractor, for intubation, 420; bristle, 642 Exudative bronchitis, syn. of plastic bron- chitis. 99 laryngitis, syn. of membranous croup, 411 stage of croup. 412 Fagge, Hilton, surgery in croup, 415 Fahnestock, tousillitome, illus.. 372 False croup, syn. of spasm of the glottis, 496 Falsetto voice, 503, 504 Faradism or faradization. 511, 513, 514, 640 Fasciculated sarcomata. 407 Fatty heart. 242-2-14 etiol.. symp., 242: diag. prog, treat.. 244 cliff, fr. chronic endocarditis, 226, 227; fr. chronic myocarditis, 232 Fauces, diseases of the, 311-381 examination of the, 271-310 Fauvel. malignant tumors in the larynx, 476 Feeble respiration, 42 Fetid form of tracheitis. 461, 462 Fibrinous bronchitis, syn. of plastic bron- chitis, 99 Fibro-cellular tumors, in the larynx, illus., 466 Fibroid degeneration of the lungs, syn. of fibroid phthisis, 156, 167 disease of the heart, syn. of chronic myo- carditis, 231 disease of the lungs, cliff, fr. emphysema, 111 phthisis, 156, 167-169 syn.. 156, 167; anat., path., 167; etiol., syrup., 168; prog., 169; treat., 170 diff. fr. other forms. 166, 167 phthisis, syn. of dilatation of the bronchial tubes. 100 tumors, diff. fr. adenoid growths. 616 Fibroma of laryngo-pharynx, illus.. 386 of the vocal cords, illus., 466, 467 Fibromata of the nares, syn. of nasal fibrous polypi. 569 Fibro-mueous tumors, retro-nasal. 024. (125 diff. fr. nasal fibromata. 621 Fibrosis, syn. of fibroid phthisis, 167 Fibrous growths, diff. fr. nasal mucous polypi. 566 polypi, nasal, 569 tumors of the naso-pharyux. 620-624 diff. fr. cancer of the pharynx, 387; fr. retro-nasal fibro-mucous tumors, 624 Filer's phthisis, syn. of dilatation of the bronchial tubes, 100 First stage of lobar pneumonia. 117: of peri- carditis. 213: of phthisis, 161-104 Fissures, pulmonary, 8 Flat chest, illus,. 12 nasal probe, illus.. 537 Flatness, hepatic, cardiac. 85, 26 diff. fr. dulness, 29 Flexible oesophageal forceps, illus., 641 Flint, Austin, cyrtometer, illus. , 17, 18; ham- mer and pleximeter, illus., 21; per- cussion. 25. 96, 2S; tympanitic reso- nance, 66; pulmonary gangrene, 141; pulmonary phthisis, 102 Florida for phthisis. 175 Fluctuation of fluid in the pleural cavity, signs of, 16 Follicular disease of the naso-pharynx, syn. of rhino-pharyngitis, 607 glossitis, acute, chronic, 347, 348 pharyngitis, acute, 339, 340; chronic, 340- 340 Fontaine, citric acid in diphtheria. 335 Force of the heart, increased, diminished, 186, 187 Forceps, tonsil, 373: laryngeal. 471; tube, 472; punch, 485; nasal dressing, 576; septum. 596; right angle cutting, 597; removing pharyngeal gland with, 618-620; flexible oesophageal, 641 Foreign bodies in the larynx, 490^192 symp.. 490; diag.. prog., treat., 491 diff. fr. abscess, 384, 385; fr. acute lar- yngitis. 396; fr. phlegmonous laryn- gitis, 428; fr. stenosis of the larynx, 457 bodies in the nose, 603, 604 symp., diag., 603; prog., treat., 604 diff. fr. atrophic rhinitis, 549; fr. em- pyema, 581 ; fr. nasal mucous polypi, 565; fr. nasal malignant tumors, 573; fr. exostosis, fr. rhinoliths, fr. sim- ple catarrh, fr. polypi, 603 bodies in the oesophagus, 640-642 symp., 640; diag., prog., 641; treat., 6 12 diff. fr. stricture of the oesophagus, 635 fr. globus hystericus, fr. paraesthesia, 641 bodies in the pharynx, 382, 383 symp., diag., prog., treat., 383 bodies in the trachea, 492-495 symp., 492; diag., 493; prog., treat., 494 Formula for focal distance of reflector, 276 Formula? for prescriptions, 645-658 Fornix pharyngis, syn. of vault of the phar- ynx, 309 Fort, A., electrolysis for stricture of the oesophagus. 637 Fossa innominata. 297 of Rosenmueller, illus., 309 Foster, illustrations of the action of the heart, 208, 210 Fowler, George B., laryngectomy. 483 Fox. Higston, acute tonsillitis. 363 Fracture of the larynx, 489, 490 anat., path., etiol., symp., diag.. prog., treat., 489 Fractures of the nose, 593, 594 symp. , diag. . prog. , 593 : treat. , 594 Fraenkel. diplococcus pneumoniae. 115: stain- ing bacilli. 165; illuminator, 279, 280; rhinoscope. illus.. 303: cause of in- fantile coryza. 522 Fraentzel. resonance in pleurisy, 66 INDEX. 669 Frasnum obstructs laryngoscopy, a short, 290 France for phthisis, 175; goitre in, 639 Frank, aortitis, 254 Fremitus, normal vocal, 15; friction, bron- chial or rhonchial, 16 French, Thomas R., registers of male and female voice, 298 Friction fremitus, 16 sounds or murmurs, 48, 51, 52, 53; ex- ocardial, pericardial, cardiac, 195; endocardial pleuritic, cardio-pleu- ritic, 196 treatment in laryngeal tumors, 472 Friedlander, diplococcus pneumoniae, micro- coccus, 115 Frog face, 620 Frontal sinus, inflammation of the, 584, 585 Fuming inhalations, formulae, 654, 655 Functional aphonia, syn. of bilateral paralysis of the lateral crico-arytenoid mus- cles, 508 disease of the heart, neurotic or, 247-249 Furunculosis of the nose, 558, 559; treat., 558 Fiitterer, L. G., treatment of chronic pleurisy, 78 Gags, 419, 618 Gairdner, diagram of physiological action of the neart, 181 Galvano-cautery in various diseases of the throat and the nose, 266, 340, 346, 348, 367, 372. 373, 374, 380, 386, 410, 453, 470, 501, 537, 538, 539, 544, 563, 568, 569, 570, 571, 576, 578, 586, 588, 617, 622 compared with chromic acid, 537 ecraseur, 573 handle with ecraseur, illus., 567 snare, illus., 623, 624 Gangrene, amphoric resonance in, 31 ; in lobar pneumonia, 115; pulmonary, 144, 145 Garcia, Manuel, laryngoscopy, 272 Gargles, formulas, 647 Garland, G. M., curved line of flatness in pleurisy, illus., 64 Gazette des Hopitaux, sterilized air in pneumo- thorax, Potain, 88; potassium iodide for angina pectoris, Huchard, 253 ; removal of foreign bodies with skein of thread, Crequy, 642 Gazette Hebdomadaire, fracture of the larynx, Henoque, 489 Gee, cyrtometer, 17; tympanitic resonance, 30 Generative organs to tonsils, relation of, 375 Georgia mountains for phthisis, 175 Gerhardt, pulmonary emphysema, 109 Germain See, lactose diuretic, 230 German mountains for phthisis, 175 student's lamp for laryngeal illumination, 279, 281 Germany for phthisis, 175 ; rhinoscleroma in, 588 Gibb, erysipelatous laryngitis, 429 Gibbes, Heneage, bacilli, illus. (colored plate), 165; secured immunity to tu- bercular virus, 172 Giraldes, multiple secretions of pus in the antrum, 579 Glanders, 589, 590 anat., path., etiol., symp., 589; diag. , prog., treat., 590 diff. fr. rheumatism, fr. pyaemia, fr. typhoid fever, fr. syphilis, fr. scrof- ulous eruptions, 590 Glands, enlarged bronchial, 152, 153 enlarged at base of tongue, 319, 389 Gleitsmann, tubercular sore throat, 352 Globe nebulizer, illus., 174 Globus hystericus, 500 diff. fr. foreign bodies in the ceso-- phagus, 641 Glossitis, acute follicular, 347 chronic follicular, 347, 348 Glottis, 298 spasm of the, 496, 497 Goitre, 629-631 syn., anat., path., etiol., 629; symp., diag., prog., treat., 630 diff. fr. exophthalmic goitre, fr. ma- lignant tumors, 630 aerial, 486 exophthalmic, 632 Gold and sodium chloride for immunity to tubercular virus, 172; for syphilitic laryngitis, 448 Gottstein, malignant tumors in the larynx, 476; wool tampons, 552 Gouty affections diff. fr. chronic rheumatic sore throat, 319 Grancher, diphtheria propagated by infected, clothing or furniture, 334 , Granular sore throat, syn. of chronic follicu- lar pharyngitis, 340 Graves' disease, syn. of exophthalmic goitre, 632 Gray hepatization, 113, 114; illus., 117 Great Lakes, rhinitis near the, 527 Grippe, syn. of influenza, 519 Gross, S. D., foreign bodies, 492, 494; instru- ments for removing foreign bodies, from cavities of nose and ears, illus. , 604 Guaiacol, for phthisis, 173 Guaiacum for acute tonsillitis, 366; unsatisfac*. tory in phlegmonous tonsillitis, 369 Gueneau, Noel, diaphragmatic pleurisy, 82 Guido Boeelli, pus diff. fr. serum, 77 Guillotines for throat, 473 Gumma, 353, 354 Gurgles, 48, 52 . Gussenbauer, artificial larynx, 482, 483 Guttmann, tympanitic resonance, 30 Hack, hay fever, related to conditions in nasal passages, 553 Haamadynamometer, 19 Haematemesis diff. fr. haemoptysis, 135 Haamatoma of the nasal septum, etiol. , symp. , diag., prog., treat., 602 diff. fr. mucous polypi, fr. cartilagi- nous tumors, fr. hypertrophy of the turbinated body, fr. ecchondroma, 602 670 INDEX. Haemic murmurs. 2''J Haemoptysis. 134. 135, 859 diff. fr. baematemesis, 135; fr. epis- taxis. fr. lit- morrhage of the gums or the pharynx, 136 Hemostatics, spray inhalations, formulae, 663 Hahn. F. . nasal tuberculosis. 578 Haines. W. S. . iodine trichloride in tubercular laryngitis. 441 Hairy heart. 812 Hamilton, milk spots. 212; pneumoperi- cardium. 218; acute endocarditis. 219, 820; myocarditis, 231 Hammer for percussion. 21 Hammond, haemadynamometer. illus. . 19; ex- piratory force greater than inspira- tory. 80 Harkin. epistaxis. 561 Harries and Campbell, etiology of lupus of the larynx. 452 Harsh respiration, syn. of broncho-vesicular or rude respiration. 44 Hay asthma, syn. of hay fever. 553 fever. 553 " - syn.. anat.. path., etiol.. 553: symp.. diag. . 554: prog., treat.. 555 diff. fr. acute rhinitis. 524: fr. simple chronic rhinitis, 529 ; fr. simple acute rhinitis, fr. spasmodic asthma. 554. 555 Hayden, illustration of motion of the heart, 209. 810 Head, sections of, 302. 541. 579. 584 for laiyngoscopy, good and poor positions of, 384, 885 lower than the body in taking food in cer- tain throat diseases. 442. 506 Heart, the. 177-211 aneurism of the. 245 apex beat of the. 10. 180, 182. 1-4 atrophy of the. 242 congenital deformity of the. 227 diastole of the, 180 dilatation of the. 839-242 failure in atheroma of the aorta. 255 fatty. 242 244 : defeneration, infiltration, 242 force of the. modified. 184. 186, 187 hairy. 812 neoplasms of the. 240 neurotic or functional disease of the, 247-249 physical examination of the. 1N3-194 physiological action of the. 180-183 rupture of the. 245 sounds, how caused. 190. 191 : modified by disease. 191-194: anomalous syphilis of the. 245 systole of the. 180 to find the limits of the. 188 tumors of the. 246 valvular disease of the. 223-230 Heath. Christopher, empyema of the antrum. 588 Helcosis laryngis. syn. of tubercular laryn- gitis. 434 Hemiplegia causes exaggerated respiration. 42 Hemming. Hugh, syrup of chloral in diph- theria. 336 Hemorrhage, pulmonary. 134-136: after ab- scission of the uvula, 359 ; after ton- sil lotomy. 374 Hemorrhagia narium, syn. of epistaxis. 559 Hemorrhagic infarctus. syn. of pulmonary apoplexy, 137 pleurisy, 61 Henoque. fracture of the larynx, 489 Henrotin. gag. illus., 419, 618 Hepatic duluess. flatness, 25, 26 pulsation, 187 Hepatization, red. yellow, gray, 113, 114 Heredity of phthisis, 158 Hernia, diaphragmatic, 88 Herpetic sore throat, syn. of simple membra- nous sore throat. 324 ulceration. 395 Herynge (see Krause and Herynge) Hilton, sacculus laryngis. 297 Himalayas, goitre in the. 629 Hippocrates acquainted with suecussion, 20; percussion, 21 Holden. E. . chorea laryngis, 501 Home and its comforts best for advanced cases of phthisis. 176 Hooper, F. H. , operating on benign tumors in the larynx. 473 Hopmann, nasal papillary tumors, 569 Hospital sore throat, syn. of chronic follicular pharyngitis. 340 Hot applications in pneumonia, 122; in diph- theria. 335 : in phlegmonous tonsillitis, 369: in croup. 410: in tracheitis, 461 Hotz. F. C, throat deafness. 611 Huber, myocarditis. 231 Huchard. free protracted use of potassium iodide to cure angina pectoris. 253 Hungary, rhinoscleroma in. 588 Hunter. John, empyema of the antrum, 579, 582 Hutchinson, spirometer. 18 Hydatid cysts of the lungs, 148-150 anat.. path., etiol., 148; symp., diag., 149: treat.. 150 diff. fr. phthisis. 149; fr. circumscribed pleurisy. 150 Hyde. J. Nevins. treatment of lepra of larynx, 455 Hydrastine identical with berberine. 95 for chronic follicular pharyngitis, 344 Hydro-pericardium or pericardial effusion, 15, 218, 219 anat., path., etiol., symp.. diag., 218; prog., treat.. 219 diff. fr. hypertrophy and dilatation of the heart. 238 Hydrothorax, 13. 15. 84 etiol.. symp., diag.. prog., treat., 84 diff. fr. pneumonia, 120; fr. pulmo- nary collapse. 143 Hyperaemia, pulmonary. 132-134 Hyperesthesia of the larynx, 82. 500. 501 anat.. path., etiol.. symp.. diag., 500; prog., treat., 501 INDEX. 671 Hyperesthesia of the pharynx, 388, 389 Hypersarcosis cordis, syn. of simple cardiac hypertrophy, 234 Hypertrophic rhinitis, illus., 528, 540-547 anat., path., etiol., symp. , 540; diag., 542; prog., treat., 543 diff. fr. intumescent rhinitis, 534, 542; f r. syphilis, f r. nasal mucous polypi, 542, 543 Hypertrophy, simple cardiac, 14, 234-236 and dilatation of the heart, illus., 211, 236- 239 syn., symp., 236; diag., prog., treat,, 239 diff. fr. retraction or consolidation of the lung, fr. cardiac dilatation, fr. pericardial effusion, fr. cardiac dis- placement, fr. thoracic aneurism, 237-239 of the larynx, 455 of the liver diff. fr. pleurisy, 70 of Luschka's tonsil, syn. of hypertrophy of the pharyngeal tonsil, 613 of the pharyngeal tonsil, illus. , 613-620 syn., anat., path., 613; etiol., symp. ,614; diag., prog., treat., 616 diff. fr. nasal mucous polypi, fr. fibroid tumors, 616; fr. fibromata, 621 of the spleen or of the liver, diff. fr. pleu- risy, 70 of the tonsils, 370-375 syn., etiol., symp., 370; diag., prog., treat., 371 diff. fr. diphtheria, 332; fr. cancer, 380, 381 of the turbinated body. diff. f r. ha?rnatoma of the nasal septum, 602 Hypodermic syringe, illus., 568 Hypostatic congestion, 133 Hysteria, diff. fr. chorea laryngis, 502 Hysterical aphonia, syn. of bilateral paralysis of the lateral crico-arytenoid mus- cles, 508 Hysterical or pseudo angina pectoris, diff. fr. angina pectoris, 251 Ice in diphtheria and other diseases of the throat, 334, 367, 369, 416, 428, 633 Ichthyosis linguae, syn. of leucoplakia bucca- lis, 360 Illumination of the throat, 275-384 Immediate auscultation, 34 percussion, 21 Immunity to tubercular virus, how secured, 172 Incipient hypertrophy due to Bright's disease, illus., 210 Incompetency of heart valves produced, 224 Increased vocal resonance, 56 India, myasis narium in. '605 Induration of the lungs, syn. of fibroid phthi- sis, 167 Infants, syphilitic sore throat in, 356; syphili- tic laryngitis in, 449; acute rhinitis in, 526; syphilis of the nose in, 577 Infectious endocarditis, syn. of acute endocar- ditis, 219 Inferior costal breathing, 11 meatus, illus., 809 sternal region, 4, 6 turbinated bodies, illus. ,308 Inflammation of the antrum or frontal sinuses diff. fr. acute rhinitis, 524 of the frontal sinuses, illus. , 584, 585 symp., treat., 584 of the larynx, syn. of acute laryngitis, 394 of the lungs, popular name for pneumonia, 113 of the uvula, acute, chronic, 358-360 Influenza, 519-522 syn., anat., path., etiol., symp., 519; diag., 520; prog., treat., 521 diff. fr. rhinitis, fr. inflammation of the larnyx, 521 Infra-axillary region, 4, 8 Infra-clavicular region, 4, 5 Infra-glottic dropsy, syn. of oedema of the larynx, 430 laryngoscopy, illus., 292 Infra-mammary region, 4, 8 Infra-scapular region, 4, 8 Infra-thyroid laryngotomy, 476 Ingals, emballometer, illus., 33; flat trocar, illus., 79; drainage tubes for empy- ema, illus., 81 ; nasal speculum, illus., 301 ; modification of Shurly's battery, illus., 345; cautery electrodes, illus., 346; tonsil forceps, illus., 373; laryn- geal applicator, illus., 405; chromic acid applicator, galvano-cautery handle, illus., 409; punch forceps, illus., 485; nasal scissors, illus., 545 nasal syringe, illus., 550; snare, illus. 567 ; nasal dressing forceps, illus. , 576 electric lamp for transillumination 581 ; drainage tube for the antrum illus., 583; septum forceps, illus. septum knife, illus., 596; right angle cutting forceps, 597; nasal saws, illus., 599; nasal spatula, illus., heavy -bone scissors, illus., nasal bone forceps, illus., 600; post -nasal snare applicator, illus., 623 Inhalations, formula?, vapor, 649-651 ; spray, 651-653; dry, 654; fuming, 654, 655 Inhaler, 649, 654 Injections for pleurisy, stimulating, 81 Inspection, 9-14, 86, 88, 183, 184, 272, 302 Insufflations, formulas, 656, 657 Insufflator, illus., 536 Intensity of sound, 22, 39, 41 of heart sounds, modified by disease, 191 of vocal resonance, modified by disease, 55 Inter-arytenoid fold, illus., 299 Intercostal neuralgia or pleurodynia, diff. fr. pleurisy, 68; fr. pneumonia, 119; fr. angina pectoris, 251 Interlobular emphysema, 107 pneumonia, often included in lobular pneu- monia, 123 Intermittent dilatation preferred in stenosis of the larynx, 459 rhythm of the heart, 193 672 INDEX. Intermittent venous murmurs, 207 Internal treatment, diphtheria, 337 International clinics, operating on benign tu- mors in the larynx, F. H. Hooper, 473 Congress Laryngology and Otology, Trans- actions, myxomata transformed into sarcomata, Schiffers, 566 Journal of Surgery and Antiseptics, nasal vascular tumors, J. O. Roe, 570 Medical Annual, tachycardia, L. Bouveret, 249 Medical Congress, Transactions, epistaxis, Harkin, 561 ; Walton Brown, 562 Internationale klinisehe Rundschau, pericar- ditis, von Stoffela, 214: nasal tuber- culosis, Michelson, 578; adenoid growths in deaf-mutes, Wroblewski, 614 Interrupted or cog-wheel respiration, 43 Interscapular region, 4, 7 Interstitial pneumonia, often included in lobu- lar pneumonia, 123 pneumonia, syn. of fibroid phthisis, 128, 167 Intubation in diphtheria, croup, and other Throat diseases, 338, 397, 415. 418-421, 428, 429, 432, 450, 453, 458, 459, 472, 484, 490, 513, 515 described, 418-421, 458, 459 instruments, 418 Intumescent rhinitis, 528, 531-540 anat., path., etiol., symp., 531; diag. , prog., treat., 534 diff. fr. simple chronic rhinitis; fr. nasal mucous polypi, 534; fr. hyper- trophic rhinitis, 534, 542 Inversion of a patient to remove foreign bodies from the trachea. 491 Involution of the trachea. 485, 486 etiol., symp., diag., prog., treat., 486 Iodine for immunity to tubercular virus, 172; for tuberculosis, 631 trichloride in surgery, 441 Inspiratory power less than expiratory, 20 Irritability of the tongue remedied for rhino- scopy, 304 Irritable fauces an obstacle to laryngoscopy, 289; remedied, 305 heart of soldiers, 249 Irritative cough, treat., 498 Italy, rhinoscleroma in, 588: goitre in, 629 Jaccoud, pleurisy, 83 Jackson, Hughlings. nose-bleeding preceding apoplexy, 560 Japan, distoma pulmonale, 150 Jarvis, small nasal speculum, illus. , 301; tu- bercular laryngitis, 441 ; snare for- ceps, 473; rhinitis, 545; snare, 567: nasal vascular tumors, 570: drill, 598 Jaworski, pneumonia contagious. 116 Johnson, H. A., inspection in phthisis, 162 Journal American Medical Association, pneu- monia contagious, Jaworski, 116 de Medecine de Paris, epileptic asthma, Poulet, 104 Journal of Laryngology, lepra of the larynx, Morell Mackenzie. 454 Jugular veins, collapse of the. 207 June cold, syn. of hay fever, 553 Keloid diff. fr. rhinoscleroma, 589 Kennedy, fatty heart, 242 Klebs-Loffler bacillus a cause of diphtheria, 329 Klemperer, G. and F., experiments with blood serum or anti-pneumatoxin in pneu- monia, 123 Knife, laryngeal, 474; septum, 596, 599 Knife-grinder's rot, syn. of dilatation of the bronchial tubes, 100 Knight, stethoscope, illus., 36 Charles H., galvano-cautery in chronic follicular tonsillitis, 372; nasal osse- ous cysts, 570 F. I., lupus of the larynx, 451; chorea laryngis, 501, 502; laryngeal vertigo, 504 Koch, bacilli in lupus of the larynx, 451 tubercle bacillus, 159 tuberculin, disastrous use of. 454; in tu- berculosis of nares, 579; curative in lupus of the nares, 588; inactive in rhinoscleroma, 589 Konig, canula, 486, 488 Kramer, head-band for reflector in laryngo- scopy, 277 Krauseand Herynge, treatment of acute tuber- cular sore throat, 352 operations on the antrum, 582 Krishaber, illuminator, illus., 278; thyroto- my. 475 Kuhn, pneumonia contagious, 116 Labus, Carlo, trachoma of the vocal cords, 408 Lactic acid in diseases of the throat and nose, 335, 336, 380, 381, 417, 578 Lactose diuretic, 230 Laennec, theory of the cause of pulmonary emphysema, 20; mediate auscultation, 34; bronchial respiration, 45; rales, 51 La France Medicale, carbon dioxide in asthma, Weill, 106 Lamp for laryngoscopy, German student's, 279; for transillumination of the nasal cavities, electric, 581 Lancet, laryngeal, 397 Larry, aerial goitre, 486 Laryngeal and tracheal respiration, 41 applicator, 405 cough, 59 electrodes, 509 forceps, illus., 471 knives, 474 lancet, 397 phthisis, syn. of tubercular laryngitis, 434 tuberculosis, syn. of tubercular laryngitis, 434 tubes. 418, 459 (see intubation) tumors, illus., 463-485 diff. fr. syphilis, 447 vertigo, treat., 504 INDEX. 673 Laryngectomy, modes described. 482, 483 Laryngismus stridulus, syn. of spasm of the glottis, 496 Laryngitis, acute, 393-397 chronic, 398-408 chronica, syn. of chronic laryngitis, 398 due to small-pox, 455 erysipelatous, 428, 429 exudative, syn. of membranous croup, 411 of measles, 455 of scarlet fever, of small-pox, 455 phlegmonosa, syn. of phlegmonous laryn- gitis, 427 sero-purulenta, syn. of phlegmonous laryn- gitis, 427 subacute, 397, 398 submucosa purulenta, syn. of phlegmon- ous laryngitis, 427 syphilitic, 443-450; in infants, 449, 450 traumatic, 398 tubercular, 434-443 Laryngopharyngeal sinuses, 296 Laryngophony, 54 Laryngoscope, a, 272; preferred form, 282; manipulation of, 283-289 Laryngoscopic mirror in position, illus., 286 Laryngoscopy reflector, illus., 283 Laryngoscopy, illus., 272-292 infraglottic, 292 obstacles to, 289-292 Laryngotomy, supra-thyroid, infra-thyroid, 475, 476, 642 Larynx, a normal, illus., 293, 295; of women, in forming head tones, illus., 298 abscess of the, 429, 430 anaesthesia of the, 499, 500 artificial, 482 benign tumors of the, 465-476 cancer of the, 476-483 chronic stenosis of the, 456-459 cystic growths of the, 466 diseases of the, 394-515 dislocation of the, 490 extirpation, partial, complete, 481-483 foreign bodies in the, 490-492 fracture of the, 489, 490 hypersesthesia of the, 500, 501 hypertrophy of the, 455 illumination of the, 275-283 lepra of the, 454 lupus of the, 451-454 malignant tumors of the, 476-483 morbid growths of the, 463-483 neuralgia of the, 500, 501 oedema of the, 430-433 pareesthesia of the, 500, 501 resection of the, 481 spasm of the, in adults, 497, 498 ventricles of the, 297 La Semaine M6dicale, causes of angina pec- toris, 251 Lateral region, 3 La Tribune Medicale, lactose diuretic, Germain S6e, 230 Laugenbeck, retro-nasal fibrous tumors, 621 Lawrence, retro-nasal fibrous tumors, 621 43 Lazarus, heredity in asthma, 303 Leared, binaural stethoscope, 35 Lefferts, George M., history of lupus in the larynx, 451 ; eversion of the ventri- cles of Morgagni, 483; chorea laryn- gis, 501 ; retro-nasal cystic tumors, 626 Leichtenstern, pleurisy, 71 ; empyema in chil- dren, 77 Leidy, Joseph, thyrotomy, 475 Leiter coil for applying cold through a circu- lation of water, in tonsillitis, 369 ; in croup, 416 Lepra of the larynx, illus., 454, 455 path., etiol., symp., diag., prog., treat., 454 diff. fr. benign tumors, 469 Leptothrix buccalis, 376 Leucoplakia buccalis, 360-362 syn., anat., path., etiol., 360; symp., diag. , 361 ; prog. , treat. , 362 diff. fr. professional patches, 357; fr. smoker's patches, fr. mercurial patches, fr. syphilitic patches, fr. cancer, fr. psoriasis linguae, 361, 362 buccalis et lingualis, syn. of leucoplakia buccalis, 360 Levret, laryngoscopy, 272 Lewin, benign growths in the larynx, 465 Lewis, foreign bodies in the trachea, 492 Leyden, cause of asthma, 103 LiSgeois, cause of angina pectoris, 250 Ligation for extirpation of tumors, 622 Lime-water vapors in diphtheria, 416 Lincoln, R. P., nasal cancerous tumors, 573;- extirpation of nasal tumors, 621 Linsley's translation Frankel's Bacteriology,, staining bacilli, 165 Lipomata, 467 Liston, laryngoscopy, 272 Litten, pulmonary thrombosis and embolism, 138 Liver, enlargement or hypertrophy of, 68, 70 Lobar pneumonia, 113-123 syn., anat., path., 113; etiol., 115; symp., 116; diag., 119; prog., 121 1 treat., 122 diff. fr. capillary bronchitis, 97; fr. lo- bular pneumonia, 127 Lobular pneumonia, 123-128 syn., anat., path., 123; etiol., symp., 124; diag., 125; prog., 127; treat., 128 diff. fr. capillary bronchitis, 97; fr. capillary bronchitis, fr. pulmonary collapse, fr. lobar pneumonia, fr. acute tubercular phthisis, 125-128 Local anaesthesia produced by a pigment of morphine, carbolic acid, tannic acid, glycerin, water, 442 anaesthesia, produced by cocaine, 457, 470, 495, 544, 557. 568, 582, 603, 616, 617, 623 anaesthesia, pigments, formulae, 655 Loewenberg, forceps, illus., 617 London Hospital Clinical Lectures and Re- ports, nose-bleeding preceding apo- plexy, Hughlings Jackson, 560 Lancet, diagnosis of congenital disease ot 074 INDEX. the heart in children. Sansom. 246: removing foreign bodies from the trachea, Padley. 494; goitre. Morell Mackenzie, 631 ; tube used in stricture of the oesophagus. Charters J. Sy- monds. 636 London Practitioner, treatment of ulcerative endocarditis. Sansom, 223 Loomis. A. L.. percussion sounds, 28; treat- ment of pleurisy, 72, 7S; double pneu- monia, 115; treatment of pulmonary hemorrhage, 136; mortality in infants from atelectasis following bronchitis, 141; rhythm of heart sounds, illus., 183; reduplication of heart sounds, 194 ; endocarditis. 221 ; simple cardiac hypertrophy, 234; thoracic aneur- isms, 265 Henry P., bacilli in healthy persons, 159 Lozenges, trochisci or. formula?. 647-649 Lubet-Barbou, spasm of the glottis, 496 Lumniczer, Josef, cause of putrid bronchitis, 91 Lung fever, popular syn. of pneumonia, 113 Lungs, apoplexy of the, 15 collapse of the. 70 consolidation of. 237, 264 hydatid cysts of the, 148-150 retraction of the, 237 syphilitic disease of the, 151, 152 L'Union Medicale, Klebs-Loffler bacillus. Roux and Yersin, 329; case of excessive nose-bleeding, Martineau, 560 Lupus exedens, non-exedens, 587 of the larynx, illus.. 451-454 anat.. path., etiol., 451; symp. . diag., 452; prog., treat., 453 diff. fr. tuberculosis, fr. syphilis, fr. cancer, 453. 454, 479; fr. benign tu- mors, 469 of the nares, 587, 588 anat., path., etiol., symp., diag., 587; prog., treat., 588 diff. fr. atrophic rhinitis, 549: fr. syphilis, fr. epithelioma, fr. tuber- culosis, 587 of the pharynx, diff. fr. scrofulous sore throat, 349 vulgaris. 549 vulgaris laryngis. Chiari and Riehl. 451 Luschka's tonsil fsee hypertrophy of the pharyngeal tonsil) Lyon Medicale, cause of angina pectoris, 251 McBride. anaesthesia of the larynx. 499; em- pyema of the antrum, 580 McDonald. Greville, atrophic rhinitis most C' mmon in girls. 547; atrophic rhi- nitis. 552; nasal osseous cysts, 570; empyema of the antrum. 581 ; hyper- trophy of the pharyngeal tonsil, 614 Mackenzie. John N., syphilitic sore throat in infants. 356 : syphilitic laryngitis in infants. 44'.': hay fever related to con- dition in nasal passages, 553 ; forceps. 617 Mackenzie, Morell. rack movement bull's-eye condenser, illus.. 278. 279; fossa in- nominata. 297; erysipelatous sore throat, 316; lactic acid in diphtheria, 335: syphilitic sore throat, 356; laryn- geal lancet, illus., 397; identity of diphtheria and croup, 411; syphilitic laryngitis, 443, 445; lepra of the larnyx. 454; laryngeal dilator, illus., 458; laryngeal tumors, 463. 465; tube forceps, illus.. 472; guarded wheel ecraseur, 474: thyrotomy. 475, 476; laryngeal cancer, 477; mode of com- plete extirpation of the larynx, 482; tracheocele, 486; syphilis of the trachea, 487; laryngeal electrodes, illus., 509; rhinitis, 525; hay fever, 556; mucous polypi, 565; nasal pa- pillary tumors, 569: nasal syphilis, 574. 577: tonsillitis. 574; anosmia, 592; deflection of the septum, 594; rhino-pharyngitis, 607, 609; throat deafness. 613; goitre, 631; paralysis of the oesophagus, 639, 640; electric inhaler, 649 MacNamara, epistaxis, 561 Maggots in the nose, syn., of myosis narium, 605 Malformations and new growths of the uvula, 359 Malignant (see also cancer) disease of the oesophagus cliff, fr. paralysis, 639 endocarditis, syn. of acute endocarditis, 219 growths on uvula, 360 tumors diff. fr. benign tumors, 469 tumors, nasal, 572, 573 tumors of the larynx, illus., 476. 483 anat., path., symp., 476; diag., 479; prog., treat., 480 diff. fr. syphilis, fr. chronic catarrhal inflammation, fr. lupus, fr. tubercu- lar laryngitis, fr. benign growths, 478. 479 tumors of the naso-pharynx, anat., path., etiol., symp., diag., prog., treat., 625 diff. fr. retro-nasal fibro-mucous tu- mors, 625; fr. nasal cartilaginous tumors, 571 Mammary or nipple line, 6 region, 4, 5 Marey, sphygmograph, illus.. 208 Martineau. case of excessive nose-bleeding, 560 Massage with foreign bodies in the oesophagus, 642 Matheson, pneumonia, contagious, 116 Mathieu. tonsillitome, illus., 372 Measles, sore throat of . 322. 323; laryngitis due to. 455; nasal affections in, 591 Meatus, inferior, middle, superior, 309 Mediastinal tumors, solid, 193, 267, 268 diff. fr. pericarditis, 216 Mediate auscultation. 34 percussion. 21 Medical Xews. danger in washing pleural cav- ity, Bowditch, resection of ribs, W. INDEX. 675 M. Strickler, 78; promotion of renal secretion in. children with capillary bronchitis, 98; asthma due to poison in the blood, Robinson, 104; Medical Press and Circular, pneumonia — contagious, Mosler, 116 Record, acute pleurisy, Drzewiecki, 72 Register, pneumonia contagious, Wells, 116 Society of London, Transactions, acute ton- sillitis, Higston Fox, 363 Membranous croup, 14, 411-426 syn., anat. , path., etiol., 411; symp., diag. , 412, 413; prog., 415; treat., 416 diff . f r. acute laryngitis, 396 ; f r. catar- rhal laryngitis, fr. laryngismus stri- dulus, fr. diphtheria, 413-415 laryngitis, syn. of membranous croup, 411 sore throat, simple, 324-327 Meningitis diff. fr. pneumonia, 121 Mensuration, 9, 16-20, 86 Menthol and alboleue spray, 441, 551 Mercurial patches diff. fr. leucoplakia bucca- lis, 361 Mercury to infants, mode of applying, 577 Mesosternal line, 7 Metallic tinkling, 20, 54, 87 Mexico for phthisis, 175; nasal syphilis in, 574; myasis narium in, 605 Michelson, nasal tuberculosis, 578 Michigan for hay fever, 555 Micrococcus of Friedlander exciting pulmon- ary inflammation, 15 Microscopic examination, lobar pneumonia, 114 Middle meatus, illus., 309 turbinated bodies, illus., 308 Miliary tuberculosis, acute, 165-167 Milk most important nutritious drink in diph- theria, 334 spots, 212 Minnesota for phthisis, 175 Minot, pneumonia in children, 115 Mirrors for laryngoscopy, throat, 273 ; position for, manipulation of, 286-289 Mitral area, illus., 198 constriction, illus., 210 murmurs, 198. 201 obstruction, 225, 228. 230 regurgitation, illus., 209, 225, 228 stenosis, 225 valves, 7, 178 Moist rales, 48. 50 Montana for phthisis, 175 Morbid growths in the larynx, 14, 463-485 anat., path., etiol., 463; symp., 464 Morbus caeruleus, 246, 247 syn., symp., diag., 246; prog., treat., 247 Morgagni, eversion of the ventricle of, 483 Morsen, creasote for phthisis, 173 Mosetig-Moorhof mode of injecting iodoform in goitre, 631 Mosler, pneumonia contagious, 116 Mountains for phthisis 175; for hay fever, 555 Mount Bleyer, tongue depressor, illus., 464 Moure, regeneration of atrophied structure, 550 Mucous click, 48, 52 patches, 353 polypi, myxomata or true, 466 polypi, nasal, 564-568 rales, 48, 50 tubercles, 353 Mulhall, J. C, falsetto voice, 503 Multilocular pleurisy diff. f r. other forms, 83 Miinchener medicinische Wochenschrift, the aneurismatiscope, Ferdinand Schnell, 261 Murmurs, vesicular, 39; cardiac, 195-211 ; exo- cardial or pericardial friction sounds or, 195; endocardial, 196; diastolic, 203, 204; ventricular, congenital has- mic, 204; subclavian, 206 Myalgia diff. fr. angina pectoris, 251 Myasis narium, 605, 606 syn., etiol., symp., diag., prog., 605; treat., 606 Mycosis of the tonsils, 376, 377 anat., path, etiol., symp., diag., 376 diff. fr. acute and chronic follicular tonsillitis, 376, 377 Myocarditis, 213, 231-233 anat., path., etiol., symp., 231; diag., prog. , treat. , 232 Myxomata or true mucous polypi, illus., 466 Nares, tuberculosis of the, 578, 579; lupus of the, 587, 588 Nasal affections in acute diseases, 591 bone forceps. 600 bones, dislocation of the, 594 bony tumors, 571, 572 syn., anat., path., etiol. symp., 571; diag., prog., treat., 572 diff. fr. exostoses, fr. rhinoliths, fr. cancer, 572 burrs, illus. , 546 cartilaginous tumors, syn., anat., path., symp., diag., prog., treat., 571 diff. fr. fibrous polypi, fr. malignant tu- mors, fr. exotoses, fr. ecchondroses, fr. bony tumors, 571 cavities, diseases of the, 519-606 douches, illus., 551 douches, formulae, 658 dressing forceps, 576 fibrous polypi, syn. , treat. , 569 malignant tumors, 572, 573 anat., path. , 572; etiol., symp., diag., prog., treat., 573 diff. fr. rhinoliths, fr. foreign bodies, fr. abscess, fr. benign growths, 573 mucous polypi, 564-568 syn., anat., path., etiol., symp., 564 diff. fr. intumescent rhinitis, 534; fr. hypertrophic rhinitis, 543; fr. de- viation of the septum, fr. thick- ening of the turbinated bodies, fr. chronic abscess of the nasal sep- tum, fr. foreign bodies in the nose, fr. fibrous, sarcomatous, and can- 676 INDEX. cerous growths, 565; fr. empyema. 581; fr. chronic suppurative ethmoi- ditis. 585; fr. haematoma, 602: fr. for- eign bodies, 603; fr. hypertrophy of the pharyngeal tonsil, 616; fr. retro- nasal fibrous tumors. 621 : fr. retro- nasal fibro-mucous tumors. 625 Nasal myxomata. syn. of nasal mucous polypi. 564 osseous cysts, anat.. path., etiol., symp., diag., treat.. 570 papillary tumors. 569. 570 syn.. anat.. path., symp.. diag., prog., treat.. 569 probe, flat. 537 saws, 599. 600 scissors. 545. 600 septum, deflection of the. 594; ecchon- droma and exostosis of the. 507: per- foration of the, 601 : haematoma of the. 002 : abscesses of the, 603 snare. 359. 507 spatula. 600 speculum. 301 spud, illus.. 599 syringe. 550 trephines, illus., 546 vascular tumors, syn.. treat.. 570 Naso-pharynx. cystic tumors of the. 626 diseases of the, 607-626 malignant tumors of the. 625 Natural light for laryngoscopy, 282 Navratil. dilator. 457 Nebraska for phthisis, 175 Neoplasms of the heart, rare, 246; of the lar- ynx. 464 Nervous aphonia, syn. of bilateral paralysis of the lateral crico-arytenoid mus- cles. 508 cough, treat., 498. 499 Netter. diplococcus pneumoniae, 115 Neuralgia, iutercostal. 68 of the larynx., 500. 501 anat., path., etiol., symp., diag., 500; prog., treat., 501 diff. fr. chronic rheumatic sore throat, 319 of the pharynx, treat., 389 Neuroses of the pharynx, 388-392 Neurotic or functional disease of the '.heart, 247-249 etiol., symp., 247; diag., prog., treat., 248 diff. fr. chronic endocarditis, 226 Newcomb, James E.. electrolysis in disease of septum, 601 New Hampshire for hay fever, 555 New Mexico for phthisis, 175; rhinitis in, 527 New York Medical Journal, pneumonia, infec- tive. Delafield, 115; pneumonia, con- tagious. Wells, 116; acute tubercular » sore throat. Gleitsmann. 352; electric- ity in rhinitis, D. Bryson Delavan. 552; nasal vascular tumors, J. O. Roe, 570 New York Medical Record, iodide trichloride in surgery, Wm. T. Belfield. 441 ; ever- sion of the ventricles of Morgagni, 483; fracture of the nose, J. O. Roe, 594 ; electrolysis in disease of septum, James E. Newcomb, 601 Night sweats remedied. 171 Nipple line, mammary or, Nitroglycerine for angina pectoris. 252: athe- roma of the aorta. 256 Nitrous oxide gas for anaesthetic in aspiration in empyema. 80 Normal bronchial whisper, 58 bronchophony. 55 radical pulse, illus., 208 vesicular resonance, 25 vocal fremitus. 15 vocal resonance. 54, 55 North Carolina mountains for phthisis, 175 Nose bleeding, syn. of epistaxis, 559 congenital deformity of the, 593 diseases of the. 518-626 foreign bodies in the. 603, 604 fractures of the. 593. 594 furunculosis of the. 558, 559 syphilis of the. 574-577; cdngenital. 577 Nottinghamshire, goitre in, 629 Obstacles to laryngoscopy. 28! to posterior rhinoscopy, 304-306 Obstruction, aortic, mitral, tricuspid, pul- monic. 225. 220. 228, 230 Obturator for intubation tubes, illus.. 418 Odontological Society Transactions, empyema of the antrum, Christopher Heath, 582 O'Dwyer, Joseph, intubation. 338, 415, 490; in- tubation instruments, illus.. 418, 420; laryngeal tubes, 433. 4:54. 449, 457, 459, 485, 488, 47ii. 4;-,' CEdema glottidis, syn. of oedema of the lar- ynx, 14. 4:% of the larynx, 430-433 syn., 430; etiol., symp., 431; prog., treat.. 432 diff. fr. retropharyngeal abscess. 384; fr. chronic laryngitis, 402, 403; fr. tubercular laryngitis, 439 of the uvula, acute inflammation and, 358 pulmonary, 15, 42. 142-144 (Edematous laryngitis, syn. of cederna of the larynx, 430 CEnothera biennis unsatisfactory with pertus- sis, 155 Oertel, carbolic acid in diphtheria, 336; pilo- carpine in diphtheria, 337 Oesophageal bougie, 635 forceps, flexible, 641 tube. 387, 388, 392 CEsophagismus. syn. of spasm of the oesopha- gus. 037 Oesophagitis. 032-634 acute, 632. 633 chronic. 633, 634 OEsophagotome, 636 CEsophagotorny, 642 INDEX. 677 Oesophagus, compression of the, 637 diseases of the, 632-643 foreign bodies in the, 640-642 parsesthesia of the, 642. 643 paralysis of the, 638-640 spasm of the, 637, 638 stricture of the, 634-637 Oil atomizer, 536 Olivary bougies, 635 Oilier, retro-nasal fibrous tumors, 621, 622 Opiates prohibited in capillary bronchitis, 98 Opium objectionable in pneumonia. 123 Orth, gangrene in lobar pneumonia, 115 Osseous cysts, nasal, 570 tumors diff. fr. nasal mucous polypi, 566 Osteoma diff. fr. rhinoliths, 605 Osteomata of the nose, syn. of nasal bony tumors, 571 Outgrowths diff. fr. benign tumors, 469 Owsley, F. D., spray of solution of cloves in laryngitis, 442 Oxyhydrogen light for laryngeal illumination, 275 Ozsena diff. fr. empyema of the antrum, 581 Packing nasal cavities to check bleediDg, 619 (See Plugging : see Tampon) Padley, method of removing foreign bodies from the trachea, 494 Palasciano, fibromata, 621 Palate retractors, 306 ulcerative destruction of, 354 Pallor in chronic pulmonary disease, 11 Palpation, 9, 14-16, 185 Panas, fracture of the larynx, .489 Papillary growths on the uvula, 359 Papillomata of the larynx, illus. . 465, 476 of the nares, syn. of nasal papillary tu- mors, 569 Parsesthesia of the larynx, 500. 501 anat., path., etiol., symp., diag. , 500; prog., treat., 501 of the oesophagus, 642, 643 etiol., symp., diag., prog., treat., 643 diff. fr. foreign bodies, 641 Parsesthesia of the pharynx, 389 etiol., prog., treat., 389 Paralysis of the abductors diff fr. stenosis of the larynx, 457 (see Paralysis of the posterior crico-arytenoid muscles) of the arytenoid muscles, symp., diag., treat., 511 of the crico-thyroid muscles, illus., symp., diag., prog., treat., 506 of the oesophagus, 638-640 anat. path., 638; etiol., symp., diag., 639; prog, treat., 640 diff. fr. spasm of the pharynx, 390; fr. stricture of the oesophagus, 635: fr. spasm, fr. malignant disease, 639, 640 of the pharynx, 391, 392 etiol., symp., diag., prog., 391; treat., 392 diff. fr. spasm of the pharynx, 390 of the posterior crico-arytenoid muscles, bilateral, 511-513; unilateral, 514 Paralysis of the posterior crico-arytenoid muscles, diff. fr. stenosis of the la- rynx, 457 of the thyro-arytenoid muscles, illus., 507, 508 anat., path., etiol., symp., diag., prog., treat.., 507 of the tbyro-epiglottic and ary-epiglottic muscles, 505, 506 etiol., symp., diag., prog., treat., 505 of the vocal cords, diff. fr. acute laryngitis, 396; fr. chronic laryngitis, 402 Parosmia, diag., treat., 591 Partial extirpation of the larynx described, 481 Passive aneurism of the heart, syn. of dilata- tion of the heart, 239 hypersemia, 133 Pathological Society Transactions, men more affected by plastic bronchitis, Pea- cock, 99 Pear-shaped chest, 10 Pectoriloquy, 55, 57; whispering, aphonic, 58 Pendent epiglottis an obstacle to laryngo- scopy, 291 Percussion, 9, 21-33, 63, 85, 86, 88, 188; mediate, immediate, 21; in health, 21-27; in disease, 28-31; auscultatory, 32, 33 Perforated concave reflector, 275-278 Perforating ulceration in syphilitic sore throat, illus., 353 Perforation of the nasal septum, 601, 602 treat., 601 Pericardial effusion and hydro-pericardium diff. fr. eccentric cardiac hypertro- phy, 238 friction sounds or murmurs, 195 Pericarditis, 13, 212-217 anat., path., 212; etiol., symp., 213; diag., 215; prog., treat., 216 diff. fr. pleurisy, 68, 215; fr. endocar- ditis, fr. mediastinal tumors, 216; fr. endocarditis, 220; fr. chronic endo- carditis, 226, 227; fr. hypertrophy and dilatation of the heart, 238; fr. dilatation of the heart, 241 fibrinosa, serosa, 212 Pericardium, the, 177 Perichondritis of the laryngeal cartilages, chondritis and, 433, 434 Peri-pneumonia, peri-pneumonia vera, syn. of pneumonia. 113 Pertussis or whooping-cough, 153-155 anat., path., 153; etiol., symp., diag., prog., 154; treat., 155 Perverted sense of smell, 591, 592 Peter, 31., devised the plessigraph, 31; pulsa- tion on back of hands, 207 Phagedenic ulceration, 354 Pharyngeal bursa, illus., 309 tonsil, hypertrophy of the, 613-620 Pharyngitis, acute follicular. 339, 340 chronic follicular. 340-346 sicca, or atrophic follicular, 343 Pharynx, anaesthesia of the, 388 and posterior nasal cavities, vault of the, illus., 307-310 678 IXDEX. Pharynx, cancer of the. 380. Si diseases of the, 382 -393 foreign bodies in the, - 1 - hyperesthesia of the, 388, 389 lupus of the. 349 neuralgia of the. 389 neuroses of the. 38 paraesthesia of thi paralysis of tli* 3 . 391. scalds and burns of the, 392 spasm of the tumors of the. 386 Phlebectasis laryngea, anat.. path., etiol.. symp., diag., treat., 409 Phlegmonous laryngitis, 427, 438, 431 syn., etiol.. symp.. diag., 427; prog.. treat.. 428 diff. fr. laryngismus stridulus, fr. retro-pharyngeal abscess, fr. foreign bodies in the larynx, fr. diphtheritic laryngitis. 427. 428 sore throat, syn. of phlegmonous tonsilli- tis. 368 tonsillitis, 368-370 syn.. anat.. path., etiol., symp., diag., 368; prog., treat., 369 diff. fr. diphtheria. 332; fr. acute ton- sillitis, 365 Phthisis infectious. 170 fibroid, 167-169 pulmonary, 13, 15. 89, 31, 161-164. of the heart, syn. of atrophy of the heart, 242 Physical diagnosis. 3-59 examination, methods of, 9-58 examination of the heart. 183-194 Physiological action of the heart, illus., 180-183 Physiology of the heart, anatomy and, 177-1ni Pigeon breast, illus.. 12 Pigments, formulae, 650. 656 Pilocarpine in diphtheria. 337: in erysipelas. 429; in cedema of the larynx. 432 Pincette, 291 Pineapple juice in diphtheria, 335 Pins, E. , pericarditis. 214 Piorry, mediate percussion. 21 Pitch of sound. 22. 39 of heart sounds modified by disease, 191 Pityriasis as a sign, 11 Plastic bronchitis, 99, 100 syn.. anat., path., etiol., symp., 99; prog., treat., 100 diff. fr. pleurisy, fr. pneumonia, 99 or dry pleurisy, t'.i Plessigraph, the. 31 Plessimeter. pleximeter or, 21 Pleurisy, acute. 61-72 bilocular, 83 circumscribed, 82. 150 diaphragmatic. 83 hemorrhagic. 61 of the apex. 82 or empyema, chronic, 76-82 or pleuritis. 12. 29. 60-84 anat.. path., 60 diff. fr. plastic bronchitis, 99; fr. pneu monia. 110; fr. pulmonary collapse, 141 Pleurisy, plastic or dry. 61 subacute. 72-75 multilocular. 83 unilocular. 83 sero-fibrinous. 61 Pleuritic friction sounds diff. fr. pericardial. 196 Pleuritis, pleurisy or. 60-84 Pleurodynia or intercostal neuralgia, diff. fr. pleurisy, 68; fr. pneumonia. 119 Pleurotomy, 78 Pleximeter. 21. 22 Plugging for epistaxis. 561-663, 623, 624 Pneumococci in endocarditis. 222 Pneumo-hydropericardiuni. etiol., symp., diag., prog., treat.. 218 Pneumo-hydrothorax. illus.. 85-88 diag.. *7: treat., 88 diff. fr. emphysema, fr. chronic pleu- risy, fr. diaphragmatic hernia, 88 Pneumonia. 113-129 syn., 113 diff. fr. pleurisy. 69; fr. plastic bron- chitis, 99; fr. pulmonary (edema. 119, 143: fr. abscess of the lung. 130: fr. pulmonary collapse. 141 bilious chronic or interstitial, typhoid, 128 from disease of the heart, from Bright"s disease. 128. 129 lobar. 11:3-123 lobular, 123-128 Pneumo-hydropericardium. etiol., symp., diag.. prog., treat.. 318 Pneumo-hydrothorax. 85 diag.. 87; prog., treat.. 88 diff. fr. emphysema, fr. chronic pleu- risy, fr. diaphragmatic hernia, 87, 88 Pneumothorax. 13. 15. 31. 84, 85 etiol., 84; symp., 85: diag., 87; prog., 88; treat., 88 diff. fr. emphysema. 87: fr. chronic pleurisy, fr. diaphragmatic hernia, 88; fr. emphysema. 110 Pneumonorrhagia. syn. of pulmonary apo- plexy. 134. 137 Pocket tongue-depressor, illus., 271 Polasciano, retro-nasal fibrous tumors, 621 Polikier, B., foreign bodies in oesophagus. 642 Polypi, nasal fibrous. nasal mucous. 5' Polypus, diff. fr. phlegmonous laryngit: Porcher, self-retaining uvula and palate re- tractor, illus., 306 Position for rhinoscopy, illus., 304 Positions of head for laryngoscopy, good, poor, illus., 284. 285 Posterior crico-arytenoid muscles, bilateral paralysis of. 511-513 region. 3 rhinoscopy, illus.. 302-306 Post-nasal catarrh, syn. of rhinopharyngitis, 607 snare applicator. 023 INDEX 679 Post -nasal syringe, illus.. 609 Post-tracheotomy vegetations. 485 etiol.. symp., diag\ . prog., treat., 485 Potain, use of sterilized air in pneumothorax, 88 Potassium iodide for angina pectoris, 247, 253 Poulet, epileptiform asthma. 104 Powder-blower for insufflation, illus., 536 Powell, R. Douglas, siphon drainage in pleu- risy, 79; cause of angina pectoris, 250; aortitis, 254 Prentiss, classification of causes of slow pulse, 250 Prescriptions, formula? for, 645-658 Presystolic venous pulsation, cause of, 207 Probang, cotton, 405 Probe, flat nasal. 537 Processus vocales, the, illus., 299 Professional patches, cliff, fr. leucoplakia buc- calis, 361 Progressive bulbar paralysis, 391 Prolonged interval between inspiration and expiration, cause of, 43 respiration, cause of, 44 Prophylactic treatment most important for distoma pulmonale, 151 ; for acute rheumatic sore throat, 321 : for diph- theria, 333, 334; for rhinitis in catar- rhal tendencies, 534 Prophylaxis in phthisis, 170: in rhino-pharyn- gitis, 609 Prudden, T. M., streptococcus of diphtheria, 329 Pseudo-angina pectoris, diff. fr. angina pec- toris, 252 Pseudo-apoplexy, 243 Pseudo-diphtheria, 329 Pseudo-membranous bronchitis, syn. of plastic bronchitis, 99 Psoriasis linguae, diff. fr. leucoplakia buc- calis, 361 Pulmonary apoplexy. 29. 137, 138 syn., anat., path., etiol., symp., 137; diag., treat.. 138 area, illus., 198, 199 artery, 180; aneurism of the, 264, 265 cancer, 146-148 anat., path., etiol., symp., 146; diag.. 147, prog., treat., 148 diff. fr. chronic pleurisy, fr. phthisis, fr. aortic aneurism, 148 Pulmonary collapse, 139. 142 syn., anat., path., 339; etiol., symp., 140; diag., prog., treat., 141 diff. fr. lobar pneumonia, 120; fr. lob- ular pneumonia. 125 ; f r. pneumonia, fr. pleurisy, 141 Pulmonary emphysema, 12, 107-112 anat., path., 107; etiol.. symp., 108; diag., 110; prog., treat., 112 diff. fr. chronic bronchitis, 93; fr. asthma, 105; fr. pneumothorax, 110: fr. acute tuberculosis, fr. fibroid dis- ease of the lungs, fr. asthma, 111 fissures, 8 gangrene, 144, 145 Pulmonary gangrene, anat., path., 144: etiol., symp., diag., prog., treat., 145 diff. fr. phthisis, fr. bronchitis, fr. di- latation of the bronchial tubes, 145 hemorrhage, 134-136 syn., anat., path., 134; etiol., symp., diag., 135; prog., treat., 136 diff. fr. bronchitis, 93, 94; fr. haema- temesis, fr. epistaxis, fr. hemor- rhage from the gums or the phar- ynx, 135, 136 hyperaemia, 132-134 anat., path., 132; etiol., symp., prog., 133; treat., 134 cedema, 30, 142-144 anat., path., etiol., 142; symp., diag., prog., treat., 143 diff. fr. capillary bronchitis, 97, 143; fr. pneumonia, 120. 143; fr. pneumonia, fr. hydrothorax. 143 phthisis, 13, 156-176 syn., 156; prog., 169; treat.. 170 diff. f r. pleurisy, 69 ; f r. bronchitis, 93, 94; fr. capillary bronchitis, 98; fr. bronchiectasis, 101 : fr. pneumonia, 120 ; f r. pulmonary gangrene, 145 ; f r. pulmonary cancer, 147; fr. hydatid cysts of the lungs, 149 : f r. syphilitic disease of the lungs, 151 ; f r. enlarged bronchial glands. 153 resonance, exaggerated, 28 semilunar valves, 178 thrombosis and embolism, 138, 139 anat., path., 138; etiol., symp., diag., prog., treat.. 139 tuberculosis, 30. 156-165, 169, 170 anat., path.. 156; etiol., 158; symp., 159; diag., 164; prog., 169, 170; treat., 170 diff. fr. other forms of phthisis, 166 tumors, 148-153 Pulmonic obstruction, regurgitation, 226 Pulsating empyema. 77 diff. fr. aortic aneurism, 263 Pulsation in the veins on the back of the hands, cause of, 207 Pulse, an indication of action of the heart, 185 normal radial, illus., 208 senile, illus., 210 Punch forceps, 485 Purring tremor, 187 Pus, diff. fr. serum in the pleural sac. 77 Putrid or fetid bronchitis, 91, 102 Pyaemia, diff. fr. glanders, 590 Pyo-pericardium, 217 Pyo-pneumothorax, 88 Pyramidal, pyriform sinuses, 2% Pyrenees, goitre in, 629 Pyriform sinuses, diseases of the. 393 Quaes- 's stethometer, illus., 17 Quality of a murmur, third in importance. 196 of sound, 23, 39, 41 ; of heart sounds modi- fied by disease, 191 Quinsy, syn. of acute tonsillitis, 362; syn. of phlegmonous tonsillitis, 368 080 INDEX. Rales or rhonclii, illus., 48-52 Ramon de la Sota, lupus of the larynx, 452 Rampolla, retro-nasal fibrous tumors, 621 Rankin, D. N., myasis narium, 605 Rapid tracheotomy, 425, 426 Raulin. rhinitis, 532 Recessus pharyngei, illus., 300 Red hepatization, 118, 114; illus., 117 Reduplication of sounds of the heart. 198 Reference Handbook of the Medical Sciences, leptotbrix buccal is, 376 Reflected light for laryngoscopy, 275-278 Reflectors, laryngeal, 275-283; perforated con- cave, 283 Regeneration of atrophied structure, 550 Regions of the chest, illus., 4-8 Regurgitation, aortic, mitral, tricuspid, pul- monic, 225, 228, 230 Renal origin of dropsy, 11 Resection of the ribs in pleurisy, differing views. 78-80; in abscess of the lung, 131 ; of the larynx described, 481 Resonance, normal vesicular, 25; cracked pot, 28, 31; exaggerated pulmonary, 28; tympanitic, 28, 29; amphoric, vesic- ulotympanitic, 28, 30; normal vocal, 55, 56 Respiration, bronchial, broncho - vesicular, laryngeal and tracheal, 41 ; exagger- ated, feeble, 42; suppressed, inter- rupted, or cog-wheel, 43; rude, broncho- vesicular or harsh, 44; cav- ernous, broncho - cavernous, am- phoric, 46 Respiratory organs, physiological action of, 38, 39 Retraction of the lung, syn. of consolidation of the lung, 237 Retro-nasal cartilaginous tumors, 625 catarrh, syn. of rhino-pharyngitis, 607 fibro-mucous tumors, illus., 624, 625 anat., path., etiol., symp., diag., 624; prog., treat.. 635 diff. fr. fibrous tumors, fr. mucous polypi, fr. malignant growths, 624 fibrous tumors, 620-624 anat., path., etiol., symp., 620; diag., prog., treat., 621 diff. fr. polypi, fr. sarcomata, 621 Retro-pharyngeal abscess, 383-386 anat., path., etiol., 383; symp., diag., 384; prog., treat.. 385 diff. f r. croup, fr. oedema of the glottis, fr. foreign bodies, fr. convulsive dis- orders, 384. 385; fr. phlegmonous lar- yngitis, 428; fr. abscess of the larynx. 430 Revue d'Hygiene et de Police sanitaire, infec- tion of diphtheria. Grancher. 334 de Laryngologie, d'Otologie et de Rhino- ogie. rhinitis. Raulin, 532 mensuelle des Maladies de PEnfance, spasm of the glottis, Lubet-Barbon, 496; for- eign bodies in the oesophagus, B. Po- likier, 642 Rheumatic pharyngitis diff. fr. diphtheria. 331 Rheumatic sore throat. 316-331 ; acute, 316, 317; chronic, 818 381 Rheumatism, diff. fr. glanders, 590 nasal affections in, 591 Rhinitis, 522-552; simple acute, 522-526; acute in infants,traumatic,526; chronic, 527- 552; intumescent, 531-540; hypertro- phic, 540-547; atrophic, 547-552; in measles, scarlet fever. 591 chronica, syn. of chronic rhinitis. 527 hypersesthetica, syn. of hay fever, 553 Rhinoliths, 604, 605 symp., 604; diag., prog., treat., 605 diff. fr. atrophic rhinitis, 549; fr. nasal bony tumors, 572; fr. malignant tu- mors, 573 ; fr. osteoma, f r. cancer, 605 Rhino-pharyngitis, 607-610 syn., etiol., 007; symp., diag., prog., 608; treat., 609 diff. fr. adenoid growths, fr. syphilis, 608 Rhinoscleroma, 588, 589 etiol.. diag.. prog., treat., 589 diff. fr. syphilis, fr. epithelioma, fr. keloid, 589 Rhinoscope, a, 272 with uvula holder, illus., 306 Rhinoscopic image, illus., 307 Rhinoscopy, illus., 272, 293-310; anterior, 301, 302; posterior, 302-306 obstacles to posterior, 304, 305 Rhonchi or rales, 48-52 Rhonchial fremitus, bronchial or, 16 Rhythm of sounds, 39, 41 ; of a murmur, second in importance, 196, 200; of heart sounds modified by disease, 191, 193 of the heart, illus., 182, 183 Ribs, resection of the, 78-80, 131 Riegel, signs of chronic myocarditis, 232 Riehl (see Chiari and Riehl) Right-angle cutting forceps, 597 Rima glottidjs, 298 Robinson, Beverley, asthma due to poison in the blood, 104; feeding in laryngitis, 443; rhino-pharyngitis, 607, 609 Roe, J. O. , hay fever related to conditions in nasal passages. 553; nasal vascular tumors, 570; fracture of the nose, 594 Rose cold, syn. of hay fever. 553 Rotch, T. M., pericarditis. 215 Rouge, retro-nasal fibrous tumors. 621 Roux and Yersin, Klebs-Loffler bacillus in mouths of healthy children, 329, car- bolic or boric acid in diphtheria, 336 Rubber palate retractor, illus., 306 Rude, broncho-vesicular or harsh respiration. 44 Ruffer. Armand, diphtheritic bacilli. 329 Rupture of the heart, syinp., 245 Sacculds laryngis, the, 297 Sajous, Charles E., self-retaining nasal specu- lum, illus.. 301; simple membranous sore throat, 326; cocaine in tubercular sore throat, 352: syphilitic sore throat, 356; chromic acid in trachoma IXDEX. 681 of vocal cords, 409; hay fever related to conditions in nasal passages, 553 ; snare, 567 ; nasal osseous cysts, 570 ; knife, nasal saws, illus., 599 Salicylic acid, objectionable in pericarditis, 216 Salter, heredity in asthma. 103 Sands, cesophagotome, illus., 636 Sansom, treatment of ulcerative endocarditis, 233; diagnosis of congenital diseases of the heart in children, 246 Sarcomata, 467, 478 diff. fr. nasal mucous polypi, 566 Saws, nasal, 599 Scalds and burns of the pharynx, symp. , diag. , prog., treat., 392 Scapular region, 4, 7 Scarification of the tonsils, 367, 369 Scarlatina, diff. fr. acute sore throat, 312; fr. diphtheria. 332; fr. acute tonsillitis, 364, 365 Scarlet fever, sore throat of, 323, 324; laryn- gitis due to, 455; nasal affections in, 591 Schaffer, Max, nasal papillary tumors, 569; differentiation of nasal affections, 566 Schech, anaesthesia of the larynx, 499 Schiffers, myxomata transformed into sarco- mata, 566 Schmidt "s Jahrbuch, pleurisy, Biegauski, 66; epilepsy following irritation of pleu- ral surfaces, De Cerenville, 78 Schnell, Ferdinand, the aneurismatoscope, 261 Schrotter, head band for reflector in laryngo- scopy, illus., 278; tubes, dilators. bou- gies or sound, 433, 449, 457, 472, 485, 515 Schuller, Max, tracheotomy, 486 Schuster, nasal syphilis, 576 Scirrhus of the lungs, syn. of fibroid phthisis, 167 Scissors for amputating the uvula, illus., 359; nasal, 545; heavy bone. 600 Scrofulous eruptions, diff. fr. glanders, 590 sore throat, 348-350 etiol., 348; symp., diag., 234; prog. treat., 350 diff. fr. lupus of the pharynx, fr. syph- ilis, fr. tuberculosis, 349; fr. acute tu- bercular sore throat, 352 ; f r. syphilitic sore throat, 355 S-curve, illus., 64 Sea voyage for convalescents from subacute pleurisy, 75: for plastic bronchitis, 100 : for hay fever, 555 Seashore for hay fever, 456 Seat of a murmur first in importance, 196 of heart sounds modified by disease. 191, 192 Second stage of pneumonia, period of red hepa- tization, 117; of phthisis, 161, 162; of pericarditis, 213, 214 Sections of head, illus., 302, 541, 579, 584 Sedatives, formula?, gargles, 647 ; trochisci or lozenges. 647; vapor inhalations, 650; spray inhalations. 651 ; dry inhala- tions, 654: fuming inhalations, 655; insufflations, 656 Seiler, Carl, tube forceps, illus., 495 Self -retaining nasal speculum, 301 Senile pulse, illus.. 210 Senn, Nicholas, guaiacol in phthisis, 173; lar- yngoscopy, 272 Septic endocarditis, syn. of acute endocarditis, 219 Septum forceps, knife, 600 Septum narium, illus., 308 abscesses of the nasal, 603 deflection of the nasal, 594-597 ecchondroma and exostosis of the nasal, 597-601 hasmatoma of the nasal, 602 perforation of the nasal, 601, 602 Sero-fibrinous pleurisy, 61 Serum diff. fr. pus in the pleural sac. 77 Sex modifies form of chest and percussion sounds, 10, 11, 27 Shattuck cites Soltmann on asthma among Hebrews, 103 Shawl-pin removed from the trachea, a, 495 Shoemaker, pilocarpine for erysipelas, 429 Short f rasnulum obstacle to laryngoscopy, 290 Shortened inspiration, 43 Shurly, E. L., battery, 345; iodine hypodenni- cally for immunity to tubercular virus, 172, 442 Sibilant rales, 48, 49 Sibson. treatment of endocarditis, 221 Signs and symptoms differentiated, 9 of inter-thoracic disease, 16 tussive. 59 nervous, 206 Simon, capillary bronchitis in children, 98 Simple acute rhinitis. 522-526 syn., anat., path., etiol., 522: symp., 523; diag., prog., treat., 524 diff. fr. hay fever, 524, 554; fr. inflam- mation of the antrum or frontal si- nuses, fr. measles, 524 acute sore throat diff. fr. acute follicular pharyngitis, 339 cardiac hypertrophy. 234-236 syn., etiol., symp., 234; diag., prog., 235; treat., 236 catarrhal inflammation diff. fr. syphilitic sore throat in infants. 357 chronic rhinitis, 528-530 etiol., symp., 528; diag., prog., 529; treat., 530 diff. f r. hay fever, 529 ; f r. intumescent rhinitis. 534 membranous sore throat. 324-327 syn.. anat., path., 324; etiol.. symp., 325; diag., prog., treat., 326 diff. fr. diphtheria. 326, 332; fr. syphi- litic sore throat, 355 Sinus, empyema of the frontal, 581 ; of the sphenoidal, 583. 584 inflammation of the frontal. 584, 585 Sinuses, diseases of the valeculae and pyri- form. 393 of Valsalva, aneurism o the 257, 259 pyramidal, pyriform. laryngopharyngeal, 296 682 INDEX. Siphon drainage in pleurisy, 79. 82 Skoda, bronchial sound. 46; heart sounds, 100 Small-pox, sore throat of. 381, 322; laryngitis due to, 455 ; nasal affections in, 591 Smeleder, support of reflector in laryngoscopy, 277 Smith and Warner, pseudo-diphtheria, 329 Smoker's patches d iff. fr. leucoplakia buccalis, 361 Snare for excisions in the throat, 386, 507, 570 applicator, post-nasal, 623 forceps, 473 Sodium sulpho-carbolate in endocarditis, 223 Solid mediastinal tumors. 207. 268 syrnp., 267; diag. , prog., treat., 268 diff. fr. thoracic aneurism. 262 Soltmann. asthma among Hebrews, 103 Sonorous rales, 48 Sore throat, acute, 311-314; erysipetalous, 314- 810; rheumatic, 310-321 : acute rheu- matic. 316, 317; chronic rheumatic. 318-321 ; simple membranous. 324-327 ; scrofulous, 348-350; acute tubercular, 350-353; syphilitic, 353-357 throat of measles, symp., diag., prog., treat.. 322 throat of scarlet fever. 323. 324 anat., path., symp., diag., 323; prog., treat., 324 throat of small-pox. 821, 322 anat.. path., diag., prog., treat.. 322 Sound in moving fluid transmitted in the di- rection of motion. 19! South America, myasis nariuiii. 005 South Carolina for phthisis, 175 Spain for phthisis, 175 Sparteine in chronic endocarditis, 229 Spasm of the adductors diff. fr. paralysis of the abductors. 513 of the glottis, 490. 497 syn.. symp., diag. ,496; prog., treat.. 497 diff. fr. acute laryngitis, 395. 390: fr. phlegmonous laryngitis. 427; fr. true croup. 414. 197 of the larynx in adults. 497, 498 etiol.. 497; symp., diag., prog., treat.. 498 diff. fr. asthma, 105 of the oesophagus. 63! syn.. etiol.. symp., 637; diag., prog., treat., 638 diff. fr. stricture of the oesophagus, 635; fr. paralysis, 639 of the pharynx, etiol. , symp. , diag. , prog. , treat., 390 diff. fr. stricture of the oesophagus, fr. paralysis, fr. paralysis of the pha- rynx or the oesophagus. 390 of the vocal cords. 502. 503 anat., path., 502; symp.. treat.. 503 Spasmodic asthma diff. fr. hay fever. .V>4 stricture of the oesophagus, syn. of spasm of the oesophagus. 037 croup, syn. of spasm ol the glottis. 496 Spasmus glottidis, syn. of spasm of the glot- tis, 496 Spatula, nasal. 600 Sphenoidal sinuses, empyema of th>'. 584 Sphygmograph, the, illus. , 808-211, 260 Spirometer, illus., 18 Spleen, variable in size, 27; enlargement of, diff. fr. pleurisy, 70 Spray inhalations, formula?. 651-653 Sprays, powders, pigments, of successive value for chronic laryngitis. 405 Spud, nasal, 599 Staining tubercular bacilli, 164, 166 Staphylococci in pleurisy, 01 Starvation treatment of aortic aneurism. 206 Stenosis of the aorta, syn. of coarctation of the aorta, 366 of heart valves produced. 224. 228 of the larynx, chronic, 456-459 of the trachea, diag.. prog., treat.. 400 Sterilized air in pneumothorax, 88 Sternal region, 4, 6, 7 Sternberg, diplococcus pneumonia?. 115 Stethogoniometer. 18 Stethometer. 17 Stethoscopes. 34-37; disadvantages of. 34 Stimulant and caustic pigments. 656 (see astringents and stimulants, antisep- tics and stimulants) Stimulants, formula?, gargles, 647: trochisci or lozenges. 643: vapor inhalations, 650, 651 ; dry inhalations. 654 Stimulating injections for pleurisy, 81 Stirling, inhalation of lime water in plastic bronchitis. 100 Stoerk, ecraseur. guillotines, forceps, blades, illus.. 473 Stokes, pseudo-apoplexy and fatty heart, 244 Stowell, C. H., sections of head, illus.. 302, 541, 579, 584 Streptococci in pleurisy, 61 Streptococcus erysipelatosus. 315 Strickler. W. M., resection of ribs for pleu- risy, 78 Stricture of the resophagus, 634. 637 anat.. path., etiol., symp., 634; diag., prog.. 635; treat., 630 diff. fr. spasm of the larynx, 390; fr. tubercular laryngitis, fr. tumors in the pharynx, larynx, oesophagus, fr. spasm, fr. paralysis, fr. foreign bodies, fr. spasm, 635 Strong, A. B., resection of ribs for pleurisy, 78; drainage tubes, illus., 79 Strophanthus in exopthalmic goitre. 632 Struma, syn. of goitre, 629 Subacute bronchitis (see acute bronch i t i s"> laryngitis, 397, 398 prog., treat., 397 pericarditis, 212 pleurisy, 12, 72-75 anat.. path., etiol., 72: symp., diag., prog., treat., 73 Subclavian murmurs, 306 Subcrepitant rales. 4^ 50 Subcutaneous emphysema shown. 11 Subglottic hypertrophy. 401 INDEX. 683 Submucous infiltration of the sides of the vomer, illus. , diag. , treat., 547 laryngitis, syn. of phlegmonous laryngitis, 427 laryngitis, syn. of oedema of the larynx, 430 Succussion, 9, 20, 86 Suffocative laryngismus, syn. of spasm of the glottis, 496 stage of croup. 412 Superficial ulceration in syphilitic sore throat, 353; of vocal cords, of epiglottis, il- lus., 395 Superior costal breathing, 11 meatus, illus., 309 sternal region, 4, 6 turbinated bodies, illus., 309 Suppressed respiration, 43 Suppuration of the anterior ethmoid cells diff. fr. empyema of the antrum, 581 of the antrum, diff. fr. atrophic rhinitis, 549; fr. chronic suppurative ethmoi- ditis, 586 Suppurative ethemoidltis, chronic, 585-587 tonsillitis, syn. of phlegmonous tonsillitis, 368 Supra-arytenoid cartilages, 296 Supra-clavicular region, 4 Supra-glottic dropsy, syn. of oedema of the larynx, 430 Supra-scapular region, 4, 7 Supra-sternal region, 4, 6 Supra-thyroid laryngotomy, 475 Swallowing the tongue, 392, 393 treat., 393 Swiss mountains for phthisis, 175; goitre in, 629 Symonds, Charters J. , gum-elastic tube to keep stricture of oesophagus pervious, 636 Symptoms and signs differentiated, 9 Syphilis of the nose, 574-577 anat. , path., etiol., 574; diag., prog., treat., 575 diff. fr. atrophic rhinitis, 549, 575; fr. simple catarrhal rhinitis, fr. lupus, 575 ; f r. empyema of the antrum, 581 ; fr. lupus of the nares, 588; fr. rhi- noscleroma, 589; fr. glanders, 590; fr. rhino-pharyngitis, 608 of the trachea, illus. , 487, 488 anat., path., etiol., symp., 487; diag., prog., treat., 488 Syphilitic condylomata of the larynx diff. fr. benign growths, 468 disease of the heart, 245 disease of the lungs, 151, 152 symp. , diag. , 151 ; prog. , treat. , 152 laryngitis, illus., 443,450, 456 etiol., symp., 444; diag., 446; prog., treat., 448 diff. fr. chronic laryngitis, 403; fr. tubercular laryngitis, 439, 440; fr. tubercular laryngitis, fr. tumors, 446-448; fr. lupus, 453; fr. benign tumors of the larynx, 468 ; fr. cancer, 479 Syphilitic laryngitis in infants, 449, 450 diag., 449; prog., treat., 450 patches diff. fr. leukoplakia buccal is, 362 sore throat, illus., 353-357 anat., path., 353; etiol., symp., diag., 354; prog., treat., 355 diff. fr. chronic rheumatic sore throat, 320; fr. chronic follicular pharyn- gitis, 344; fr. scrofulous sore throat, 349; fr. catarrhal sore throat, fr. scrofulous sore throat, fr. tubercular sore throat, 354, 355 ; f r. acute tonsil- litis, 366; fr. cancer of the pharynx, 387 sore throat in infants, 356, 357 anat., path., etiol., diag., prog., treat., 357 diff. fr. simple catarrhal inflammation, 357 ulceration of the tonsil diff. fr. tubercular ulceration of the tonsils, 378; fr. can- cer, 380, 381 Syringe, nasal, 550; hypodermic, 568; post- nasal, 609 Systole of the heart, 180; auricular, illus., 201; ventricular, illus., 202 Systolic murmur, 201, 202 souffle, 244 venous pulsation, cause of, 207 Tachycardia, 249 prog., treat., 249 Taenia echinoc, coccus, cause of hydatid cysts of the lungs, 148 Tait's Cliniques de Laryngotomie, thyrotomy, Krishaber, 475 Tampon, for the nose, wool, 552; surgeons' lint, 561, 562; lint or gauze, 600; styp- tic gauze, 624 Teeth, empyema of the antrum from diseased, 579 Tennessee mountains for phthisis, 175 Texas for phthisis, western, 175 Thickening of turbinated bodies diff. fr. mu- cous polypi, 565 Third stage of pneumonia, period of gray he- patization, 117; of phthisis, 161-164; of pericarditis, 213, 215 Thompson, R. E., percussion sounds, 28, 30; pulmonary emphysema, 110 Thoracic aneurism, aortic or, 256-266 arteries, diseases of the, 254-268 Three stages of acute pleurisy, 81 ; of pneu- monia, 117; of phthisis, 161; of peri- carditis, 213 ; of croup, 412 Throat, the, 271-310 acute rheumatic sore, 316-317 acute sore, 311-314 acute tubercular sore, 350-353 chronic rheumatic sore, 318-321 consumption, syn. of tubercular laryngitis, 434 deafness, 610-613 etiol.. symp., 610; diag., prog., 611; treat., 612 diseases of the, 271-515 684 INDEX. Throat, erysipelatous sore. 314-316 gout3 - affections of the. 319 mirrors for laryngoscopy, illus., 273 of measles, sore. 332 of scarlet fever, sore. 323, 324 of small-pox. sore. 321, 322 rheumatic sore, 316-321 scrofulous sore, 348-350 simple membranous sore. 324-3-07 syphilitic sore. 353-357 Thrombosis and embolism, pulmonary, 138, 139 Thymus vulgaris, unsatisfactory with pertus- sis, 155 Thyro-arytenoid muscles, paralysis of the. 507. 508 Thyro-epiglottic and ary-epiglotcic muscles, paralysis of, 505 Thyroid gland, diseases of the. 629-632 Thyrotomy described. 474-47(3. 483 Tink'.ing, metallic. 20. 54. 87, - s Tobacco smoking a cause of leukoplakia buc- calis. 360 sore throat, diff. fr. chronic rheumatic sore throat. 320 Tobold. illuminator. 280; laryngeal knives, il- lus.. 474 Tongue, arching of the. 200: swallowing- the. 392; enlarged glands and veins at base of the. 319 (see paresthesia of the pharynx) ; depressors, illus.. 271, 4C4 Tonsil forceps, 373 Tonsilla pharyngea. 310 Tonsillitis, acute. 362-367; phlegmonous 369: chroDic (see hypertrophy of the tonsil) Tonsillitome. the. 372. 373 Tonsillotomy, 373. 374 Tonsils, concretions in the. 375 cancer of the. 380, 381 hypertrophy of the, 369-375 to generative organs, relation of the. 375 hypertrophy of the pharyngeal. 613-620 Luschka's. 613 mycosis of the. 376, 377 obstacle to laryngoscopy, enlarged, 290 removal of the. 371-375 tubercular ulceration of th( " S - Tornwaldt. Dasal tuberculosis, 57 1 -: rhino- pharyngitis. 607 Trachea, examination of the. 300 involution of the. 485, 486 .osis of the, syphilis of the. 487. 488 il cartilages, illti- respiration, laryngeal and. 41 tumors, illus.. 4*3. 484 etiol., symp.. diag.. prog., treat.. 4*4 Tracheitis. 460-462 anat.. path., etiol., symp., 4C0; diag.. prog., treat., 4^1 diff. fr. laryngitis, fr. bronchitis. 4C1 Tracheocele. 481 syn.. anat., path., etiol.. symp., 486; diag.. prog., treat.. 4 "-7 Tracheophony, 54 Tracheotomy described, 421-426 in aneurism of the aorta. 266 in various throat diseases. 338. 397, 432, 434, 442, 448, 450, 454, 455, 457. 459, 470. 472. 474, 481. 484, 486, 488, 495 rapid. 425. 426 vegetations after, 485 Trachoma of the vocal cords, illus., 408, 409 syn., anat.. path., etiol.. symp., diag., prog., treat., 408 Transillumination of the antrum. 580; electric lamp for. 581 Traube, pulmonary percussion, 66 Traumatic laryngitis, symp.. diag., prog., tivat.. 398 rhinitis. 526. 527 symp., treat.. 527 Traveller's nasal douche, illus., 551 Trephines, nasal. 546 Triangle of dulness. illus., 64 Tricuspid area, illus., 198, 199 obstruction. 226. 228 regurgitation. 225. 228, 230 stenosis. 225. 228 valves. 7, 178 Trocar, flat. 79 Trochisci or lozenges, formula?. 647-649 Trousseau, percussion. 32: laryngoscopy, 272; tracheal forceps. 495 True croup, syn. of membranous croup, 411 Tube for antrum, drainage. 583 forceps. 472 to keep stricture of oesophagus pervious, 636 Tubes for chronic pleurisy, drainage, 79-83 for intubation. 418 Tubercle bacilli, illus. ,157; staining, 164; in lupus of the larynx, 451 bacillus. Koch. 159 Tubercles, mucous, 353 Tubercular laryngitis, illus., 434 443 syn., 434; anat.. path., 435: etiol., symp., 436: diag.. 437: prog., treat., 431 diff. fr. chronic laryngitis. 403: fr. anaemia, fr. (edema of the larynx, fr. catarrhal laryngitis, fr. syphilis. 437-440; fr. syphilitic laryngitis. 447; fr. lupus, 452: fr. benign tumors, 468; fr. cancer. 479 sore throat (see acute tubercular sore throat) ulceration of the tonsils. 378-380 anat.. path., symp., diag.. 378: prog., 379; treat.. 380 diff. fr. syphilis, fr. cancer. 379 Tuberculin of doubtful value in phthisis, 173; disastrous results in lupus of the larynx. 453: in tuberculosis of the nares, 579; curative in lupus of the nares. 588; inactive in rhinosclero- ma. 589 Tuberculosis (see acute tubercular sore throat) acute miliary. 165-167 of the nares, 578, 579 anat.. path., etiol.. symp.. diag., prog., treat INDEX. G85 Tuberculosis of the nares cliff, fr. lupus of the nares, 588 pulmonary, 156-165 Tufnell, treatment of thoracic aneurism, 266 Tumors, see also aneurism nasal: fibrous, 569; papillary, 569, 570; vascular, 570; cartilaginous, 571; bony, 571, 572; malignant, 572, 573 of the heart, diag. , prog., treat., 246 of the larynx: benign, 465-476; cartilagi- nous, 468; malignant, 476-483 of the naso-pharynx : malignant, 625; cys- tic, 626 of the pharynx, illus. , treat., 386 pulmonary, 148-153 retro-nasal, fibrous, 620-624; fibro-mucous, 624; cartilaginous, 625 solid mediastinal, 193, 267, 268 tracheal, 483, 484 Turbinated bodies, 308; hypertrophy of, 541, 542 Tiirck, tongue depressor, illus., 271; laryngo- scopy, 272 ; attempt to magnify laryn- geal image, 282; syphilitic laryngitis, 446 Turgescence, venous, 206, 262, 267 Tussive signs, 59 Tympanitic resonance, 26, 28, 29, 30, 66 Typhoid fever, nasal affections in, 591 ; diff. fr. pneumonia, 121 ; fr. glanders, 590 pneumonia, 128 Ulceration of the pharynx, 357 of the tonsils: tubercular, 378-380; syphilitic, 379, 381 Ulcerative endocarditis, 222, 223 etiol., symp., diag.. prog., 222, treat., 223 Unilateral paralysis of the lateral crico-aryte- noid muscles, illus., 510, 511 etiol., symp., diag., 510; treat., 511 paralysis of the posterior crico-arytenoid muscles, illus., symp., diag., prog., treat., 514 Unilocular pleurisy diff. fr. other forms, 83 United States, goitre in, 629 Utah for phthisis, 175 Uvula, abscission of the, 359 acute inflammation and oedema of the, 358 and palate retractor, self -retaining, 306 diseases of the, 358-300 elongated, 289, 305, 343 chronic inflammation and elongation of the, 358, 359 malformations and new growths of the, 359, 360 malignant growths in the, 360 Uvulatome scissors, illus. „ 359 VALECULiE, the, illus., 295 and pyriform sinuses, diseases of the, 393 Valsalva, sinuses of, 257, 259; treatment of aortic aneurism, 266 Valves of the heart, 7, 178 ; position of the, 179 Valvular disease of the heart (see chronic en- docarditis) murmurs, 203 Vapor inhalations, formulae, 649-651 Vaporizer, 612 Vapors from lime water in membranous croup,' 416 Varicose veins at base of tongue, 389 diff. fr. chronic rheumatic sore throat, 319 Vascular tumors, angiomata or, 467 tumors, nasal, 570 Vault of the pharynx and posterior nasal cavi- ties, 307-310 Vegetations, post-tracheotomy, 485 Veins at base of tongue, varicose, 319, 389 Velum palati attacked in syphilitic sore throat, 353, 354 Venous murmur or hum, 207 pulsation, presystolic, systolic, 206, 207 signs, 206-208 Ventilation with diphtheria, mode of, 334 Ventricle of Morgagni, eversion of the, 483 Ventricles of the heart, right and left, 178 of the larynx, the, 297 Ventricular bands, illus. , 297 murmurs, 204 systole, 182; illus., 202 Verneuil, oesophageal dilator, 638 Vertigo, laryngeal, 504 Vesicular emphysema, 107 murmur, the standard of comparison, 39, 40 resonance, normal, 25 Vesiculotympanitic resonance, 30 Vierteljahresschrift fur Dermatologie und Syphilis, lupus of the larynx, Chiari and Riehl, 451 ; nasal syphilis and lupus of the larynx, Shuster, 576 Virchow, pulmonary emphysema, 107; malig- nant endocarditis, 219 Virchow's Archiv, nasal papillary tumors, Hopmann, 569 Virginia mountains for phthisis, 175 Vocal cords, illus., 297 cords, atrophy of the, 515 cords, paralysis affecting the, 505-514 cords, spasm of the, 502. 503 cords, trachoma of the, 408, 409 cords, tumors of the, 465-468 cords, ulcers of the, 395 fremitus, normal, 15, 16 resonance, normal, diminished, 55; in- creased or exaggerated, 56; whisper- ing, 58 sounds, 54-59 Voltolini, attempt to magnify laryngeal im- age, 282; staff for lifting the epiglot- tis, 291 ; friction in laryngeal tumors, 472 ; transillumination of the antrum, 580 Vomer or septum, illus., 307; submucous infil- tration of the sides of the, illus., 547 Von Stoffella, pericarditis, 214 Vulsella forceps, 367 Wagner, Clinton, pneumonia contagious, 116; retro-nasal cystic tumors, 626 Walsham, deflection of the nasal septum, 596 686 INDEX. Warden, laryngoscopy, 272 Warner Csee Smith and Warner) Wash bottle, 586 Waxham, gag, illus., 419 Weber, cause of asthma, 103 Weber-Liel, throat deafness, 610 Weichselbaum, diplococcus pneumonias, 115 Weill, carbon dioxide in asthma, 106 laryngeal illumination, 280 Wells, pneumonia contagious, 116 Weitheim, attempt to magnify laryngeal im- age. 282 Whisper, normal bronchial, exaggerated, ca- vernous, amphoric, 58 Whispering bronchophony, pectoriloquy, vocal resonance. 58 Whistler, cutting dilator, illus., 458 White Mountains for hay fever, 555 Whittaker, James T. , transmission of bacilli to foetus, 158 Whooping cough, pertussis or, 153-155 Wiener medizinische Presse, cause of putrid bronchitis, Josef Lumniczer, 91; pericarditis, E. Pins, 214 Williams. C. J. D., rhinitis, 525 Winter cough, 91 Wintrich, tympanitic resonance. 66; pleurisy, 83 ; cause of asthma, 103 • Woakes, Edward, mucous polypi, 564; throat deafness, 610 W T olff, pneumonia contagious, 115 Wool tampons, 552 Wright, C. H., burr for nasal surgery, 598 Wrdblewski, adenoid growths in deaf mutes, 614 Wyoming for phthisis, 175 Yellow hepatization, 113, 114 Yeo, J. Burney, pleurisy of the apex and low- necked dresses, 82 Yersin (see Roux and Yersin) Zejtschrift der Bakterienkunde, contagious pneumonia, Wolff, 115 fiir klinische Medicin, signs of chronic myocarditis, Riegel, 232 Ziehl, solution for staining bacilli, 164 Ziemssen, chorea laryngis, 501 Ziemssen's Cyclopedia of Medicine, carbolic acid in diphtheria, Oertel, 336; glan- ders eleven years, Bollinger, 590 Zimmermann, siphon drainage in pleurisy, 79 Zuckerkandl. nasal papillary tumors, 569; de- flector of the nasal septum. 594 Zwillinger, H., nasal osseous cysts, 570 COLUMBIA UNIVERSITY This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the rules of the Library or by special ar- rangement with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE C28 C381M50 [••t^v^^^iS^l^l&Ji* '^RwS ^JKKSSS >t>i»t>i»v»B&>i>&>K»!»i» t»t>X»{vK >i»t»ts>l>iK»MK»i»tt>l»i>i !^K^^&5t»JwK> SJvjJsNSb S^^Wv>t»K>t»t»K?t »NNVVVlKV'i*£%SJ»%SS lig^js^^Kss >i^»XK£»}*iK»K»5 i *s > «j»Stvjvjij;*Kj?»<»Kv\» m^^^^m