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c.
.^^i- &0
DISEASES
CHEST, THROAT
AND
NASAL CAVITIES
INCLUDING
I%ysic3l Diagnosis and Diseases of the Lungs, Heart, and Aorta,
Laryngology and Diseases of the Pharynx, Larynx,
Nose, Thyroid Gland, and (Esophagus;
E. FLETCHER INGA]^, A.M., M.D.
hofeuor of Laryngology and DiKcates of the Chest , Rush Medical College ; ProfeMor of Diseauei of
the Throat and Chest, Northwestern University Woman's Medical School ; Professor ot
Laryngology and Rhinology, Chicago Polyclinic; Laryngologisi to the St. Joseph's
Hospital and to the Presbyterian Hospital, etc.; Fellow of the American
Laiyngological Association and American CI imalo logical Assodation ;
Member of the American MiKlical Associatiui] , Illinois State
Medical Society, Chicago Medical Society, Chicago
Pathological Society, etc., etc.
1ReY>i0e& Ii:bir& £Mtton
With Appendix Containing Many Important AoDtrioNs
Two Hundred and Forty Illustrations
NE\V YORK
WILLIAM WOOD AND COMPANY
1898
COPVKicHTKD, 1894, i8g8
Uv WILLIAM WOOD AND COMPANY
PBess o^
IME PUSlISHERS' printihq comamv
J3-3* LAFAYETTE PLACE
NEW yORX
TO MT PRECKPTOR,
EPHRAIM INGAL8, M.D.,
RUBRITUS PROFRSSOR 0¥ MATKRIA MEDICA AKD HEDICAI.
TURISPRL'DKKCU IN RUSH MEDICAL COLLEQR. TO
WHOSE RXCOURAOEMBNT AND WISE
COUNSEL I Ail GRRATLT
INDEBTED,
ZbiB J9oott t0 BTTectlonatels S)edfcate&
BY THE AUTHOR.
PREFACE TO THE REVISED THIRD EDITIOJS".
The rapid changes in medical science Iiave necessitated numerous
additions to this work, which have been supplied in the Appendix,
the alphabetical table of contents of which will enable the reader
easily to locate the changes.
The most importjmt additions will be found in the articles on
Pneumonia, Pulmonary Tuberculosis, Actinomycosis of tlie Lungs
and Mouth, Chronic Endocarditis, Diphtheria, Ludwig's Angina, and
Goitre. E. F. I.
30 WASfflNOTON STKEET, CHICAOO,
September, 1B08.
PREFACE TO THE THIRD EDITION.
ri iHIS ia 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 1 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 comraend 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 bo prepared to meet any emergency.
As it is but little over a year since the second edition was published
no great alteration in tlie 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,
34-80 Washisotos St., Chicago.
PREFACE TO THE SECOND EDITIOK.
TN tlie 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 ralue 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
onr 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 nnsal passjtges, as
well as the more important affections of the ccsophagus 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 hiive made no attempt to collate the viirious
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
BD 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.
indebtedneBS. 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. R L
84r^ Washisoton St.. Chicaoo,
Stptember, 1892.
PEEFACE 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 moasures. When these lectures were de-
livered, notliing 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 diiignosis 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 PREFA CB TO FIRST EDITION.
the fact that much of which they treat has long since become pablio
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 Co}ien, 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 famished electro-
types for the illustrations of instruments.
E. F. I.
CONTENTS.
PAOB
Preface vii
List of illuBtrations, xziii
DISEASES OF THE CHEST.
CHAPTER I.
Physical diagnosis 8
DivisioDB of the chest 8
Methods of ezaminatioii 9
Inspection, 0
Palpation 14
Mensuration, 16
Succussion . . 20
CHAPTER n.
Physical diagnosis, continued, 21
Percussion, 21
In health, • 21
In disease 38
The Plessigrap)! 81
Auscultatory percussion 32
CHAPTER m.
Physical diagnosis, continued, 84
Auscultation, 84
In health 80
In disease, 41
CHAPTER IV.
Physical diagnosis, continued, 48
Adventitious sounds 48
Vocal sounds, 54
CHAPTER y.
mmonary disease! 60
Pleurisy 60
Acute pleurisy 61
Sabocnte pleurisy, 72
xiv CONTENTS.
CHAPTER VI.
rAom
Pulmonary diseases, continued 76
Chronic pleurisy or empyema 70
Peculiar local forms of pleurisy 83
Hydrothorax 84
Pneumothorax 84
Pneumo-hydrotfaorax, 85
CHAPTER Vn.
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 Vni.
Pulmonary diseases, continued, 113
Pneumonia, . 118
Lobar pneumonia 118
Lobular pneumonia 123
Peculiar forms of pneumonia, 138
Abscess of the lungs, 129
CHAPTER IX
Pulmonary diseases, continued 133
Pulmonary hypertemia, 133
Britwn induration 184
Pulmonary hemorrhage 134
Puliuonary apoplexy, 137
PulinoDary thrombosis and embolism 138
Pulmonary collapse. , . . 189
Pulmonary cedema, 143
Pulmonary gangrene, 144
Pulmonary cancer 146
Pulmonary tumoni 148
Hydatid cyots of the lungs 148
Distouia pulmonale 150
Syphilitic diseases of the lungs, 151
Enlarged bronchial glands 153
Pertussis or whooping-cough 153
CHAPTER X.
Pulmonary diseases, continued, 156
Pulmonary phthisis, 156
Pulmonary tuberculosis, 156
Acute miliary tuberculosis, 165
Fibroid phthisis, 167
COm'ENT& XV
CHAPTER XI.
PAOI
The heart, 177
Anatomy and physiology sf the heart, 177
Fhysiolngical action of the heart 180
Physical examination of the heart, . . 18S
Cause of the heart sounds, 190
Modification of the heart sounds by disease, 101
CHAPTER Xn.
Hie heart, continued 196
Abnormal heart sounds, cardiac murmurs, 19S
Anomalous heart sounds 305
Subclavian murmurs, 206
Venous signs. 306
The spfaygmograph 306
CHAPTER Xin.
Cardiac diseases, 313
Pericarditis 213
Pneurao-hydropericardium, 318
Hydropericardiimi, 318
Endocarditis 219
, Acute endocarditis, 219
Ulcerative endocarditis 233
Chronic endocarditis, valvular disease of tiie heart, . . . 33S
Myocarditis 231
CHAPTER XIV.
Cardiac diseases, continued 384
Simple cardiac hypertrophy 284
Hypertrophy and dilatation of the heart 336
Dilatation of the heart, 339
Atrophy of the lieart, 342
Fatty heart, 343
Aneurism of the heart 245
Rupture of the heart, 245
Syphilitic disease of the heart, 345
Tumors of the heart 346
Morbus ceeruleus, 246
Neurotic or functional disease of the heart, 347
Tachycardia 249
Bradycardia, 3.50
Angina pectoris, 350
CHAPTER XV.
Diseases of the thoracic arteries, 354
Aortitis, 254
Atheroma of the aorta 254
xn
COXTESTS.
Aortic or thoracic aneiirisni 396
Anenrism of the ainuMa of VahalTa, S6T
Aneazism oi the mrcfa of the aorta, SS7
Anearism <rf the deacending aorta, 257
Coarctation of the aorta, 368
Solid nKdiastinal tumors, , . 367
DISEASES OF THE THROAT.
CHAPTER XVI.
The throat, 871
EzaminatioD of the fauces, 371
l*ryngo«!cop>-. . . 273
Obstacle) to larrogcecopf 389
Infra'Klottic laryogoecopT'. 393
CHAPTER XVII.
The throat, continued S93
The latTDxand rhinnt^ropr 393
Examiuation of tlie trachea, 300
RhinoHcopy, 30t
Anf^rior rhinoncopr 301
Pofltfcrior rhinfjscopr, ^ . 303
OliHtaclefl to prjeterior rhini'AcopT 304
Vault of the pharynx and jK«ter:or nasal caTitiee, 307
CHAPTER XVni.
Diseases of the faiiren.
Acute Hort: thrctat,
En'stfH-latoii^ h'lr^ thrrjAt, .
Rheutiiatir- horf tlir<>at.
Aciitf; rlifijiuatir sore throat,
Chronif; rh'-urnatic wire throat,
Sore lliroiit (.f siiiaM-|»ox, .
Srjre llm^t of iiifa.'^lf-s,
fkfre throat of hfsirU-t f*;ver.
Simple iiieinhrMnoiJs Hor«; throat.
311
311
314
316
316
318
321
322
323
334
CHAPTER XIX.
Diwaws tif tlie faiireH, continufd,
iJiplitli'-ria, .,..,.
338
328
CHAF*TKR XX
DiseaRes of the fauces. continin-<l, .
Acute follHTiihir i>}iaryrii;ili-j,
Chroitif follicular pluirvniritiH, .
Acute follicuUr gloiwitiM
339
339
340
347
CONTENTS. XVil
PAOB
Chronic follicular gloeaitis, 847
ScrofuIouH sore tliroat, 846
Acute tubercuar sore tliroat SSO
Syphilitic sore throat 8S3
Syphilitic sore throat in infants. 356
CHAPTER XXI.
Diseases of the fauc-es, continued SIS8
Diseases of the uvula, 3S8
Acute inflammation and oedema of the urula 35B
Chronic inflammation and elongation of the uvula .... 858
Malformation and new growths of the uvula 859
IjBUcoplakia buccalis, 860
Acute tonsillitis S62
Phlegmonous tonsillitis, . 868
Hypertrophy of the tonsils, v 370
Concretions in the tonsils, 875
Mycosis of the throat, 876
Tubercular ulceration of the tonsils, 378
Cancer of the tonsil, 380
CHAPTER XXn.
Diseases of the pharynx 883
Foreign bodies in the pharynx, 383
Retro-phurj-ngeal abscess, 383
Tumors of the pharynx 386
Cancer of the phar>'nx 386
Neuroses of the pharj-ni. 388
Anft>sthe8ia of the pharynx 388
HypenuHthcsia of the pharynx 388
Para>NtheHia of the pharynx, ' . . . 380
Spa-sm of the pharynx, 390
Paralysis of the pharj'nx, 391
Scalds and burns of the phar>'nx 892
Swallowing the tongue, 393
Diseases of the valeculss and pyriform sinuses, 393
CHAPTER XXIU.
Diseases of the larynx, 394
Acute laryngitis 394
Subacute laryngitis 397
Traumatic laryngitis, 398
Chronic laryngitis, 398
Trachoma of the vocal cords, - 408
Phlebectaais laryngea, 409
CHAPTER XXIV.
Diseases of tiie larynx, continued, 411
Uembranoua croup 411
xvui CONTENTS.
CHAPTER XXV.
PAOB
Diseases of the larynx, continued 427
Phlegmonous laryngitis, 427
Erysipelatous laryngitis, 428
Abscess of the larynx, 429
(Edema of the larynx, 480
Chondritis and perichondritis of the laryngeal cartilages, . . . 488
Tubercular laryngitis 484
Syphilitic laryngitis 443
Syphilitic laryngitis in infants, 449
CHAPTER XXVL
Diseases of the larynx, continued 461
Lupus of the larynx, 461
Lepra of the larynx 464
Hypertrophy of the larynx, . . . ' 456
Lfuyngitis of small-pox 456
Laryngitis of measles 465
Laryngitis of scarlet fever 465
Chronic stenosis of the larynx, 456
Stenosis of the trachea 460
Tracheitis. 460
CHAPTER XXVII.
Diseases of the larynx, continued 463
Morbid growths in the larynx, 463
Benign tumors of the larynx 465
Malignant tumors of the larynx 476
Eversion of tlie ventricle of Morgagni 483
Tracheal tumors 483
Post- tracheotomy vegetations, 485
Involution of the trachea, 485
Tracheocele 486
Syphilis of the trachea, 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 493
Spasm of the glottis, 496
Spasms of the larynx in adults, 497
Irritative cough, 49S
Nervous cough 498
Anaesthesia of the larynx 499
Hypersesthesia, pariesthesia, and neuralgia of the larynx, . . . 500
Chorea laryngis, 501
CONTEHTS. xix
PAbC
Spasm of the vocal ooids, 502
Falsetto voice 503
lArytigeal vertigo. 604
CHAPTER XXIX.
DiBeasee of the larynx, continued, 505
ParalyBisof the thyro-epiglottic and ary-epiglottic muscles, . . 505
Paralysis of the crico-thyroid muscles, 506
Paralysis of the thyro-arytenoid muscles, 507
Bilateral paralysis of the lateral crico-arytenoid muscles, . . . 508
Unilateral paralysis of the lateral crico- arytenoid muscles, . . . 010
Paralysis of the arytenoid muscle 511
Bilateral paralysis of the posterior crico-arytenoid muscles, . . 511
Unilateral paralysis of the posterior crico-arytenoid muscles, . . . 514
Anchylosis of the arytenoid cartilages, 514
Atrophy of the vocal cords, .... 515
DISEASES OF THE NOSE.
CHAPTER XXX.
Diseases of the nasal cavities 619
Influenza, 619
Rhinitis 622
Simple acute rhinitis, 523
Traumatic rhinitis 536
Chronic rhinitis, 627
Simple chronic rhinitis 538
CHAPTER XXXL
Diseases of the nasal cavities, continued 581
Rhinitis, continued, 6S1
Chronic rhinitis, continued 6S1
Intumescent rhinitis, 631
Hypertrophic rhinitis, 640
Submucous infiltration at the sides of the vomer, . , . 647
Atrophic rhinitis, . . 647
CHAPTER XXXIL
Diseases of the nasal cavities, continued, 553
Hay fever 553
Fnrunculosis of the nose 558
Epistaxis. 559
CHAPTER XXXm.
DiaeassB of tiie naaal cavities, continued, 564
Nasal mucous poly pi 564
Nasal fibrous polypi . . 569
XX
CONTENTS.
Nasal papillary tumors, ... 069
Nasal vascular tumors 570
Nasal osseous cysts, 670
Nasal cartilaginous tumors, 571
Nasal bony tumors 571
Nasal malignant tumors, 072
CHAPTER XXXIV.
Diseases of the nasal cavities, continued, 674
Syphilis of the nose, . 574
Congenitalsyphilisof the nose, ... . . , . . , 577
Tuberculosis of tlie nares, 578
Empyema of the antrum, 578
Empyema of the sphenoidal sinuses, 588
Intlammation of the frontal sinua 584
Clironic suppurative ethmoiditia. 685
Lupus of the nares 587
Rliinoscleroma, 588
Glanders 689
Nasal afTectiona in acute diseases, . 591
Perverted sense of smell 591
Parosmia, 691
Anosmia, 691
CHAPTER XXXV.
Diseases of the nasal cavities, continued, 598
Congenital deformity of the nose, . 593
Fractures of the nose, 593
Dislocation of the nasal bones, 594
Deflection of tlie nasal septum, 694
Ecchondrotna and exostosis of the nasal septum, 597
Perforation of the nasal septum, 601
Ila-niatoma of tlie nasal septum, 602
Abscesses of the nasal septum, 603
Foreign bodies in the nose, 603
RhiDoliths 604
Myasis narium or maggots in the nose, 605
CHAPTER XXXVI.
Diseases of the nasopharynx, .
Rliino-pliarynfritis, ....
Throat deafness. ....
HyiHTtriiphy of the pharyngeal tonsil,
Retronasal libi'ons tumors.
Retronasal filiroiiiucous tumors.
Retronasal cartilaginous tumors,
Malignant tumors of the naso-pharynx,
Cystic tumors of the naso-pharynx, .
607
607
610
613
620
634
625
626
626
CONTENTS. Xlt
DISEASES OF THE THYROID GLAND AND THE
(ESOPHAGUS.
CHAPTER XXXVII.
PAQI
Goitre 629
Exophthaltnio goitre 683
CEsophagitis, 632
Acute oesophagitis 633
Chronic nsophagitis, . 688
Stricture of tlie oesophagus, 684
Compression of the oeflophagus, 687
Spasm of the cesophaguB 687
Paralysis of the oesophagus 688
Foreign bodies in tlie oesophagus 640
F&TEesthesia of the oesophagus, 643
CONTENTS OF APPENDIX.
VBge of Page of
Book. Appeudix.
Actinomycosis of the Lungs.
Etiology and Pathology, Symptomatology 156 (648)
Diagnosis, Prognosis, Treatment 156 (648)
Actinomycosis of the Mouth.
Anatomy and Pathology, 363 (e-lfl)
Etlofogy, Symptomatology 368 (656, 057)
Diagnosis, Prognosis, Treatment, 868 (657)
Angina Pectoris.
Diagnosis, Prognosis, Treatment. 353 (652)
Acute Sore Throat.
Treatment, 313 (653)
Abscew of the Tongue 363 (65&
Anosmia rm (660)
Antrum of Ilighmore, Operation on, 583
Antiseptic Surgeon's Lint, 600 (661)
Bronchitis.
Symptomatology, . aO (646)
Bronchitis, Chronic.
Symptomatology 91 (646)
Bronchitis, Capillary.
Dellnition 95 (046)
Prognosis, 98 (046)
Bradycardia 350 (053)
Dilatation of the Heart.
Etiology, 340 (651)
Diphtheria.
Etiology, 329 (053)
Diagnoflis, Bacteriological Examination 333 (653J
Loffler's Blood-Serum Mixture, Prognosis 333 (653)
XXll CONTENTS.
VMge ot Pigeor
Book. AppBodbc,
Traatment, Topical 886 (654)
Antitoxin, 837 (654)
Fumigation, 887 (606)
Deflection of the Nasal Septum 596 (661)
Endocarditis, Clironic.
Treatment 239 (650)
Exercise, Oertel's and Schott's Methods 230 (650)
Eversion of the Ventricle of Morgagni, 488 (658)
Empyema, or Chronic Pleurisy, 77, 78 (645)
Empyema of the Antrum.
Treatment ' . .583 (669)
Senn's Operation 583 (609)
Ecchondroma and Exostosis of the Nasal Septum.
Treatment, 598-600 (661)
Fatty Heart.
Symptomatology, 243 (651)
Fracture of the Larynx.
Prognosis 489 (65B)
Foreign Bodies in the Larynx.
Treatment, 492 (659)
Foreign Bodies in the (EmpliagUB.
Treatment 643 (663)
Frontal Sinus, Inflammation of 584 (660)
Goitre.
Treatment. 631 (663)
Hypertrophy and Dilatation of the Heart 389 (651)
Hypertrophy of Pharyngeal Tonsil.
Anatomical and Pathol<«ieal Characteristics, ... 618 (661)
Hypertrophy of the Tonsils.
Pn^^oeiB and Treatment, 871 (658)
Heart.
Fatty, Symptomatology 348 (651)
Syphilitic, Disease of 345 (651)
Dilatation 340 (651)
Hypertrophy and Dilatation 339 (651)
Ldffler's Blood-Serum Mixture, 3S2 (653)
Ludwig'B Angina 868 (657)
Larynx.
Fracture of, 489 (659)
Foreign Bodies in the 493 (659)
Nasal Mucous Polypi.
Anatomical and Pathological Characteristics, . . '>&'> (659)
Perverted Sense of Smell— Parosmia 501 (660)
Pharyngeal Tonsil, Hypertrophy of Q\3 (661)
Pleurisy.
Exciting causes, 62 (645)
Treatment 72 (645)
Diagnosis and Prognosis 78 (646)
Pleurisy, Chronic, or Empyema.
Prognosis 77 (645)
CONTENTS. xxili
Pbko of PaK« of
Book. Appendix.
Treatment, Pleiirotomy 78 (040)
Pneumonia.
Lobar 116 (640)
Symptomatology, 116 (646)
PrognoBiB, 121 (646)
Treatment 123, 138 (646)
Lobular. ^ 128 (657)
Anatomical and Pathological CharacteriBticB, . .138 (647)
Etiology 124 (647)
PertusBis, or Whooping- Cough.
Treatment, 155 (647)
Pulmonary Phthisis.
Etiology 159 (648)
Diagnoeis 164 (648)
Prognosis 169 (648)
Treatment. 170-174 (649)
Parosmia 091 (660)
Retro-Nasal Fibrous Tumors, ...:.... 624 (661)
Rhinitis.
Anatofnical and Pathological Characertistics, . .522 (659)
Senn, N. , Operation on Antrum, 582 (6&9)
Syphilitic Disease of the Heart, 345 (651)
Ttehycardia, .349 (651)
FORMULA. ,^
Prescriptions, 668
Gargles . 665
Sedatives 665
Astringents, 665
Stimulants, 665
Antiseptics .*,... 605
Trochisci or lozenges, 065
Sedatires 665
Demulcents, 660
AstriagentB, 666
Stimulants, 666
Antiseptics 667
Vapor inhalations 667
Sedatives 668
Antispasmodics 66tl
Mild stimulants ecu
Strong stimulants 669
Spray inhalations OOi)
Sedatives. 6^
Astringents and stimulants, 670
Haamostatics, 871
Antiseptics, i^Tl
'tSJV CONTENTS.
PAOB
Dry inlialatioDfl BTS
Sedatives, 872
StimulantB 878
Fuming inhalations 672
Sedatives, 678
Stimulants 673
Pigments 673
Local antestheticB, ... .... 673
AstringentB, 674
Stimulants and caustics, 674
Antiseptics, 874
Insufflationa 674
Sedatives, 674
Antiseptics and stimulants, 675
A8trin«ent8 and stimulantB, . 675
Nasal douches 076
LIST OF rLLUSTRATIONS.
no. nan
1. Regions of tbe chnt, 4
2. Regions of the chest 0
3. Outline of the chest, 10
4. Quain's Btethometer, 17
a. Cairoll's Btethometer .17
6. Flint's cyrtonieter 18
7. Spirometer 18
8. Allison's stethogoniometer, .18
9. Hamniond'i) heemadynamometer, 19
10. Flint's hammer and pleximeter, 21
11. Camman's stethoscope 32
12. Ingals' emballometer 83
13. Solid wooden stethoscope, 86
14. Knight's stethoscope, .36
15. Allison's differential stethoscope, , 37
16. Fhlhisis, . 47
17. Bronchial r&les 49
18. Acute pleurisy, RS
19. Curred line of flatness in pleurisy, posterior view, .... 04
20. Curved line of flatuess in pleurisy, anterior view, 65
21. Subacute pleurisy, 73
22. Cabot's drainnge tubes 79
33. 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. Marej's sphygmograph, 208
37. Normal radial pulue, tracings, . 208
38. Normal radial pulse, tracingH, 208
89. Aortic obstruction '•^dlt
40. Aortic obstruction, 20!)
41. Uitral regurgitatiou, 30V
xivi LIST OF ILLUSTRATIONS.
no. PASS
42. AneuriBm, 200
43. Aortic regurgitatioD 209
44. Aortic regurgitation and obstruction, 309
45. Cardiac hypertrophy in Bright's disease, 210
46. Tracing of the senile pulse, 310
47. Mitral constriction, tracing 210
48. Mitral constriction and aortic regut^itation, tracing, .... 211
40. Mitral hypertrophy and dilatation ' . . . . 211
.50. Torek's tongue depressor, 271
51. Pocket tongue depressor, 271
62. Bosworth's tongue depressor, 271
58. Throat mirrors for laryngoscopy 278
54. Scbrotter's head band with nasal rest, 278
55. Krishaber's illuminator, 278
56. Modified Mackenzie's rack-moTenient bull's-eye condenser, . . . 278
57. Modification of Mackenzie's illuminator, 279
58. LaryngOBCopic reflector 288
59. Position of the bead giving the best view of the larynx, . . 284
<t0. Position of the head giving a poor view of the larynx 285
61. I^ryngoscopic mirror in position, . . . * 28S
62. Brun's pincette 291
63. Infra-glottic laryngoscopy 201
64. Relative relations of the larynx and its image, 203
65. Normmal larynx in respiratitxi, * . . 298
66. Pitcher-shaped inter-arytenoid fold, 295
67. Lapping of arytenoid cartilages in phonation, 295
68. Cushion of epiglottis, 295
69. Pointed epiglottis 205
70. Jewe'-harp epiglottis 296
71. Larynx of a woman in respiration SOS
72. View of left side of larynx 207
78. Normal larynx of woman in formation of head tones, .... 298
74. View of posterior wall of tracliea, ........ 800
75. View of anterior wall of trachea, 800
76. IngaU' nasal speculum 801
77. Jarvis' nasal speculum, 801
78. SajouB' nasal speculum, 801
79. Cross section of head ehowing ethmoid cells and nasal cavities, . . 802
80. Fraenkel'srhinoscope 308
81. Position for rhinoscopy, 804
82. Rubber palate retractor 306
83. Porcher's self-retaining uvula and palate retractor 306
84. Palate retractor 806
85. Rhinoecoi>e with uvula holder, 306
86. Rhinoscopic image, . 307
87. Adfuoid tissue at vault of the pharynx, 800
88. Pharyngeal bursa 800
80. ChroDic follicular pharyngitis, 348
90. Modification of Sluirly's battery 845
91. luj^al.-*' cimtcry ^-li-ctrDileK, ......... 346
92. Perfuratiou of the piiiati'. syphilitic, 354
LIST OF ILLUSTRATIONS. ixvii
no. FAOB
98. SciBBora for amputating the uvula, 3S8
04. Hathieu'B touBillitome 873
95. Mathieu's tonsitlitome, oblique fenestra 873
96. Ingals' tonsil forceps, 878
07. Fibroma of pharynx 866
98. SuperBcial uIcerB of the vocal cords, . 895
99. Superficial ulceration of the epiglottia, . . . , • . . . 395
100. Mackenzie's laryngeal lancet, . 897
101. Catarrhal ulcer of the vocal cord 899
103. Chronic catarrhal laryngitis, with defonui^, 899
108. 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. 69 old style 406
109. Trachoma of vocal cords, . . 408
110. Ingals' chromic acid applicator and handle, 409
111. IngaU' galvano- cautery handle 409
113. O'Dwyer's intubation instrumentu, 418
113. Henrotin's gag, 419
114. Waiham'sgag 419
115. Allingham'sgag, 419
116. O'Dwyer'B 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. (Edema of the larynx 482
121. Tubercular laryngitis, .......... 435
122. Tuberoular laryngitis, pyriform swelling of the arytenoids, . . 435
123. Tubercular laryngitis, pyriform swelling of the arytenoids, . . 435
124. Tubercular laryngitis, 485
125. Incipient tubercular laryngitis, 436
126. Tubercular laryngitis 436
127. Tubercular ulceration of the vocal cords, 487
128. Tubercular ulceration of the vocal cords 437
139. Tubercular ulceration of the ventricular bands, ..... 438
130. Tubercular ulceration of the ventricular bands and vocal cords, . . 438
181. Tubercular laryngitis, sluggish action of the vocal cords, . . 438
132. Tubercular ulceration of the larynx, 440
133. Tubercular laryngitis, with syphiliB, 440
134. Condyloma of the epiglottis, . . 444
135. Gumma of the larynx, 444
186. Multiple gumma of the larynx 444
137. Syphilitic laryngitis 444
138. Syphilitic laryngitis, 446
189. Syphilitic ulceration of the epiglottis 446
140. Syphilitic ulceration 446
141. Lupus of the larynx (Ziemssen) 451
142. Lupus of the larynx (TQrck), 452
148. Lepra of the larynx, 454
xxviii L7ST OF ILLUSTRATIONS.
no, FAOB
144. Syphilitic laryngitis 456
145. Syphilitic stenosis of laryDX, ... 4S6
146. Mackenzie's laryngeal dilator, , . 468
147. Whistler's cutting dilator 458
148. Tube for laryngO;tracheal stenosis '459
149. Mount Bleyer's tongue depressor, 464
mo. Papilloma of right vocal cord, 465
151. Papilloma of the larynx, . . 465
152. Papilloma of vocal cords, 466
153. Papilloma of vocal cords, 466
154. Papilloma of the lar>-nx, 466
155. Fibroma of left vocal cord, 466
166. Fibro-cellular tumor of the larynx, 467
157. Cystic tumor of the larynx, 467
158. Cystic tumor of the larynx 467
159. Cyst of the epiglottis, 467
160. Adenoid tumor of the larynx, 467
161. Adenoid tumor of the larynx 467
163. Cartilaginous tumor of the larj'nx, 468
163. Vascular tumor of the larynx 468
164. Vascular tumor of the larynx 468
165. Laryngeal forceps, 471
166. Mackenzie's tube forceps, 473
167. Stoerk's larj-ngeal iustrumeuts . . 478
168. Tobold's laryngeal knives, 474
169. Cancer of the larynx, 477
170. Cancer of the larj-nx 477
171. Cancer of the larynx 477
172. Cancer of the larynx, 477
173. Cancer of the larynx 478
174. Cancer of the larynx 478
175. Mixed sarcoma of larynx, 478
176. Cancer of the larynx 478
177. Tumor in the trachea, 484
17H. Ingals' punch forceps 485
1T9. Syphilitic laryngitis, 487
IMd. St'iler'a tube for eps, 495
isi. Jiilateral paralysis of the cricothyroid muscles 507
lHi>. Acute laryngitis, 507
18:t. Paralysis of tlie thyro-arytenoid muscles 508
184. Ptiralysis of the lateral criro-arytenoid muscles, 508
185. Miickeiizie's laryngeal eli-ctroiles, 509
IHfi. Unilateral paralysis of tlic liiteral crico-arytenoid muscles, respiration, 510
187. Unilateral paralysis of tin' latoial crico-arytenoid muscles, phonation, . 510
188. Unilateral paralynis of the cvico- arytenoid muscles, .... 510
189. ZieniswTi'H laryngeal eleclroile.H, . 511
190. Hilateral paralysiw of the piwterior crico-arytenoid muscles, inspira-
tion 513
191. Bilateral paralysiis of the |K»st('riorcrico-arytenoid muscles, expiration, 513
192. Unilateral paralysis of the |io:jlerior crico-arytenoid muscles, inspira-
tion, 614
UST OF ILLUSTRATIONS. xxix
m. PAGE
19S. tTailateral paralysis of the posterior crico-arytenoid muscles, pfaona-
tion 514
194. Anchylosis of the arytenoid cartilages 914
195. Powder blower, 586
190. Davidson's oil atomizer. No. 60, 586
197. Flat nasal probe and applicator, 587
198. Hypertrophy of the inferior turbinated body, Ml
199. Hypertrophy of the posterior ends of the inferior turbinated bodies, . 642
200. logals' nasal scissors, 54S
201. Nasal burrs 546
203. Nasal trephines 546
203. Submucous infiltration at sides of the vomer, ..... 547
204. Ingals' nasal syringe 550
205. Nasal douclie, 551
200. Nasal douche, traveller's, 551
207. Galvauo-cautery handle with ecraseur 567
208. Ingala' snare ."iO?
209. Cotton applicator 568
210. Hypodermic syringe, long silvernozzle, ,. S6H
211. Ingals' nasal dressing forceps, ........ .576
212. Cross section of head looking from behind forward, .... 579
213. Ingals' electric lamp 581
214. Brainanl's bone drill 582
215. lugals' drainage tubes for antrum 583
216. Cross section of head, 584
217. Curtis' ethmoid-cell wash-bottle, 586
218. Ingals' septum forceps, 596
210. Ingals' septum knife, 596
230. Ingals' right-angle cutting forceps, 597
221. Exostosis from the septum 598
222. Sajous' knife .509
233. Nasal spud 509
234. Ingals' nasal saw, 509
225. Ingalri' flat nasal saw 509
226 and 237. Sujous' saws 599
228. Ingals' heavy hone scissors . 6(H>
229. Ingals' nasal bone forceps, . (HM
23'J. Ingalu' utiaal spatula 600
2.'^1. Gross' instruments for removing foreign bodies. 604
233. Post-nasal syringe, 009
233. Curtis' Eustachian tube vaporizer 613
2'*4. Rhinoscopic view of post-nasal vegetations, 614
335. Mackenzie's, John N., post-nasal forceps, 617
236. Ingrls' post-nasal snare applicator 633
337. Retro-nasal fibro-mucous Dolypus, 624
238. Sand's oesophagotom«, G3(>
239. Flexible oesophageal forceps, . C41
340. Bristle extractor, . . 642
Diseases of the Chest
CHAPTER I.
PHYSICAL DIAGNOSIS.
Jy this vork I ehtill first describe the methods for dctocting disease
which nre based upon the inithoIogicixJ changes in the organs iiffcutcd;
next point out the ehuructeristics and significance of the various signs;
aucl tiually consider the iudividuul diseases.
The term physical diaguut^i:^ is used Lo designate the methods re-
ferred to, whether used iu tlie examination of the chei<t or in the exnm-
inatiou of any otiier purt of the body; but as it is in the exploration of
the chest that such methods have yielded the most brilliant resnlls, it i»
now customary tu apply the term physical diagnosis simply to the ex-
AiuiuatioD of the thorax.
It is iu this limited sense that we shall genemlly 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 intni-thoracic organs, the chest has been divided into a
number of regions which are purely arbitrary, and their boundaries vary
vith different authors.
J. M. Du Costa divides the chest into the anterior, the posterior, and
two lateral regions, and subdivides these into upper and lovrer regions.
He locat<?8 signs present in these regions by certain fixed nuirkfi which
may be found on the surface of the ohest. For instance, anteriorly, a
sign may be located in a certain intercostal space, or beneath a rib or
Ihe clavicle, at a given distance from the sternum. Posteriorly, a sign
may be tucaled iu a similar manner with reference to the spinous proc-
cews, or to the angles and the bordora of the scapulte. Such a division
is well enough for the record of cases, but it dues not aid us in remem-
bering the location of the intra-thomeic organs.
The division here adopttnl is similar to one quite commonly taught,
with only such changes as make it plainer and more easily remcmberetl.
M'hile learning these boundaries, one should fix in mind the exact
pOMition of the intra-thoracic organs.
We divide the chest primarily into anterior, poaterior, and lateral
regiong, and subdivide as follows.
■i i'nraiCAL DiAQNoam.
Upon the anterior surface on either side^ from ubove downward, we
have tliti Hiipra-cluviculitr, elaviculur. infru-claviciilur, nmiiiniary. and
infru-namniary regions; between tlieae two In t era] gruujw we And the
supra-sternal above tlie line of the c.Iavirles, ant! the sternal region enb-
divided into the enperinr-jftornnl and inferior-stenm!.
The posterior portion of the chfst. on ejieh side, is subdivided into
thesupni-ficapularancl tbesc:ipuTar regionit, between tliesc the inter-sciip-
ular region, and below the erupnlte the infru-scBjuilar regionB (Fig. 2).
XiSterally we have the axillary and the infra-axillary regions.
I
Fio. 1.— A, Supra^Uvlcular redoa : B. clAricular rpgloa : C, Infra-vlftvlculAr tvclnii ; D, nuun-
■DAry reiffton; E. Infra niiimniiir>' reKtoo : F. Hii|>T>rior4i«mal r«ittoa : n, lnr<!rinr-«t«rnal mrlon.
Ttut wAvy Unn rv^rvnnttt tfie borderi ot [|i<* iuDgB and Ibe putijtuiuuy Ibwiin-n Tltp AvAitA linon
cormpotut to the outlloen of Ihe vartouo organs. vU.. Iractifa. iu>rtn. brondiU) tubes, iMArt. Ilv«r,
sjlivn, (uid titomscb. Tb» v<>i'>- dnrk iiluwllu|{i>vfr ili« hulnl rlKit-rn mIiob* Ibn oormMl «rp«« of
itatocn. Bad the kJuuHng Dext4i«lit«r over tbe ut>pt-r piirt of ibe li«vr bIjowi Dii* hvpaik- duloeiiL
Tbo bUck rwLuiKulu- qtol* ii«kr Um tliinl rib curi-miHNiil t« Uw podltJoii of lliv ralf es ot the bMUT.
The bcpba-clavicular reoiox corresponds to that portion of the
pleural cavity whieh extends above the clavicles. It is triiingular iu
form, with il£ base internal, its apex external. It is bounded above by u
line drawn from the up{)er 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 npper margin of the inner
two'tbirds of the clavicle. The internal boundary corresponds to the
sterno-cleido-mii6toid mnsrlo. This region cuntaius, on either side, the
_gf the luug and portions of the subclavian artery and vein.
lOLATictiLAR RKOION corre8{>onds to the inner two-thirds of
DJVISIOm OF Tits CUBST, B
ihn claviole and In, bounded iibuve mid below by ibe borders uf tlio bono.
It contains long ttosue. Upon tbe rigbt side. exUtniaU)' wo liud tho
•abolnrian arterr, and at the inner cxlrcniity tlio ortvrin innominuu
Mii ibe recurrent bryngenl nerve rts it passes up lo eti)ip)y (be niii«otefl
of ibe larnix. Atiourisins in. tliis loailiiv, by jiressing iijmui iIuh nerve,
give rise to seriouM symptoms due to jmndyeiU or spusm of ibp glottis.
TTpon the left side, nt tbe inner end of tbirt region wo find tbe ctroltd
and tbe eubcliiviiin iirterios, deeply ttuiiLetl jind rnnnini; iilmost nt ri^iht
angles with the clnvicle.
The ixPRA-CLAVici'i.AK HKOlos jg bounded nliove hy the clnvielo,
internally by the margin of tbe sternnin. iind externally by n stniigbt
•Sc^/fvh
'<
Tn. 1— Tba wsrx llofis eomKpoD-I to tli>- '>■ rt>'r- nn'X n«uro« of llw lunc«i. Tlw doU«d ltt»«
11^ Lhescaimlar i<r<[)(>n iiiUtcali* thr> ]Ki<klii<«. nf iIk- '\Mif nr Uu*M'a|)iila TbiMlDtlMl lUMvaDil
saa to tliv Ittf ra-fleapuUr mgtotH liMticutv Lba pOKliloti trf Ui« Uv«r anil Hfiln-a.
line let full from the onter extremity of tbo rlnvicubir ref^iun, und puMfl-
ingubuutan inch extermdly from the nipplv. It in buunditd below Uy
the lower margin of the third rib. Thi* region contain* lung tiiwutt un
either side. On ibe right, olo«y to the border of tbe sternum, wo Hnd
portions of the aBcending oorto und of the deeeending venii oiva. Just
beneath the second costal curtilage, wc Gnd tbe right bronchus as it
passes into the rigbt lung. Upon the left, in tbe iiecond iiitercostiU
s{«oe, close to tbe ninrgin of ihe Hternum, tbe ptilinoiuiry artery is
lucated. In tbe same space is found thp left bronchas, which indinM
more downward, und it bK^ited lower than tbe main bronchus on the
oppoeite side. A portion of the base of the heart occupies tbe interiial
inferior angle of this region.
Tiir. MAMNAUV HKoioN. which lies immediately below tbe precrd*
ing, ii bounded internally by the margin uf the •Lemnm, eztf!mally by
a continuation of the Hue which bounds the infni-clavioular region, an
iiiferiorly hy the lower iimrgin of the sixth rib. We may eaailv remem-
ber the boundaries of lue infra-clavicular and the miuuiiiury regions, hy
recollecting that we have three riba in each. The inferior border of the
tliird 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 tlie
lung, which overlaps tlie liver, reaches to the siJith interspace, and ejc-
tends even lower in full inapiraiion. Deeper seated we lind 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 fuurili
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 jmrt of the left mam-
mary region, the lung tissue is ir. front as low as tlio fourlii rib. Hci-o
the border of the tuug passes outward and downward to the fifth rib,
leaving between it and the median line a triangular space iu vrhich the
heart and its investing membrane are superficial.
TiiK iNFHA-siAMMAKY KEoiON is bounded externally by ft 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 ninrgin of
the sternum and the lower borders of the false ribs. This region con-
tains, on the right side, the liver, und 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 oulwanl,
near the middle of the region, we liave 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.
7'/i(r tiiaimnilliiry ar ntpph Uue is a vertical lino drawn through the
nipple, and, according to some authors, it forms the external boundary
of the infra-clavicular, mammary, and iufra-ninmmary regions.
The regions between the lateral portions of the anterior enrfaco of
the chest are three in number.
The stPRA-STERNAL REGION, the first connting from aboTc, is
bounded inferiorly by the upper end of the sternum, or inler-elavicular
uotch; laterally by the stcmo-cleido-maetoid 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 nn each side of
tlie trachea and are connected by the isthmus in the upper part of this
region. Here are also found certain small veins and frteries which are
of interest to the surgeon. In the lower right ang'e of this region the
innominate artery is found, and in the inter-cloviculai notch we can
frequently feel the arch of the aorta.
The si'pehior-sterxai. itK<iios, next in order, is bounded below
by a line connecting the lower margins of tlm third ribs, and lat*
*
DIVISIONS OF TUB VITBST, 7
erally by the borders of the boue. This region contains Inng tissnc.
Su peril ciaUy, the inner or anterior margin of each lung roaches the
mclinn line. Deeper, we find tho descending vena cavn, the ascending,
the tranavcrae, and a part of the descending portion uf the arch of the
aorta, and at the left a portion of the pulmonary artery. At a point
opposite the second costo-stemal jimetiou is tho bifurcation of the
traohea.
The iSFRniOK-STKBNAL REGION, known also as the sternal rrgion,
haa for its houndsiries the borders of all that portion of the sternum
lying below the third rib. In it the anterior margin of the right luug
corresponds to the median line, and is superficially situated. But tho
corresponding margin of tho left lung recedes from the median line at
the levul of the fourth rib, paiitiing uutwiird and downward, leaving a
triangular space between it and the niurgin of the right lung. In thii
space the right ventricle of the heart is superficial. In the npper part
of this region we find a hirge portion of the right auricle and the origin
of bolh tho aorta and the pulmonary artery. The portions of the left
side of Ihe heart which present anteriorly He to the left of this region.
In tliis region mo find portions uf the four sets of valves which guard
the orifices of the heart (Fig. 1). At the left edgeof the sternum, under
the third rib, are the pulmonary valves ; a trifle lower, beneath the
Ctitttre of the sternum, are located the aortic vidvrs; lower yet, at its left
border in the tliird intercostal spnce, we find the mitral valves. We
locate the tricuspid valves beneath the middle of the sternum on a line
with the fourth costo-stcroal articuktion. 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 wc have a portion of tho liver and
of the attachment of the pericardium to the diaphragm.
The megoalertial Hue is an imaginary line passing down the centre of
the sternum.
The stfrrnal linen of the right and left sides correspond to the borders
of the iitemum.
Posteriorly are the supra-scapular and tho scapnlar regions on each
side. FXtonding from the second to the seventh rib and corresponding
very nearly to the outlines of the scapula when the patient's arms are
banging loosely by his sides (Fig. 2).
The suPRA-scAi'i'i.AR REoioN' Corresponds to the supni*6pinou8
foen. It is occupied hy lung tissae.
The scAprLAR REniOK corresponds to tho infra-spinous fossa. It is
uccopied by lung ti^ue.
Thb iNTEB-snAPCLAE BEOios lics between thebordors of the 8capul»
divided hy the spinous processes of the vertebra?, and extends from the
level of ihe second dorsal vertebra to the level of the seventh. It c^n-
inini lung substance, the main bronchi* and the bronchial glands. The
o 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-scapulak beoiok on either side is bounded internally
by the spinous processes of the vertebra; externally by a vertical lino
let fall from the inferior angle of the scapula j 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 portion of the region, and externally we find the spleen (Fig. 2).
Ihe 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-axili.ary 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, wo find the commencement of another fissure, which
passes inward to the margin of the lung near the fourth costal cartilage.
Uy 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 luugs.
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-
bis 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 diiignosis.
The evidences of disease which these methods furnish are kuown 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 cyxWi^A presvniplive 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 upou the surface of the chest;
tlien 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 whiob we have discovered
by physical diagnosis.
INSPECTION. ;
By inspection we learn the general appearantt of the patient, the
color of the integument, the presence or abseno^jof subcutaneous em-
physema, oedema, or tumors, and the size, form, and movements of the
chest.
Whatever method oi. 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, wo 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
PHYSICAL DIAGNOSIS.
Tory diBtinct, while in ntliora th«)* are liiddun by n(li[HJSti iig^ue. The
ohliquitj of the inferior rilw viiries greatly in different iiuUvidiialH.
In the fifth intercostal spare, about two inches to the left of the
Bternum, we obi^crve ihe iiHpiiUe of ihe chest walls cyiused hy the a]ivx
beat of the hejirt.
Occaiiionally we find local bulging or depression, independent of dis-
ease of the inlernul organ». 'I'he ]ironiinenL sternum known at> pigeon-
breast, usually due to Tiolent cough or obHtriicled reapiration, as from
citarrh or enlarged toneile in childhood; the pear-shaped rhcst, due to
rachitis, and the long, narrow, and flat cheat, whioh often results from
rapid growth, are all futuid iudcpendeut of intra-thoracic disease.
There is often bulging of the prwconiial region, especially in chil-
dren. Deep dBpressioua of the lower st^-rnal region, and of the ribs ia
Tf. Sl— TlAicBTciisK OcTUKW or Cektaih Fomw or TKK Chest (TnoinwMO.
rare instances, occur in healthy iudividuala. I have a cast taken from
life, which shows u depression of the lower sternal region from an inch
and a htilf to two inc-hes 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
ourvatures of the spinal column. In the examination of a large number
of patieuta, not more than ono in seven will be found with a perfectly
symmetrical chest.
In health, the respiratory movpments are repeated sixteen to twenty
times a minute in adults, and from twenty to twenty-five or even thirty
times in children.
Considerable difTerenco in the form and in the movements of the
cheat exkts in peraons of different ages and sexes. In women the upper
imPBCTTOTT,
11
portion is more prominent tliun in men. The resjiiratory moremeiit-s
vary afconlingly, being more inarkert at the upper part in women, Mt
the lower pan in men. This liisijarity is most conspicnmis in rapiii res-
eviration. In children of either sex, the cliest wulls often hardly move at
nil; and respirntion seems to be performed hy the uiiHominjil mtiBcles.
Tiie respiratory movements in these tbrco localities Sltc numed 8U|)tiriur-
»tal, iuferior-costal, and abdominal breathing.
The movetnuntsof the chest may bo altered considerably, irrespective
of pulmonary or cardiac disease. In health, the respiratory nioremeuts
are rejidily accelerated by active esercise, and in hyKteriwd patients tliey
lire noiirly always rapid and snpcrficiul, being confined mostly to the upper
part of the chest. In persons siilTering from some diseiises of the brnin
the respiratory movement* hecomo slower and slower until they may not
excet-d ihree ur four per minute. In hemiplegia the respiratory niove-
tnonts an? incomplete or wanting, on the affected side of the chest.
Pregiiuney, ascites, or large abdominal tumors cause pressure ou the
diaphragm, and consequent intHrference with respimtiun. The pain of
peritonitis compels the pationt to roalrain the movements of the abdom-
iual muscles, and thus continei; the respiratory movements to the
chest and renders thent deficient and consequently more frequent.
Often among the first signs noticeable on inspecting a patient with
diaeuse of the iutra-thoracic organs are pallor, cyuuosis, icterus, pityria-
siSj dropsy, and subcutaneous emphysema.
Pallor of the liurface and emaciatiun are seen in chronic pulmonary
disease. Pallur uUo results from fatty degeneration of the heart, and, in
aomo cases, from mitral disease.
Cy(inwf»V, more or less marked, indicates incomplete oxidation of the
blood, due to obstruction of the air passages or tu diminution of breath-
ing surface; also to affections of the heart, such as congenital malfor-
mnliousor valvular disease. Occiisionally this sign results from inter-
ference with the descent of the diaphragm by disease of the abdominal
organs.
IrteruH h found in bilious pneumonia and in the later st^es of those
cardiac diseases which cause congestion of the portal circulation,
Piljfriw*iit is often found with phthisis pulmonalis. but it also occurs
with other diseases, ^nd sometimes even in apparently healthy indi-
viduals.
lirop-stf due to recent renal disease usually shows itself first in the
lower eyelids, and subsequently disappears from this Ioi?ality. to appear
in the lower limbs and in the barks of the hands. Dropsy due to t'<ir-
diac disease usually ajipears first over the instep, and gradually extends
upward, involving the limbs, trnnk, and serons cavities.
SuhcutanettHs fimphtfsema may be caused by internal or external in-
joriea of the larynx, the trachea., or the lungs. Air escaping from the
13 PHYSICAL DIAGNOSIS.
larynx or the trachea causes emphysema in the region of the throat.
Kupture 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 appeitrs first on
the chest.
Alterations in the form and in the movements of the chest may be
most advantageously studied when grouped together as they occur in
differen t thoracic diseases. First, let us consider the modifications found
in pleurisy.
Pleurisy is divided into threo 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 stage gradually subside.
Sub-acute pleurisy 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
fiattened; the shoulder is depressed; the inner border of the scipula pro-
jects like a wing and respiratory movements are limited.
In pulmonary emphysema^ on first sight of the patient wo notice a
dusky hue of tlie 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 stooj>
ing appearance of old age.
Inspection generiilly reveals the peculiar form known as the barrel-
shaped chest. In this condition the antero-posterior diameter of the
chest is incrciiscd {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 shniildors cause the neck to appear unusually short. The
scaleni and stcrno-cleido-mastoid muscles are hypertrophied and promi-
nent so that they stand out like tense cords, resulting from excessive use
INSPSCTWN.
13
of these roueolee whicli elevato and fix the anteriur .ind tipper part uf tbo
thorax.
Inspiration is short and qnirk, followed by prolonged and sometimes
labored expiration. With inspinition, the iiuterior iiud HUperior portiouK
of the ohoet are lifted as though composod of a single bone, uiid there
IS iip]iiireully no auteiior ov Iiitcntl expunsiuii of the chest wiilIs, huoaUBe
tho ribci »re itlreiidy rolnted it8 far att tlieir urticiilation with the spinal
column will permit. The ribs Iihto less obliqnity, forming with the
, costal cartilages more obtuse angles than in the normal chest.
The iutL>rcoBtal spaces above are much wider than nsiial. but at the
lower, lateral portion of the chest the ribs are closer together than iu
the norraiil romlition, sometimes even to the oblitenitiun of inWi^pacea.
In well-marked c'i8eH there i» generally with ini<inratiun retraction of
the inferior ribs instead of lateral expansion. This falling in of the
thoracic walla is not noticed if the disease is slight.
Sometimes wo meet with local emphysema, where a single Inng or
only one lobe is alTectcd, In suoh ins ances wc notice local bulging of
the chest, with loss of motion.
In extreme emphysema the anterior margin of the left lung overlapa
the heart, so that llie apex cannot strike tlio chest wnll, hence no ira-
pnlse can bo seen. In milder cases the impulse may bo seen closer to
the Hternnm than in health.
Jr pneumo/ild, upon first jrlance we generally notice a dusky flnsh
©f the Jieek and accelerated respiration. Inspection of the ehcst shows
diminished motion over the diseased organ. This loss of motion may he
tna ked, hut is si-ldom or never comiilete.
/i p hnonary jthlhisin, the signs obtained by inspection are of non-
•idortiblo value. If the case is advnnccd the chest wall over the diseased
lung will be depressed and its movements restricted, in phthisis more
apt to o:'cor at the apes, uud contntry to tlic general belief, quite us
commonly ujioii the rigbt us upon the left side. These phenomena r.re
duo to local shrinkago and loss of pulmonary elasticity.
Jn pncwr.othoritx wo obsarvo distention of the chest, proportionate
to the tension of the air or gas in the pleural sac, and a corresponding
loss of motion.
With groat distention there will bo no motion of the lower ribs, but
]>roroincnce of the spaces between thom.
JCxcepii(ni<il.—la some rare cases of tins disense the upper portion of fh«
lITected s'kIq itoi.'mit \f* move mere tlmn thecorrenpondlng' pnrt of the suurid siile.
Thi.1 19 Jne lo lh« cxtn>iiio cITorl* on itispirulion by wliiiOi tlic Miprrior ril«
are tiflcil direclty tipwut-il n» in vmp)iy»eiua, Ihoti^h thofe is little ur no iinterior
Tlifilrothfirax presents a condition, on hotii sidcfi, similar U> that
found in pleurisy with effusion upon one side: hence lofis of motion and
more or leas bulging of the infra-axillary regions.
PHYSICAL DIAQNOSIS.
Pericarditis, if the ainouut of effu^iiou is fiutliuient, causes oonsiooiu*
ble bulging of the prscordial regiou, eB|)€cially in children; but Id older
pntientR, on account oE the firraneea of the cartllageft, this is not so likely
to occur. Thery is uUo tiiminution of the rcspinitory movemouls on
iho left side, due to jiressurc from tho distondod pericardiura.
Cardiac hypertrophy wUq occasions local bulging, most marked in
young patients. Tho impulse, if visible, will ha seen to the left, below
its normal ]iosition. Its urea will also be iucreased.
Tumors within the thoracic cavity cause bulging when of sufficient
size to press upon the parietes. If the tumor be ancurismal or solid and
rest upon a large artery, it will usually pnlKite synchronously with tho
contraction of the heart. An enlarged liver or spleen may occasioa
local bulging.
In cases of pneumothorax and pleurisy with great effusion, we ob-
tain valuable infurniation by exaniiriing tho impulse cjuigfd by the apex
of tlio lieart, which will be seen crowded from Its normal position toward
tho unaffected side.
/« membramiHs croups oedema glottidis, foreign bodies or morbid
growths in the larynx or in the tnicbea, the amount of air entering the
'ung is considerubiy less than normal. This has the effect of prolong-
ing inspiration and rendering it laborious, though expiration is not
notably affected. Hero the respiration is not quickened as in most pul-
monary diseases, and it may be even slower than usnal This diffora
^rom cinjihysema in that here there is obstruction to inspiration; in
emphytienia, tho princi|wl interference is with expiration.
Wlien the obstruction in the larynx or trachea is considerable, wo
observe sinking in of the soft parts of the chest above the claviclo and in
the intercostal spaces, especially at the luwer part of the chest, during in-
spiration. This is duo to atmospheric pressure from without, as tho
chest walls expand more rapidly than air can enter through the ob-
structed passage to fill the lungs.
In chronic br»nt:kitis the signs obtained by inspection are of little
value, though we may occasionally observe prolonged expiration, and
in some instances irregular pxp:insIon 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*
oither with the tips of tho 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
I'uads so that, aa one site in front of the patient, the right hand rests
"|>o»i his right side and the left up<)n his left side. If the signs aro
*^"Jy slight, we thus appreciate them more clearly.
pAT.pATio:r.
15
By the sense of touch we appreciate slight alterations in Ihc move-
oienta of the heurt mid thorncic wulls; we sometimes detect the presence
of intrii-ihoracic tumors which cuut>e no bulging of the surfuce, aud
deleruiine their nature, wbeLher hurd, soft, ur pulsating; tind we may
diHerentiiile between the pain of intercostal nearolgia aud thftt of
pleurodyniA or pleurisy.
The iuformutiun rt-giirding size, form, nnd moTementg obtainable by
this method is esaentiiilly (lie same as that furnished by inspection.
NuftM.vL vutjAL FitKUiTCd is a peculiar vibration which will be
felt if the hand be getitly placed upon the chest of a healthy person
while ho is speaking. It is produced by the trangnii^sion to the chest
wall of tfao vibrations of air in the brouchi, C4Uiscd by the act of speak-
ing. Moditicatious of vocal fremitus are unioug the most important
Bigna 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 pilch cause a more distinct fn'niitus than those which arc 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 parietes, and the distance of the point examined from the larynx.
It is therefore more marked npon the right than npon (he left side,
aud in the infrn-clavicuhir 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.
Xonual vocal freniiLus rnay be increused,diminis}ied, or abolished by
di»eaee. As a ride, it is tULreased by all diseasi-s uiusing consolidation
of lung tissue, ns phthkis, jnieunionwy mUmo, and apophj:t/ of the lunge.
It is gcnerully increased by tlthfation of the bfonchiul fifftem, in which
CflKt there is more or less induration of tlio parenehyma of the lungs.
f'xreptional. — In pnc'umonia, w \wn tbo l^ronchtul liilies are completely filled
by Utc iiilliinmiatory depo^^it, vocal frpniitun ctiunot ho r<>U.
Owing to the great variation of this sign in different individuals and
to ilif mutations in disease without ck-arly deiined causes, it is not of
yery much value when taken ulone.
Vocal fremitus is diniiiiisbed or suppressed by any diseHse caamng
separation i\t the lung from the chest wall by the intervention of air,
pn»«, «r fluid. In /meunKiffionix, hijdfotlior'ix, and j>/euriiif wiih effusion,
nlwcnce of vocal fremitus over the air or the (laid is a sign of great value.
£!wej»f/«7rrt7,— Presence of vocal rn>mltiis is not always a oortain Men iliat
liil di.f-» DmI I'KiRl, Oil Bttown by a fow rarpcunes. ITtlifn- is hut a»>mnllcu1.
-rtion of an- or tlui>l in the pleural sao. vocul rremitiiH may beKJm|»ly diminnhedt
and ia miilii1i>culiir pleurisy it remains over the bauds of adhesion.
16 PHYSICAL DIAGNOSIS.
In emphysema, rocal fremitus is diminished.
- Aneurismal or other xntra-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 difiEerentiating 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 fremitus, 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
O'lly nieasurement of special clinical value is that of the circumference,
in inspiration and in expiration, which may be readily taken by means
^f 11 simple tape.
A good device for tliis consists of two tapes joined at their extremi-
ties and so padded near the line of junction as to form a sort of saddle,
^'h:ch rests upon tlie spinous processes and prevents slipping. In using
*^his ii.strument, adjust the pads to the spine and carry the tapes about
the chest on both sides to the median lino in front. The exact amount
^i motion of tlie two sides may thus be easily ascertained.
In measuring with a single tape, place the thumb nail at a certain
point on the tape, tlic 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 ])rocess and press the forefinger down beside it. This enables
^"p to iiold tlie tape firmly in position, and, by preventing the skin from
sliding in respiration, gives a fixed point from which to measure. It is
'^'wiivs desirable to mark the median line in front before commencing
thi^ measurement.
The circumference of the chest may be taken above or below tlie
^^Pples, but best on a level with the sixth costo-sternal articulation. In
^*^cording cases, always note the level of the measurement.
ME.y^iCIiA TtuN.
17
fA.
H
^-
:-p;
SI
The meusiircnieut should b« tuk»ii during butli full inspiration and
forced u^tjjii-ution, ami tlie two results should hv oninpared to detenuiae
the expHiisioii. The Iwu eidea must bo compared lo asconain whutbor
either U diutended or deflciont in movonien^. Quniu and Onnoll in-
vt-ntcd very sntisfactory Instrunifnts for taking these iiiuiitturi'iiif'iiU,
kno»n fts ^tethometers. Qttttiu's instrunieut (Kig. 4j cunsittts of n cylin-
drical box with a dial mid an imkx, moved byu ruck
towhirh in iiltachei) a cord long enough to (joinpjLis
tiie cheat. Eiich rotation of the indox about tho
dial indicates one inch of raovemont. Tho box is
plart^I upon tbu centre of the chest in front, and
the ntring is carried liurizuutally around
the chest; as the patient breathes, the r^
index revolvefi about the dial, registering
necuniU'ly tlie expansion of the clieat
walls. Carroll'^ Btethometer is ciinple and exact (Fig- o). Ordinnrily
n simple tape is sufficient.
Meii^urenicnts of the healthy chest, of course, Tary in difl'erent indi-
Tiduala. The avragc in men U thirty-tn'o and one h;df inches, (ieiier-
ally, the right side exceeds the left hy half an inch, but in Jeft-hiuided
persons the rerereeis true.
In flisfiiw, the atfected side may be distended or coiitnirted, and lU
movements may be diminished or increased, conditions usually notlcca-
blr on inspection and by palpation, but it Ig not uneomutou to Snd,upun
men^irution. that a side which had the appeajfuuco of distention ia
Fio, 4.— QfAix's STcntoMcm.
I ' 1 ■ ■
FiH. n — 4".iii«i>u.ii SrKTHojiErEa.
nnalleT than its fellow; frecjuently expansion, which hus seemed com-
paratiTety free, w*ill bo found by the tape not to cxceetl one-eighth of lui
inch.
The diseuses causing oxpansiun or contraction, and loss of move-
menu of the chest walls, were mentioned under inspection.
The tninsperso diameter of the chest may be uliti.ined by means of a
pair of calipers, or by Flint's cyrlunieter (Fig, 0).
Gee*a cyrtouieter, cunsiatiug of two pieces of conipositlou g:i8-pipe
joineil tugether by uicaus of a piece i)f rubber tubing, is the cheapest
and prrbupB the best instrument fur aacertaiuing the transverse outliua
of the cheat. In using it, the joint is places! upon the apine^ und the
piece* of pipe are accurately moulded round the chest. The instrument
18
PUYSiCAl PIAi^StOSlS.
b then removed and laid on jwipor, vhon an exnct tracing can be maie.
In a well-formed chest, the an tero* posterior diameter will be to the
tmnsveree diameter in men as tbree to four, in women as four to Sw
(Fig. 3). Scott Allison invented an instrument, known as a stetho-
goniometer, for measuring the curve* or the fiatness of the surfcicfl '>t
\
Ito, «.— FuKT** CifirroiimB.
no. r.— ftPiRoxcTsa.
the chest (Fig. 8). It has been claimed that the infra-clavicular space
should always bo convex iu hcnltli. With this instrument the cnrvn-
tures could beaccunilely u^certairicd, but unfortumitvly the information
iaof very little vulue, because, iu healthy individuals, this region is often
Hat or evfu concave.
Spiromelers are used for measuring the chest capnciiy. Hutchinson
wu, I think, tho inventor of the epirometer, but muuy modificationa
WjQ. 8.— A.UiBOf*« BrrrRoooxicMnTEit.
have been devised. Recently portulde instruments about the bIzq of a
watch Imve been made. In on© of thciiOt as the patient inspires, or
blows into tbo tube, tho iiirlcx revolves on the dial, rtgisteriug the num-
ber of cubic inches of iiir inhaled or expired.
Hutchinson found Ihnt people five fwt in height usually possess a
vital capacity of one htindrod and sovputy-four cubic inches, and for
t tt height above five feet, eight cubic inches should be added
20
pumwAL DiAoyosia,
uals Ave feet eight inches in height possess the muximam respirator;
power. Ilia iustrnmcnt (l''ig. y) consists of a bene glass tube fastened
to a graduated aculc, aud JoUied iit each end by a rubber tube, throogh
which the patient is to brcutbe. The instrument Is portiully filled with
mcrcnrj, whic]i rises on one side or the other us the patient inspires or
expires through the mouth-piei-e jiiid falls after he censes.
Hammond found the expiratory power much greater than the
iuBpiratory, the uverago man being able to raise the column of mercury
three inches by expiration, and only two by inspinition. This is a fad
which at once explains some of the phenomena of disease. For insUince,
Lnennec's hypothesis as to the cause of pulmouary emphysema was baeeJ
upon the supposition that the itiHpiratory jiowcr was greater than thh
expiratory, a supposition clearly untenable after Hammond's demon-
stration.
BUCCUSSION.
SuccuBsion, the fourth method of physical explomtion, was known to
Hippocrates. It consists of suddenly shaking the patient's body wliilo
the ear is placed against Iiis chest.
When air and fluid occupy the plenml sac, this proceeding will causo
a splashing sound. The sign is of value in pnenmo-bydrothonix (Fig.
2C). The succiission sound wiH v;iry more or less in quality with the
density of the fluid. Thick pus will not yield the 8.ime sonnd as thin
semm, bnt the quality of these sounds is not usually snfficiently distino
tive to aid us matcriully iu our diugnosis.
Meiailic tinkling, due to dropping of fluid from tho tipper part oi
the cavity into the effusion below, cua usually be heard wlien the sdcco*
fiioD signs are present (Fig. Z^),
I
\
CHAPTER IL
METHODS OF EXAMINATION— 0)ff/i»««t
PERCL'SSIOX
PESCrSSIOX IN* DEALTn.
Percussion is the art of eliciting eoiind by striking with the flngcn,
cr with iiietniments coiitftructed (or the purpose.
As a meaus of diuf^nosis, it is gencTAlly 6up]>oscd to hare originated
daring the lH*t ufinlury witli Avcnbriigger, a physician of Vienna, hot
the WL>rk8 of Uippocratea iuUic-utc timl he wua fiimlliur with ii, to a
limited extent.
Ilippocnites and Avenbrnffger recommended ivimpttiafi percusnion,
in vhiuU ihu blow is strnck directly upon the chest walL
Pte. 10.— FLIKT*! TTlMMKR JUrD rLKZIMKrKR.
This form of perciiseiou h:i8 been nearly supplanted hy one which
ttriginatod about sixty years ago, with M. Piorry, termed tnediate pereu9'
tuotif in which the blow is received on some intervening substance.
Before mediate percUHfiion was employed, ft was quite esseDtiat to ioteosify
Uic sounds; tbia was accontpHsheU by pliicing' the patient with his biick against
ft hollow wall. In some women the sij^na elicited by inimcdiale percussion are
quite distinct over the upper part ol the chest, but usually Ibis method is very
uosaUafactory,
In mediate pnrcuesion, a small hammer or plexor and an instrument
known as a jdeximeter or plcs^imeter are employed. The hammer in
common use consists of a cylindrical rnbber head attached to a light
handle abont eight inches in length. Metallic hammers fciced with
robber, 08 sometimes used, are objectiouablo on nccount or their weight,
which renders the bkw so forcible that it is apt to cause pain.
%r
PlfYSlVAL DIAONOSTS.
Pleximetere are made of tarioiis mnterials, as rubber, bono, wood,
ivor)', or leather. Some of Ihem are graduated in onler that ihay may
be used in menanration. Among tbe b«st ia one wliicli cutiBit<ta of
B narrow oval diac of hard rubber, with largo ears at each extremity.
It a1iciii1<l be narrow enonsrh to lie placed between Uie ribs* find sliould have
alarpra pri>j<H:tiua at each etui, tliat It inuy be firmly gni^spixl. I have fretjuetitly
Us«<1 a smalt cvlinJur of sort lulilter about two inclu*!! I'titi^' and Imtf nti inch in
diuniotrr. It has tlic ndvaolago of being easily adapted tutlioiiiLorcosUiiBpaocft«
and of emitting no sounds of its own wlien Ktruok.
For ordinary percussion it is best to use the middle or index finger
of one hand in place uf the pleximcter> iiud two or three fini^'cre oX the
other, with their tips brought into Vmv, us a hiiininer. The £ugi>rs used
as u 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 certaiu sense of
resistance which ia not obtained with Ingtrumunta. Often tliis would
raable ns to detect internal organic changes even witli our ears com-
pletely stopped. So raluablo ia it in intricate cases that, when there is
difficulty in making an accurate diagnosis, I always employ the fiugcra
instead of instruments for percnssion.
The sounds obtained by percuseiou arc generally described as clear,
dull, and tympanitic, but these terms are not sufficiently precise to aid
tis much in studying the method. I prefer a clasttiflcution based upon
acoustic properties. The elemt-iits of sound which concern us in per-
cussion are intensity, pitch, quality, and duration.
The intensity of a sound determines the distance at which tho
Bound maybe heArd. Other things being eqnni, the intensity of a Bound
in pulmonary percussion varies with the furcu of the blow, the volume
of air in the lung, and the thickness and elasticity of the chest wall«.
It is diminished by thick layers of fat or muscle, by rigidity of the costal
cartilages, and by coutmctiou or consolidation of the lung, and it ia iu-
creuscd by the opposite conditions.
The pitch of a percussion sound may be high or low. Those famil*
iar with mnsio will understand this, hut 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 usuallv true in
pulmonary percussion, intense sounds being low pitched, and high-
pitched sounds possessing feeble intensity.
This difference Between pitch and intenBJty can be easily recognized by
•trikin^' two note« at opposite etuis of Itie keylioaol or a piano. By striking a
bfgh note forcibly, one will obtain n notind tuuO enough to bo heard Boinc dt»>
tance ; then by gently tappmg a key at tlie other end, one will obtain a sound
[^beard at exactly the same difiiance, but of a much lower pitch.
■» pitch of the percussion note over a healthy lung is always low.
I
I
I
I
d
PBRCUSSlO.y.
23
but it will vary iu different pwrtiona of tlie chest, owing to difffrence ia
tlif; volume of air and Iho position of other intra- thoracic orgiuitj.
Quality of sound is tliut element by vrhieh we distinguish botveea
thv tones of musical instruments, or of voices of different individual^
liuviuj;, it ntiiy be, tlio same iutensity and pitch.
In pulmonary percnssion, we obtain a peculiar quality tenned vesic-
aliir, impossible to describe, but always to be obtained by percussion of
the healthy chest. It is soft and low iu pitch, and -usually seems as
though coming from a point, a couple of inches beneath the surface. It
£au be learned only by studying the healthy chest.
DcRATioK of the healthy iitTCUssiun note depends upon the same
ctinst^ as its pitch. If its pitch is high, the duration is short; if tho
pilch is low, the dunition is prolongbd. Indeeil,a definite relation exists
between all these different elementis; that is, intense sounds are opt to
be lowpitolied; those which are feeble are generally short and high
pitched, and, instead of the vesicular, they possess a solid character.
I'erciiesion seems very simple as practised by an adept, but accuracy
U not ucouired without much practice.
Certuiu rules essential to accurate percussion should be early fixed in
miud.
The surface of the chest should be bare; but if for any reason this
cnnnot be secured, have the covering soft, thin, and smooth. It is abso*
lately 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 bo In a comfortable position, whether sitting,
standing, or lying upon the back, and the two sides must be relatively
symmetrical. The fii-st two }}ositions are preferable, but very sick pa-
tients should not rise for the examination; it will be belter to make a
less critical examination than to endanger the patient.
Persons suffering from diseodes which catiitR feebleness of the heart sliould
not be askod to sit or stand. Illiuliutitig the importance of tliin ctution, I have
Men cases of sudden death from ovcrtaxinj^ of a weak heart, by nlight exertion,
•urh 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 mnsclos, 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 stune as those ou the other, will reach the oar with & different
tone. His position should be easy and unrestrained, or he will not
recognize slight differences in sound.
Iu percussing any particular region of the chest, aim to hare 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
94
PHYSICAL J>TAQNOBJB,
ahould bo throvu backw»ril. In examiniug t)io latenil regions, it i^
to liave the hands rest npon tbe head. If the arras aie held ii^j^-
musyk'S stand out so prominently tluit they xutcrfere with obtuinin^
|»uInioMiiry resommcc lii percussing the posterior regions, the tir*-
should be bent forwurd mid the arms eruttfied in front.
In jHtrciiHsing the chest, compare i-orresponding portions of tlw "^
Gid;.a. If irhuiiges from the uorniiil are slight, they can he detected
no other way. Ordinarily it is snfiipient to repeat a series of strokes Q.^*
on one side, tlien on the other, or to percuss both sides repeatedlv' -*
quick succfssiou. Howi-vlt, the ptTcussion soniids thcv sliglilly at tli-^
ferent periods of tho act of respiration; therefore, whenever tl»*
changes are so slight as to require great care for their discrintinatiuii^
the sides should ho compared dnriiig the same sljige of the respiratory^'
act. The best period at which to make tlie coiupariso?! is at the closff
of a forced expiration.
£AXcytional. — Iti Imultli the two siiles are not ulwava uliku as re^rtls OU*
parily |i<>twi>cn the noU- «>licite<l in Full inspirutioti und Diat ehcit«tl id forced ev
piraliun.
In applying the finger or the pleximeter, be rareful that it presses
evenly ujion the surface and disphices all thy air beneath it. Otherwise,
tho resonance of the pleximeter is obtained instead of that from the
cliest, and at the same time the air is suddeuly forced out, causing a
sound very similar t<> cnieked-jfot resonaucf.
Tlic force of tlie stroko should be moderute, never grciit enough to
cause the patient pain, and alike on both sides. In percussing super-
ficial portions of the lung, the stroke should he very gentU', but to
oht^iin the resonannu from dee])er jtarts it must be more forcible. Bf>-
ginners commotdy strike much too hard.
The stroke should be from the wrist ulone, whether made with the
hammer or with tho lingt-r. When striking from ihe elbow, we cannot
control the force of tlie blow. Some diagnusticiana are accustomed to
strike ti siugle blow, first npon one side, then upi)u tho other; but I get
better results by making three or four tiips in rajiid succession.
The din^ction of the stroke shouM always be perpendicular to the
surface of the uhest. If we percuss obliquely, insteail of obtaining the
rosonanco from the lung immediately beneath the pleximeter, we get
that from a ril) or from more distant tissue.
In percussing near the sternum, in the upper iwrtioii of the chest,
we obtain resonance from the trachesi instead of from the lung, unless
care be tnken to direct tlie blow toward the central i>ortion 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 plcxi-
meter, which has an effect on pulmonary resonance simibir to thai pro>
duced by touching » vibrating tuning-fork. In percussing with the
fingers, strike witli thoir tips, instead of with the pulpa.
J*£JiVUii^lOX
As tlio signs iu 11 htuiihy chest viiry in iU dillercnt regions, we
must lake special puius to familmrize oarsclvcs with ull the beulthy
sounds. Tlu're uru no two litallhj |ieo]>le vUoao cheats iiro uxactlj
ulike, therefuro we can tako no oue peraou as a staiitlanl for cmnpari-
Bon; but after percussing many heaHhy cliosts, we may form an ideal
Btand&n! from which txo ^rrcat variation can occur without indicating
disease.
Normal vesicular rfwnance is obtained most perfectly in the left
iiifrn-cluvicnlar region; and this, bo in? tho sound obtained overtho puT-
monary air vesicles, id taken as the i-tandurd for compuriaon in piihnu<
niry percussion.
In the riglit infra-clavirnlur region t!ie percussion note Is nearly the
wme lis in the left, hut is slightly harder or more tubular in finality,
owing, probably, to llic greater size of the bri>ncliiul tubes.
Ill tlic middle of the supra-oIuvicuUir re>;ivu ilio resonance la soft or
vciieular in f^unlity, but toward the inner ]iart of this region it becomes
liardor in quuUiy or tubular and higher in pitch. Austin Flint called
'iiii nn approaLl-. to tympanitic rviiunance. Kxternally in this region
tbe vehicular quality is diminiiihed. In percnssing over the centnil por-
tion of the clavicuhir rejiioti, tlie souml is fairly vesicular, but it bccomee
IfM and less so toward either end of the clavicle.
In the mnmmury regions the Bounds are altered on one side by the
prcMtnco of the lici>rt, and on the other t^ide by tlie jiresence of the liver
(Fig. 1). Iu the np]ier ]>art of tht- right niauiuiary region we obtain
Tf-«iculu.r resonanoti extending down to llie line uf he[mtic dniness in
tlie fourth intersjmcc. Helow this, where the lung overlaps the liver,
dolneaa is apprec-i:J.ila on forcible porrusnion, gradually becoming more
nnd more distinct as the lung decreases iu tbicknesg, until wc reach the
lower border of the lung ut the sixth rib, the line uf hepatic flatness,
U'low which wo lose all pulmonary n-^onanco.
The lines of hetuitic t/ufncicf and of liepatic rfff/wp.-**, tlie flret along
the upper m:irgin of the liver, the second at the lower margin of the
lung, are ordinarily a'bout two inches apart.
Extf^itional. — In d(>t>p inspiration the lowpr line may be carried ud Inch aod
a li:iir or two inchps lower, and iu ftiri-'il>le expiniiion it may hv elevultnl ti-oiii one
to tive iDch(» ; thei-efore the ar«a of hepatic diiluoss, IwIw-lmju the two lines, may
v.Lry from two to seven or even eight inches. Thi^ wide ran;;e is not conimoo,
but its DCGOsioDiil occiirTeni.-e shows tlie necessity for btudyiug the client in Uotli
inspimtion and expiration.
In the left mammary region pulmonarj' resonance exists ovpr the
outer part. Near the middle of the region forcible percussion elicits
curdioo dulncss. Near the etemuni the heart is superficial, covered only
Ity the pcricitrdinm iind by cellular tis.siie; here there is a small, triangu-
lar space yielding flatness. It iu about an inch and a hulf wide at ita
bue, which corresponds to the eixtli rib, and extends from the fourth
«6
PTtTBTCAL DTAf/NOSn^.
to the sixth cosiiil cartilnge. The ajiex uf thiti triangle is looat«d at tl
margin of the ttlernvini en a level with the fourth rib.
The rcsoimnc^e of tlie mammary region is modifled more or less by
the thickness of the muscles in men and by the mammary glands in
womeii.
In the infm-ranmraary region, on the right side astmlly, there is
nothing but the liver to ufTect the percus&iou note, hence we h%V9 a
«onnd termed flatne^g, like that obtaintMl by percUHAiug the thigh. If
the colon be distended by gas, ue obtain tympanitic resonance if> I tie
lower part of this region.
In the left infra-mammary region flatness caused by the left lol> of
the liver extends a couple of inches to the left of the median line. In
the outer portion of tiiis region we obtain n similar sound from the
Bpluen. and between the^e two orguus we elicit tympanitic resoD'-jied
from tlitt stomach.
In the upper sternal region, as low as the level of the second costal
cartilage, the sound is tubnlur, 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 apjiosition
throughout this region. Below the level of the second ribs, uii light
percussion, pulmonary resonanco may be haird, 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 mediuii line, while on forcible per*
cussion there is dulness. Left of tbc median line, the heart is super-
ficiu! and yields flatness. At the inferior portion of this region, flatness
is duo to the left lobe of tlie 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 purl of this region it
is quite clear.
In the inter-scapular regions the sounds are hard in qnality and
high pitched, because the clipst 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 cloir as in tbc infra-clavicular region. It extends
downward to the tenth or eleventh rib. On the right side we find the
line of hepatic dulnetiii at tlie eighth rib and tlte line of hepatic flatness
at the eleventh rib; but these vary from one t<> two inches during forci-
ble respiration (Fig. 2).
On the left side the resonance is slightly modifletl near the spine by
the nearness of tlie liver. Belnw the tenth rib the intestinal canal, if
flUed with gas, causes a tympanitic sound. In the outer i>art of this
PSMCUasioif.
•17
region, bctirccn the ninth and clevonth ribs* dulness is obtained over
the spleen, and for a short distance about this dull region renouunco ia
rendered more or less tymprtnitie by the stomach and intestines. In the
lower piirl of tho left infra-^cupulur region, close lo the spinal column,
dulnesfi 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 infru-clnTicuIar.
In the iufni-Axillary region the resonance is modified on the right
eide by the liver, and upon the left by the stoniuch and spleen.
In this region the margin of tiiu lung passeu obliquely ilownwiird
und hiickward from the anterior boundary neur tho sixth rib to the jk)»*
terior near the tenth rib. On the right side, heputic Hatnesji is funnd
below this line, and hepatic dnlness a wmple of inches higher. On tho
left side, below this lino, we find tympanitic resonance in front over tho
atonuich, and dulne5$ posteriorly over the spleen. In this locality the
pulmonary rcsouunce is often modified by the stomach, aa high as the
fourth rib.
The SIM of the spleen varies eonsidorjibly, even in health. The area of
dnlne^swhich it raiises seldom exfeoils twoand nn«-hal( inches in height
by about four inches in width; about half of this dull space is in the
infra-Bcapalar and half in the infra-axillary region.
ExvrptiwicU, — la fri-c cases the spleen rises as high ns the lower Ixiundary of
the axjllai*y regiun, or tho stomach may yield tleciiled tympaoitjc resonance as
high ati tlie fntirtJi rib.
In the irtf rA-scajiiilar rrcnon, upon tim H^ht side in children, dulneu is some
times very pronounced, due to the disproportionate size of the liver in early life
This ia not infrequently niistakea for the consolidaliou 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
leu elastic than in middle life, and the lung has undergone some change
which renders the sounds Iiardcr in quality and higher in pitch. In
children, the lungs are very resonant, and the costal cartilages are elas-
tic; consequently we obUun a low-pitched, intense vesicular sound. In
men the percussion note over the upper portion of the chest i« not
nsually so reeonant as in women, bnt it is more distinct over the lower
portions. It will be seen, from wliat has already been said, that there i«
notable dissimilarity of tho jwrcussion sounds on the two sides in the
mammary regions, as also in the infni-niammary, infra-axilbiry, and
iufrHrBcapular regions. In all other portions of the chest the resonance
U nearly identical on the two sides, bnt the slight normal disparity in
the infra-clavicular regions is a point of great importance
PEHCCSSIOX IK DISEASE.
In disease, the percussion sounds may occur in every gradition from
normal to tympanitic resonnnce or flatno&s. These Tarieties h;ive been
varioutily clufsiliud. I(. E. Tbonipsou classifies tlicm as t:\cuT, dull, tym-
puiiitiu, amphoric, und cracked-pot rcsominco. Flint itrniuircd lliem
ucidyr six heiuis; and A. I*. Looniis under seven, «s follows: Kx;iggeruted
pulmonary resonance, dtilness, llntness, tynip»nitic resonance, vesiculo-
tjmpuuitic rosonimce, amphoric resonance^ find cracked-pot resonance,
or the crackod-metnl sound.
ExACGEiiATKiJ PiLMJNARY BESONAycE differs from tbo normul
vustculur sound only in ils intensity. The pitch and quality are the
Biinie as iu health, but the intensity h increiuted. This sound is obtained
over lung tissue which is rpcciving more air than uHUHl,and which mighl
therefore be said to be in the highest degree of hejilth.
The sign is therefore only negative, as it is indicative of no disease
whatever iu tbu place where it is obtuined, but ntthcr points to deficieuC
action in some otht-r part of tho respiratory tmct. Exaggerated pill-
mouai'y resonance, in adults, is very nearly the same as the normal reso- ■
tiAuce iu children. Tin- sign results from obgtrucliun to the entiiince of
air into sonic portion of the reapiratury tract, wht'tiier from filling up
of the air culls by intlanimator}* exudation as in pntniraonia, from nar-
rowing of the bronchial tubes, or from collapse of the air cells. Pneu-
monia of one lung or of a siuglc lobe of a luu^ causes exaggerated
resouance over lieuUhy portions of tlie lungs. Compression of the luug
from air or tlutd in the pleural sac giveti rise to exaggerated resonance
on the sound side. If one main broncluis is oocluiicd, from causes
vithiii it or external to it, resouance u exuggerated on the opposite side.
In extreme aniemia exaggerated resoiiauco occurs on both sides, duo
probiibly to a diminished amount of bloud in the pulmonary circuit. As
the chest is practically a cavity with unyielding walls, diminution in its
fluid contents musi cause a curre-jponding incrcitio in the amount of air.
DtJLXESS indicates a small amount of air beneath the part percussed.
It can always he uhtuintd in the lieatthy chest wlicre the lung overIa|>8
tjie liver. Tlui sign ilitfers from normal vesicu'.ar resonance in having
high pitch, hard quality, and comparatively short duration. Its inten-
sity [•>■ usually less than that of vcbicuhir resonance. Varying degrees of
dulness should be carefully studied on the healthy cheat. Over the
liver, on forcible percussion, slight dulneas is fuund iu the fourth iuter-
costul splice, becoming mure distinct, higher in pitih, harder in quality,
and shorter in duration, as examination extends downward, toward the
lower margin i>f the lung.
ThiH sign, when obtained in a position which should yield vesicular
resonance, indic^ites that something has occurred to diminish the nor-
mal amount of air in tluit part of the lung. It is obtained over co/tsvli-
I
PEECCSSJoy ly DISEASE 29
wSd luagt from aimple inflammfltion or from phthisis, from com-
prea«ion of the lung or from collapse of the air cells; orer coUcciivna
of/tjitl in tho bronchi or in the «ir vesicles; over wotlcraie vxiidaliofni
in the jjlcural sac separating thu luug from tho cliest walls, but t-ffutiions
of Miy conaidcrablL' umouut deatroy pulmonary resonance entirely, giving
flittnc;^. BuhifSH lA ulst> ohtaiiiciJ over intni-lfKrrfiKtc linfwr», wlicUiur
*oliJ or flujilf jtrovidoil n small portion of lung tissne containing air
intcirencs between tlicm and tho thontcic wall. It is one of the signs
found in pttcumonui, jfhurifi^, jjhlhisvf, atelectasis, and in irttrfhthoracic
abtKtJUoitf tittcunstits, and tumtyrn.
Exceptional, — Dulness rei«ults ocutisionully from pulmonary apojileicy. In
ftuvh cnM^s it is usuully fouml ut thu lower angle of tlic Kt^iimliu II ttmy un.>u
fonn bn>wii jnt)ui':itton oT iJie Inn;;, due to a vuric(Wf> conilition of tlie |iiilinonai'y
witLt. lu Ihis diseaBe it in found near tlie middle of tli4 luti(pi on iMttJi fvides.
It may arise from eiilun^od bronchiul ^IudiIs, anti in a Tew iiititanres it in
found in Ikroncliitis over the apex of the Itingii, or more clearly at the lower pes-
tvhorii .rtoftlie clieiit, due to u collection of secretions witlitu tJio bronchi.
Flatxess differs from dulness in complete absence of vesicular res-
OHKnce. Dulneea indicates that there is some air bcuoith the point at
fbicli the titroke ih nmde; fhitne^!!, ihiit there is none. Duliietis i^ oh-
lined over that ]«>rtion of the liver overlapped by lung tissue; lljUnegg
over that portion hL>1ow the sixth rib, which is Kuperticinl. Dulness
occurs in pleurisy wlicrc the exudation has «opiiratp(I the lung a short
distance from the cliest wall and caused u corresponding diminution in
the volume of air. Fhitne&s will he found in the &ime disease, when an
eSuiiion of scrum lifts the lung above it, removing all aii'-oontiiiniiig
tissue from benciith the potut percu>?sed.
Fbttness is found bijikuri^y with effusion oftencr than iu any other
disease.
Excti^iontil.^Xn rare coros of pneumonia Uh: iiiClammaliun nms to k< toll n
height Ihiit not only the air celU, hut also the bronchia) tubtv are tilled with the
exuOution, iini) in nuch caaes absolute tlatue<t» in found over the lime tiKxiie.
Aj$atn, whet) ihc lung become« completely collapsed from pressure or obstruc-
tjoo w( a large bronclius, flatnes* results.
Tumors or ubscesees within the thorax> when thoy rest ngainst the
cbest walls, cause Qatiiess.
Tympanitic resoxasce ia the luiine 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 tiy walls thin and yield-
ing and not too tense (Oa Costa).
Under certain conditions, this sign is met with over the thorax.
Tyniiutniliu resonance is usually described as of higher pitch than the
vpsiculnr sound. Its duration may be longer or shorter, und its quality
IB hollow, conveying the idi'U nf more or less tension; it is nisu somu-
vhat bard, metallic, and ringing. Statements of diHerent authors
30
PHYSICAL DIAGNOSIS.
oonBict concerning tho pitch of this sign.
othGrs that it is lov.
Samo hold tluit it 13 hi^h.
It seems to me tUal tlie (luK:i'e|>uucy Iiiu urisvii f row tiiistukini: X\m riogiaff
tnetalUc quulity ol the sound Tui' a hj^li jittclii wlicii it may reully be luw. I flod
the WL-ii,-lit of opinion in favor of a. lii^lt |)itch. R. K. Thom[>so», in Ins UttJe
work on iihynit'nl <.-x»iiiiik:ition of tlie L-liest, Matesttiat the pitch of thU fti^n niay
be eitiier higli or low : biL^li when the tension uf lliu volimiu of air b grcati aad
low when it is sli<;ht.
This variety of resonance is never found in thfe healthy chest, nnlo?a
it bo transmitted from some of the orginis hencath the dinphn^gm ; it i*
frequently obtained below the fourtli rib, on the left side from gitseons
distention of the stomach or the iTitcstines and occasionally ovtr the
infra-nianmmry region on the right side ■nOien the colon is distcudetL
W)ien obtained over jiortions of the chest which ahoiild yield a vesicular
sound, the i\gT\ usually indicuteti a collection of air ur gas in the pleural
sac, i)8 in pnenniothonix. Occasionally it is found over a large cavity
in the Iting tissue containing air.
Pulmonary cavities are generally produced by phthisis; hence the
rule, that there arc only two dii^eases of the chest, pucuniothoi'ux aud
phthiais, in which this sign is found.
S-rcejitionnl. — Ttiittnian, Geo, and some others claim thnt this voiiMy of
remnani-e ftoiiiftlmes i-esults from diminished leu&ion of the j>ulmuiiary (wrsii-
cliytiia, and may hi! found m aay condition causing' parlial (-oUjipse of the lung",
Pe)Ti>ct tymitanitic resonance may be obtained in tliat very rai-e coatUlion la
which air or gas collects in the pei-jcaidium. ]t is said to be found io some cases
of emphysema and of acute tubeix-'ulostti. Accunliii^ to Da Costa, it is som^
times found in pulmoaai-y ccdema.
Tympanitic reconanre from the stomach may be elicited far a1>ore !t8
normal seitt, wlien the Itmg is retracted and tlic stomach and intestines
are correspondingly elevated.
Vesicclo-tvmi'Axitic resoxance is a quality of sonnd 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 besoxaxce is a modified tympanitic sonnd which Hiiiy
bn closely imitated by tapping the cheek gently when the mouth is filled
witli air, bnt not mnch distended. The sound is liollow and somewhat
metallic It is obtained in very much tho same conditions as cracked-
pot resonance — that is, over an empty pulmonary cavity with yielding
walls; but to producctbis sign the cavitymust communicate freely with
a largo bronchial tube, so that the ulr can be driven quiclcly from it by
tho ]>ercussion stroke. It is found also over collections of air in the
pleuntl sac, when this cavity 0]>cii8 through tho luug into a large bron-
chus.
Pulmonary cavities are generally caused by phthisis, but they mvf
THE PLESHWHAPH. 81
result from ulisccss. Amphoric re^biiitnce Utherefaru ii&ign ut pneumtf
Ihvrax, jfhfhiifi'', uud jKissibly of abscvas or ijnntjrene.
Bill Sound. — ^^^ltl^ listening' over a lur^ |iulnionuiy cavity. If percuKkin
tie iiiutle on the opposttit Hide of lln* cliebl, tvilli one lat^o coin utrUtiag upon
anoctier usod us a plcxtmeter, a ringing Wll tiounil will l>c heard, wliicti is S'Jiue*
times \ery laud.
Crackep-pot RF-rtoxAXCE {hruit tU }H>t fvh) may bo imitate*! by
placing' tlio hands lonsely togellicr, psilm U]kiu palm, mui utriking upon
the knee. It is doscribml ns rosembling tlic clinking of coin or tho
iimhi^ of ft cracked metallic Vcttle. Generally the sign seems to be the
resnlt of forcing air sudilenly from a |iiilmon.'iry cavity Uirough a small
opening. It has been considered by some us diagnostic of n pulmonary
cavity, but tbi* sign may occasionnlly be obtjiinod when no cavity oxistb,
ftnd aomctinies even in healthy individuals. Something closely reijcm-
bling this resonance is apt to be heard diiriug jiereussiou if the plozim-
eter is placed lightly against the surface, fiu that air remains beneath
and is suddenly forced out by the blow.
It l<i ftaid that oc'OAsionaily tliiH &oiinil may Up oliritotl iu tlie bronchitis of
ciitldreo, or just above the level o{ the fluid id pleurisy vrith etru^ion.
As arule,oruckcd>pot resonance is significant of a cavity, bnt the ma-
jority of cavities do not produce it. When found, it can seldom be
beard more than two or three times together, and it requires on interval
of re^t before it cm bo reproduced. This is probably due to the finmll
opening into the cavity — the air, having been driven out, returns slowly.
THE PLESSiaRAPH.
In pvrcuaskin with the onlinnry plexiinetei'i no matt^^r what fts material or
Hk form of conslntction. all the lifwuo b«iioath it is thrown ftito vihratian. Tliis
rvntters it n^xt tu iiii)>o«vtibIe todcdiie MJiarply tUo oittHiics of tlubu-vt wlieu solid
tissue is ovcrl«ii|tf<l liy the hmp, lirN^atise iho pKixiiuoler covem too miich si>ace,
uid tlic MiuiidR fi'oin the tLNsu(>!t containing uir ;ind froai thoKe whieli do not are
blended. For instaDce, in attcmplinj^ to ileterniioQ the lower border ot the tiuip,
overlapping the liver, wo coniniencc above udJ ]>ercuBs downward to tile point
of complete flutoess, then upwurd U{:uiQ to a point where the vosieutar rviionuiiee
is clear, and thus hack and Tortli, until two U4lj:iccnt points uro reached where
vre olitain on the one hand quite (>errect pulmonary rcsununce, and on tlto oUier
flatness. Then we judge that the border of the luug lies midway between the
two.
To avcid throwing too much liMue into vihi-ation, the si?^ of the pleximcler
muftt he aiiridft'd ; but us the si/a' )h diniinisliod, unless ciMti>ou*atcd (or in some
way, lite intensity of the tionnd is eorn>«poniliu>fl>' lenwrned. These dlHi^ullies
•eem to have heea overcome in tlm construotion of a little instrument kuuwu vtA
the ptesslgraph devised by M. Peter, of I'aris.
It consistAof a small cylinder of wood about four inches In length and flv«>
eighths of ou inch in diameter, withadiscut one end upon which percujwioaUto
be made. Tlie other end cnn-<>tslA of a truncati^d cone, the plane sui-raue of which
Deasurett neatly an eighth of au inch m diameter. In uniag' tJtc :u5lrumeut, the
3%
PHYSICAL DIAQNOSia.
small end {» plucvd on the surface of tl»e cliest^ and percu!»Iou is made u(H>n Ui«
other end with Tl>t> |>iilp of a singli^ linger. Care must W toUon tliat llic iiistnt.
nicnl t^ hflil iter|HMi>iicLilar to tiiL> siirfacd. On a<:-coiinlof tht* ftnLillUMsn «>r tli4
surface whioli r^sX& against tho rlie^it, llie Kound obtaiiiG<l would bo very Teeble,
were it not in a int'asure mtoiLsiliuU hy tlm body of the instrutiieaL actin;,' as »
8onndin^>l»ur<). Trouss«uu claimed that it is not necessary to strike upon ths
(liw, but titat wo may simply tap upou it with the y\i\\t of thv Ihtg^r. nnd that
by means of this inalninnjiit even students miiy rai»idiy map out the liver or
heati, when witli ordinary pcrcu&sioa this mi^hl he impossible, even for ii skilled
diaKU<^''*~'i^"- '^''*^ inslniiiieat iis constr tided by Peter luid upuo the siile an
ermn;;friii_-iit holding a crayon wliivJi could bu pressed down to murk Uie&kin
a'Ik-ii (hi- border of the or<{an had ho>?ri fouud, »u> thai ti dotted line would l)c left
corresponding to the otitliiies of tlit> solid viscns or tumor. I liiivr; found thr^ttp
fttrnment very natisfiictory in det^L-miiitiig siipcrndal dulno^i, so long as it if
employed only in the intercastal spaces, but not when applied over the ribs.
AUSCDLTATOHY PERCUSSION.
Aascaltutory percussion was iiisiltnted by Camman and Clurk in
184C. It consiets, a« the name impliee, of combined nutionltiitiun and
pernusflion. In praL'tiHiiigit, a Btethoscope is needed. For this purpose
tha originators of the method dovised a peculiar instrument, which gqi
Tm. It— CuuuM's Srarsoffcopc rent Amcn-TATom fKBcrmoiL
sists of a solid cylinder of wood formed at one end into a tmneated
wedge, and at the other into a disc (Fig. 11). The wedgo-shdf>cd ex-
tremity is placed in an intcrroHtul spuct*, ovi^r the mnBt superllctjtl porw
tion of the organ or tumor to be examineil, and the examiner's ejir i(»
placffi upon the (Use. An iissisUiiit then percuseee from the healthy
lung tissue towiird the instrument. The moment percnsniou is made
over solid tissue^ the changed sound reveals the fact to the listener, ar<l
thus enables him to determine the deep outlines of the solid mass mnr h
more accurately than by simple percussion. Tho ordinary binaural
stetho8(»ii>e with the smallnr chest-piece may be used for the same pur-
pose. The advantage claimed for this method is that It enables one
*fl determine the outlines of iiitm-thoracic tumcn! or organs much more
accurately and rapidly than by other means. Outlines of the liver, the
spleen, raid tlie ki<lney may also be lutcertained with coiisidorRble neca-
racy, even when ui^cites is jnTseiit.
In the practice of this method, a secoml person has been necessaty to
make the percussion, anu it is nften impossible to get a skilled assistant
at the time needed. To overeome this difficulty, I have devised an in-
strument known as the cmtKiIlometcr (Fig, 13). It consists of a hoi*
AUSCULTATOHY PSRCUHSloX.
33
low cylinder abont three inches in lenfjth by five-eighths of nn Incn to
diAmbit^T, trithin which plays a metalUo phingor. Tc tlie objective end
of tbe indtrnmflnt is tittofi a soft-rnbber chest-piece, ngiiinet wliich the
plnngcr strikes. To the other end is attached » rubber tubo about
ciglu«(>n inches in lengch* couueccing it with a rubber bulb. Conipres-
sioo ol the rubber bulb drives the plunger nguinst the chcst-piiH^e; fit
the instant the pressure is removed, the bulb expands und the plnnger is
lorced npward by atmospherio pressure. In practising auscnltatury
percussion by the aid of this inglniment^ the stethoscope ie held with,
I SHAR
SHARP ft SMITH
Flo. 11— IfOiLS' ZMSAhUtMWrtK.
the left hnnd; the bulb of the embullomcter is held in the pnim of the
right hand by the liut three fingers, and the cylinder by the thumb :ind
fon'finger. This enables the physician to move the instrument without
restraint, to strike any point as rapidly or as slowly as he chooses and
with wbatev<»r force may be desirable. Ry means of this little instru-
ment and the binaural stethoscope, auscultatory percussion can be sutis-
Inctorily pructised wtthuut the aid of aa assistant. In using the bin-
ftnnil stethoscope for this purpose, tbe small chest-piece should be
employed. Probably one still smiiller or flattened, so that it might b»
^plied between the ribs, would give even better results.
CHAPTER III.
METHODS OF EXAMINATION.— Con^iKwerf.
AUSCULTATION.
Auscultation, the art of listening to sounds produced within the
cheat, 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 inspiration 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.
Id this connection, a brief notice of Laennec, the Inventor of mediate auscul-
tation, is of peculiar interest. He vfas bom 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 Hfe 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 writteu 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 writere 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 liis
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 signidcance, lie 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 noiv 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-
AVSCULTATWN.
35
tion id tlmt it has :l peculiiir ringing Bound always confusing to begin*
ners. Until wo l>t;t;unie sufticit'ntly familiar with the inetrunjeut to ig-
nore this, we shall be nnablo to appreciate the pnlmonai-j* Bonnds. Many
of these inatniments are poorly constructed. The aiethoscope is of very
little valne in examining children, because it is likely tu frighten thcni;
besides, the respiratory murmur in them ia so loud tbut it cun be easily
beard with tlie unaided ear.
In examining the lungs, the ear alone is usually euSicient; but to
differentiate between the souuda jirodnceil at the viirious orilico of the
beart, wo must employ the stethoscope, the small chest-piece of wbicli
excludes in a great measure all sounds excepting those produced imme-
diatoly bcueath it.
Mediate auscultutiouhas, however, the advantage of greatly intensify-
ing the hitra-thoracic sounds, so that signs which could not be heard by
Ihe unaided ejir may he readily recog7iized through the in;^trnment.
JSomo portions of the chest cannot be easily examined by immediate
iiDScuItAtion— for instance, the axilbiry space and the supra-ciuviculiir
region; therefore the instrument becomes necessary; someliines it may
be uuplousuiit to uj'ply the eur to the cbyst, and somelimea for the
sake of delicacy it is not advisable.
The advantages chiimed for immediate anscultation are: It yields no
humming sound; it obviates the necessity uf carrying nn instrumeut; it
does not frighten little children^ and the results obtained arc usually
Bufficioutly accurate.
If the stethoscope moves slightly upon the chest, it produces a gral-
(ng sound much more intense than the respiratory murmur. The t^nnie
ibiug occurs if the finger maves u]M>n the instnitnent. if the hand is
ilnwn over the surface of tljo chest, or if the patient's clothes move
upon the chest or upon the instrument. In some cases neither mediate
■lor immediate auscultation alone yields ucciinite results, while the two
tombined enable us to make a proper diagnosis.
There is now a great variety of 8tethoaco|H«. They maybe classified,
(lowever, as solid and flexible, some of which are binaural and otlicrs
(4ngle. 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 u tubu-
lar inatrument about six inches in length, exjMinded at one end into a
bell-sbnped chest-piece about an inch and a fourth in diameter. At the
other extremity is a disk or eiir-piece about two inchejs 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, m> that it may be useil ns a hammer in percussion. 1
think physicians generally find more difficulty in exauiiuing the chest
with this instrument thau with the biutiural stethoseojie. A binaural
stethoscope deviseil by Lcnred, of Loudon, was made of gutta-percha and
36
PHYSICAL mAoifoaia.
oonsieted of two tubefl* one for each tmr. The oiirionlitr extremiiieB of
these tube4i were ditik-ehaped, and the other ends were fitted into a hoi.
low cyHndrical or cup-shaped chest-piece. The elasticity of the tubes
kept the disks in firm iip|>o&itiou with the care. Thiij iustrumeut was
exhiltited iu Loudon in the year ISol, but it uttrActed little ittt<'i)tion.
About the S!ime time Ciinimiin, of New York, iritroductd the biTuiund iu-
Btruiiieut that bears his mime. This consists of two met4d tubes so curved
FtO. IS.— ^UD WoODCy 8TITBn»COPt.
as to fit into both enrs, and connected with cftch other by a hirigc-joint.
These, wheu jdaoed iu tho eiirs^ nro held in position by jin clastic passing
from one to ihe (iiher just iibove tho joint, or by springs of viirions con*
trivtinco. The luiricuhirends vt these tubes lire tipped with gutta-percha
or ivory of sufficient size to close the externiil mcjitus iind prevent tho
entrance of external sounds. To the other ends nro fitted two flexible
tubes which connect them with the body of the instrument to wliich
the chcst-pier-G is attached (Fig. 14). Each instrument has two ehest-
piecea, one about an inch and a quarter iu diunioter, for exuminatioa
I
CxTSKBtoN Thh «>!tu>n«kin tiihe rmdim ft tttxy tor tb«
I fnwt coDTvaifliuM la examliitLiK |>fttleat(i Iti hml.
of the lungs; the other five-eighths of an inch in diameter, for the ex*
amination of the heart.
Of the various modifications of Camman'a 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
AC&CVLTATION
37
tlir 0ouD(l clirwtly into the auditory canal; thfcar-tipe nre of proper size
U* exclude bsU'i nal sotititU, auil ure not so small us to puss into the audi-
tory oiuii] aud occasion pain; the tubes nrliich connttct the ear-pieces
with the cheat piet'e arc very pliiiblc iind have a calibre equal to that o£
other portions of the inslrnmcnt ; tlie chest-pieces are of proper size,
anil the whole instrument is thoroughly finished.
With many instrumeuts a soXt-rubbor attachment is fi:raished which
may be fitted over tiie end of the enialler clieat-inecc^und is desi^icd for
the examination of emaciated patients. Tins chest -piece, however, is
practically worthlc&s, on account of tlie creaking which is produced, dur-
ing the reepiratory movements, by friction with the wooden chest-piece
ou whioli it is adjusted.
Charles Denntsou, of Denver, has an excellent modiGcAtion of the
binaural inatriiniciit: the cniidiictiiig tubes are of large calibre, com-
poseil of gulta-perclitt and unite in a cuumion tube with flaring extremity
abont an inch across; nito this three other chesi-pieccs may be tightly
6tte4l, two uf the same material, one of medium size and ohl- three inches
in diiimeter. The latter '\& e*i]iecirtlly valuable when it is desired to hold
SHAK^ASMlTh.CHICACa
FiQ. 15.— ALtjROff'a DtvrBRCinrtAL SrcntnAtorc
the chest-piece of the stethoscope before the patient's open mouth
vhilo jMjrcusBion is being made on the chest as recommended when tho
signs of consolidation of the lung are indistinct. The third cbesC-ijiece
is of poft rubber.
The differential stethoscope invented by Allison is essentially the
le ftS Cnmman'a, excejjt that the ilexible tulie^ are each fitted with a
jlinct chest-piece^ so that sound cxn\ hv conducted to the two ears
cimnltaneously from different portions of tho che«t (Fig. 15).
A stethoscope whicli will tit one person perfectly and allow tho
sounds to be conducted without obstruction into the auditory canal, with
another may rest ugain&t the e.\terual ear in tiUch u ])ositiou as nearly to
oivlude the orillce of the ear-piece; therefore in purchasing, one should
see that tho tubes are so bent that the instrument fits the mrs accu-
ntely. The larger chest-piece ought never to exceed one and one-fourth
mches in diameter. If larger than this, it cannot be accurately applied
to nn emaciated patient; consequently air passing beneath it will pro-
dace a hamming sound, which will drown the pulmonary wigns.
The apparatus oo KniRlit's stetlioxoopc Tor ailjufvting the pressure of the ear-
pieces works pt-rft'L-tly. uuii is otlen \-er>- useful, thouijrli a simple rubber Iwind of
proper length would aniiwer tlie purpose, if only one person were using the in-
3truincat. A rubber band, which could hu letiKthened or shortened by a buckle,
would allow the iiistfunicnt to be cuiiily udjut>lcd to uuy huud, and tvould be
Je^s expeiiiiivti tliuu Ilie nictul attuclitncuL
ConsidornbiB practice is required to perform auecultaiion properlj.
Ab guides, ti Xuw rules niuy be liiid Jown:
lu mc'iHate uuscultJitiou, the chest must be bm-cd; i» iumiediato
ansciiltiition, the covering uiust be us soft, thin, and smuoth ua jiusslble.
The iJOBition of both paticut and cxamiucr should be cosy and unre-
strained. If the ]mtient is in bed, it is prefenible to Imve him gitticg
if hcultb will permit. If the examiner ia in an uncomfortable position,
he canuot properly concentrate his attention uixin the soiindg.
In examining a child, or a patient in bed, it is :i good pbin l-o restoit
one knee, &o that the lioad will not be on a plane lower than the body,
otherwise gravitation of blood to tho brain will cause fulness of the
head, <iizzine8s, and Impaired sense of liwiring.
We must eitrly le:irn to coucentrute the whole attention on the
souud to which we are listening.
It is desirable to Imve tlie room qniut, especially in practising imme-
diate auscultation, for the ear which is not iLpplied to the chest catches
every extraneous eound, unless it is stopped with the finger.
The ear or tlie stetJioscopo should be applied liniily, bub not with
great force, to the surface, and ill such manner that no air can pa^a
beneath it.
Compare corresponding portions of tba two sides during both natural
and deep respirations. If one Bide is examined during ordinary or for^
ciblc respiration, the other must be examined under the same condi-
tions.
The pulmoimry sounds are not exactly alike in any two individuals,
nor are they the same in different regions of the chest in tho same in-
dindunl; therefore it is necessary to study healthy cases carefully, in
order to become familiar \rith :dl varieties of healthy sounds. This
iamiljarity must be so jwrfect thnt no effort of the mind is required to
remember the variations in different localities. This canuot be urged
too forcibly, because until wo can easily recognize the healthy soiinda
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 met:imurphosis, it makes a pecul-
iar impression upon the respiratory nerves, which is transmitted to the
brain as a r^ll for more oxygen. Instantly a message is flasljed back
over tho nerves, to the inspiratory muscles, causing them to contract
By this action the diajdinigm is shortened and its convexity lessened;
the ribs are lifted, and by rotation on their articulations with the spinal
column, they are at (he same timu curried forward and outward. Thua
A VSCULTA TION JS HEALTH. 3»
(he diamoters of the chest nra incruneocl in every direction, and air rusb-
ing- in through the open glottis distends the ebatic lungs as the chest
expands. Immedint<.*Iy tho resplmtory act ceases, the nuiscles rt'Ins, the
elutic tissue of the lung asserts itself, and the nir is expelled from the
pnlnionary vesicles. This hitter is a passive movement, in wliich the
Mjiimtory mnsoles take little part, excepting in forcible expiration.
While inspiration is tnking place, we hearu soft, breezy, or rustling
wnnd, known as the inBpimt()ry murmur. As eoon ns ii ccaRcs. a sound
foft and breexy, lut lesa intense and mncH shorter, occurs, which U the
expiratory ninrmnr. Tbi^ is follovcd by a period of rest, which com-
pletes tho cycle of respiration.
AU8CULTATT0N IS" HEALTH.
A variety of signs may be obtainc<l in the normal chest owing to the
position of sorronnding organs, and the difference in tlio force and vol-
nme of the air current produonig the sounds.
Auscultatory sounds arp possessed of elements similar to those of the
percnufiiun sounds, viz., intensity, pitch, quality, duration, and in nddi*
tion, rhythm. The latter refers to the relation between the different
portions of the respinitory act. The intensity of the sound varies in
aifferent people. Tho jiitck and the /junlifrf are practically the same in
all healthy cjises.
The duration of the sonnd also varies in different cases, but is about
equal to the durution of tho respiratory act which produces it. All
modifiaitiuns of the respiratory murnnir which may be ubtjiined in dif-
erent regions of the chest are simply alterations in one or more of these
elements. Tims In the different parts of the respiratory tract we ob-
tain the normal vesicular murmur, bronchial reppiration, and trachea!
and laryngeal rctpinUion, eacli of wliich differs from the others more or
less iu intensity, pitch, quality, duration, and rhythm. The clearest
vesicnhir murmur is cbtuined in the iufra-chivicuhir and infra-sciipular
regions. Tjirvngoal respiration and tracheiLl rr^piration are obtained
over the larynx and the tracliea, and are essoTitially the same. Bronchial
respiration, or more properly broncho-vesicular respiration, maybe heard
over tho bronchial tubca, au'l for an inch or more about them in every
direction upon either tho anterior or tho posterior surface of the chest.
The VERlcrLAR siriiMrR, which is the sonnd obtiiined over the
pnlmnnnr}* pnrenchynni. is taken as tho standard of comparison for nil
others. This sound may be best studied in the infra-scapular region,
though it is more intense in front, below the clavicle: bnt in the latter
position the heart soun.is interfere with its easy recognition. The vesic-
ular murmur, like all other respiratory sounds, is possessed of two pnrts.
The first of these, the inspiratory, begins as a soft and distant blowing
sound, and gradually increases in intensity and approaches more nccrly
to the car toward the end of the act, when it is breezy or rustling in
40
PHYSICAL DlAUNOSia.
character. It varies iu iutensitr in clifferehC iiiJividaHls, but is gcucr-
ally easiily heard. Its pitch is low; hi durfliion it corresponds with the
inspiratory act. Its quality, called vesicular, cuuiiot be accurately de-
Bf'ribed, though it may bo easily learned bypmctice uj>on a healthy cluut
This sounil is followed iniinedijitely by a geiitlo .•ustliug suuiid. the cj:-
piratory imirnuir, which passos off gnidually into a low breath or puff.
It is leas intimsc than the preceding, being usaolly so feeble that one
must, listen for it very attentivoly; it is of thu samu low jjilub, and about
one-fourth the duration of the iiispir.ttury sound. Though termed vesic-
ular. Its quality is nt-ither strictly vesicular nor bronchial, but aligluly
blowiug.
The normal vesicular murmur is modified in different regions of tlie
chest, by the size of the bronchial lubes, and more or less by the thick-
ness cf the chest walls and by the position of other organs. It is heard
in perfection in the left i.ifra-claviculur region. On the right side iho
snniul is more intense, and tho expiratory si»und genendly slightly pro*
lungCil; this disparity being due evidently to the dirccCiou and ehiu of
the right bronchnsascompsired with the left. There maybe averrsliglit
intcn'ul between the inspirator}* and expiratory murmurs, and the qual-
ity of both is usually slightly tubuliir.
Over the upp(:r portion of the st«mum and the inner third of the
infni-clavienlar regions, the i)ro.\iriiity of tbo ti-achua uud of the l-irge
brt>uohial tu'>es renders the normal murmur sumewhat tubular or broils
cho-resicnlar in quality.
In the inter-scapular space, owing to the thickness of the chest vti
the vesicclar sounds are less distinct; owing to the presence of the main
bronchi, they are nioi^ tubuhtr in character, so that in this position ul»o
we lind a sound which might properly be termed the broncho-vcsjcular
murmur, but whu^h i^ uitually calletl nornml bronchial breathing.
In the scapular regions, the thickness of the chest vuU renders the
vt*j<icul.ir sound indistinct.
In children, the vesicular mtirrour is much more intense than in
B'lult^. Over the u)jper portion of the chest it is usually mnch more
intense in women than in men. In the aged, it frequently Iosps some-
thing of it* ioii quoliiy, and becomes slightly more tnbnlur. and is
itltercd in its rhythm, the eipintory sound being occnjiionaUy preceded
by a short period of silence, and having a duration nearly or quite equal
to the inspiratory murmur. This change scents due to partiiil atrophy
of lung tissue and to changes in the elasticity of the chest walls.
In extreme anaemia, the vehicular murmur is intensified over the en-
lire chest.
In lisieninc |o fhere^idrationof muscular subjects, a continnons. low-
pitched, superficial, rumbling murmur is heard where the mnscles are
'htckest, whirh la due to the contraction of mnsculir fibpp?. In tare
cises this is sn marked as closely to resemble the vesicular uurmnr.
14
iTtsT"
AUaCUhTAl'lOl^ IN DISEASE.
41
lijLitTKGEAii AND TRACHEAL ItESPiRATioy. — The respirator}" murniur
ere: ihu laryiix asd the truclteu difTcrs from vosiculur respiration in its
inteosityj pitch, quality, dnmtioa, nud rbytlim. The inspinitory sound
Umuch more intense than in tlie vc^iculur niurniur, itd pitch ifi higher,
}U quality tubular, and there is a marked iuterval betweeu it and the
expimtury auuud.
Ttc expinitory sound is genendly more intense than the inspiratory,
ID(I ereu higher in piteh. It has the bunie tubular '|ualily and iibout
tbeeuiie duration. To 6Uiu up these points of distinction, lari'ngcikl ar.d
tr^cknU. respimliou diHers from the Tesieular in being laoro intense,
hijtlier pitched, and tubuhir in rjuality: in having an interval between
die ivo portions of the act, and tht> expirator}* sound is as long as the
iDf|iinttory, or even of greater duration.
ItBONCMiAL REfii'iKATioK, or, pcrJmps Hjore properly, kroxc no-
TESiccLAR BESPiKATiox, IS noxt iu iniiiortance to the vesicuhir. It
•Mj- always bo found iu the healthy chest, but is only heard in a limited
irta, immediately over and fcurrounding the large bronchial tubes. The
Iftltcr term seems more aj)propri;ttt', as this combines hotli the bronchial
uul the Tesicnlar varieties. True broni-hial brealbiug is the same na
tnche:d, excepting that it is usually It-.BS intense- If is the sound ub
tim-d in pulmonary diseases where the air vesicles are completely filled
It; iLflammatory lymph or other products. Bronelio-resicnlar respira-
tioa holds a place midway between broncliiul and vesieuhir, and is the
MUiid obtained when only a portion of the air vi'sicles are occl'ided.
Tlie sound heard over ttie main bronchial tubei> in the hcaUby chest
is more intense than the vesicular murmur, and its pitch is higher: its
qtrality is a combination of the vesicnlur and tubular, and a slight inter-
ml laav l>e noticed between inppiratinn and expinition. The expiratory
loutid is of nearly equal dunitiou with the inspiratory.
We shall at once perceive the necessity of being able to recognize
these normal soundi* and of knowing Ihe localities in which they ocenr;
iw some of these, when heard in uhnornial ])ositions, are the aigna of
gnve diseases.
ArSCCLTATIOy IK DISEASE.
The on«cnltatory sounds are altered by disease, princip-jilly in thpir
intensity, rhythm, and quality.
The intensity may he increased, giving rise to exaggeuted, compen*
Kniory. or supplementary respiration. It may he diniinish<;d, and is then
railed feeble respiration: or thcaonndsmavte entirely suppressetl. The
rhythm of the murmur may be interrupted. It is then termed jerking,
irary, or cog-wheel respiration; and the interval between the two portions
of the act may be lengthened. or the expiratory sound maybe prolonged.
The qnality of the sound may be rude, termed broncho-vesiculi.r.
or bronchial, cavernous, or amphoric.
PffYSlCAL DlAONOSrS.
ExAOOERATED RESPIRATION differs froiii tile nonnnl innrmur in fn
tensity and dnrdtion, both the iiiKpimtory and the expiratory sound
boingintoneifiod and Bonicu'lmt prolonged. It ieprodncodin lungtusu
which is jiorforming inure than ha nrdinar}* fnnntion. When ob
over the chest of an adult it closely resembles the natural soand
child, and hence has been termed puerile respirntion. It is nlso termed
pupplementary or compcnf-atory rcspirAlion. Like exaggerated percus-
sion resonance, it may be siiid to iiitjiaiie tlii' highest degree of Iiriilt}i iit
the organs where it is produced; bnt it also points to diseaso of aom*
other portion of the respiratory tniet, and is therefore a valnable nega*
live si^. It results from any condition which, by interfering with th»
entrance of air into one portion of the respiratory organs, may caoM
more afitivity in the remainder. Thus, purtial mnnoh'fliittoti, rolfajjsgj ttr
cotuprex-sioti of tJie /wi/y gives exaggerated respiration well market] in th»
sound portion of the affected organ, and more or less also on the sound
sido. So also obetrnction of a bronchial tube by secretion or dimitiuiion
in ihcalibre, by compression from tumors or thickening or contraction ol
its wall, may givu rise to this sign in the portions of the lung not that
obstructed.
(E'Uma vf the lungjt may also cause exaggerated respiration over their
apices; and in hemiplegia, more or less panilysii* of tlio respiratory mns*
cles on one side caugcs exaggerated re«pii*ation on tho other.
Feeble nEspiiuTios differs from the normal vesicular murmur In
being less intense and shorter in duration. The inspiratory part o£
the sound is most affectud. The sign may be occasioned by anything
which iuterferea with the perfect tninsmission of sounds to the surface,,
as thick chest wallti whether due to muscular or to adipose tissue; it ifl,
also caused by small quantities of air, fluid, or inflammatory lymph,
the pleural sac.
It may result from loss of elasticity of the Inng tissue in conseqn
of dilatation of the air vesicles, as in pulmonary fuijihi/^ema, or from
lubercttlaf or infiftmmntory consolidation of the lung; also from defi-
cient action of the respiratory muscles, occurring in jmrahfMi^; or it may
exist in ritsatfifa tit" the fiMmuinal or thoracic, ort/aiijf which give rise to
pain and canao the njitiont to restrain muscular movement.
Collections of ^(/i'(/ o;* ^w.-* in the pleumi cjivity, tumors in the chest
or abdomen or a pregnant uterus may interfere with the fnnction of
the lung, and prevent the descent of the diaphragm by mechanical pres-
snre, thus causing feeble respir-ition.
Obstruct ions of the Uirif>u, trachea, or broftchi also cauiie feeble respi-
ration resulting from collection of fluids, the presence of foreign bodies,
thickening of the walls by infUimmation. diphtheritic or croupous de-
posits, UHlema, and neoplasms ; from contraotinn of the walls, as In
asth ma, spasm of the glottis, or paralynis of its dilators ; or through com-
nroasion from witlmut by inflammatory growtlip, tumors, and the like.
AVaCVLTATiON AiV DiSEASB.
43
^hen this diminUhed murmur 'u found in tlio upper part of ono
hing, it often uidirates phthisis; 'if found in the lower piirt of the lung,
it is very often an indication of pucumouia; found over the lower por-
tioQ of both lungs, it i$ suggestive of a>dcina,
SrPi'KEssED RESPiKATiox 15 due to the aimeoflusos which, occurring
In a leea degrcCj give rise to feeble respirution. It is often ohscrvud
over the diseased portion of a lung, the remainder of which yields the
exaggerated re/tjtinuory nuirmur.
bf 1>*TEBUU1'TED KESPIRATION*, olsO known 06 COO-WHEEL TlESrifU-
Tios, either inspiration, expiration, or both may be broken into two or
ntnri' pnrts, tht; sound being suddenly interrupted, to return nguiu, and
[•erhiips agsiin iind again, before a einglo respiration ie complete. Thu
julerrnption take* place most frequently with iiiifpiration. The sign is
imt\ under n variety of circumstances, not only in discaiie, but also in
lealtli, BO that it is not of much importance, though sometimes helpful
ia confirming a diagnosis based on other evidence. It is sometimes
pn^rut over the whole chest, at other times confined to a limited
sjiatv,
TThcn occurring in healtli, it is often heard over the whole chest; but
wlien resnlting from pulmonary disease, it ia more apt to be localized.
lathe incipiency of phthisis this sign is frequently obtained directly
CT^r the dieeiued lung, especially when the lesions are in the left
iipu.
It may be produced by any disense which renders respiration painfnl,
u inUrcosfal jieumhjin, phurt'ni/f and ph-nriidtftiiit. It also occnra in
ctnuufl ^KTsons when agitated by the examination, and is very apt to
be found in hysterical fmlieiih. When due to nervousne&s or pain, the
lign will be found over the whole of (jue 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 iactptent phthisU the iaimediutc cause of this sign soems to be forcible
coDtrociioD of tlie heart, whereby an abnormal amuuiit of blood is forced into
ibe pulmcmary circuit, tbcruby cuubiiig suuiu narrowing of tJie calibre of the
broncliial tube*.
A PBOLOXGED IXTERVAL bctwecn inspiration and eipinition may be
ciused by shortening of the inspiratory murmur, or by a delay in the com-
loeneement of the expiratory niui-mur.
Shortfncd htfijnrah'fni. — The insi)inttory sound in this condition
teases before the act ia complete and is consequently shortened, in par*ial
consolidation of tho lung due to inftammulory or tubtrr.uhir deposits.
It is deferred in its commencement after tlie inspiratory act begins, and
thus is shortened where the air vesicles are dilaied.
Deferred Expiration. — The expiratory sound is delayed when the air
foaiclei are distended, as in pulmouary emphysema.
PSrSTCSL DiAoyosis.
pKOLONnEii KXiMRATiox rwsultH ffom :i losBofelosUcitrof tbelnngs,
eitliur by coiisolidatiun or by distention.
Wlien tlut» torntiec)H(Iutioii,iiproIongo<l expinitory mtrnnur is usnally
more intense than nomiiil. It is high pitcliwl jinil more or le*s tnbulur
in quulitr, iiud usiuitlj p.>8se86ed so mucli of the brouchial clement us to
bti termed broncho- vesicular.
The prolonged exph-utory nim-mur which is Rometimes round fn healthy
€>hests posnesBea the »&ms pitch ami (juatitv us the nonriul vehicular soimtl. which
enables us to UiatinguLth it rroiu tlic prolouireU expiration orcoasolidution, in
wliicli the pitcli is always )ii^h und the qua-lily soiuewtiat tubular. We must
not lorget llittt io heulth the vesk-ular murmur ovue Hie right ap.x is soin«liMie$
nion; or Icbs lubulur n.ti<l high in pitch, au<l tli:tl tliu expiratuiy k^-uhkI Lt pro-
loni^Ci), a^ cotii{>ari.>il nith the ktt i^idc. Thercfur*.-, i» this position the t<y^n ran-
Dot olways be considered as itidicatlveofdiftense.iinleu it be taken In connection
vitJi other Kij^na.
When obtained on the left side, jirolonged expimtion is nearly nlways
duo to phthisis or to emiihysenisi. The difference in the two is that in
consumption the expiratory sotind is liigh pitched nnd more or less
tubuhir ill quality; while in umidiyscmu, it is usually even more pro-
lunged — it may be two or thr^^ times us lung us the inspiratory murmur
— ^ud it h:is a low pitch, it is not tubul-ar Imt nitlier vetiicular in qn.ilitr,
and is apt to be cousideiubly less intense than the insplnitury sound.
Ocoa^Jonallj prolonged expimtion may he cause<1 by inlerrerenee with IImi
free exit of air rrom the lungis, as by obi^tructjon in the hirj'tix or bronchial lubeft.
[ii these caaeH it is iDiiially usHociated ^vilh i\. d<^ferred ini>|^ratory murmur, io
w!iii.'li the liound doi.-s not b*.'t;in wjili the insjiii-ulury iwt.
B^vcei>tioiial. — Pi-oloa^i-il exi>ii'utinn huvin;^ Ihi* ptU-h and quality of the
healthy iiitii-iiiur M ohtaiiied with oavcnious rf««))ii'ati»ii in rai-e nast-^^. tii stich
ii)*ttati{vs ilA sij^niricance is ascertained by the character of the jnspiiutory sound
• ml by other sijjns.
Rude RKf-PIKATIOX (BBOXrnOVESICL'LAH or HARSH BKSPiRATION)
oloselv resembles the sound which can be obtained directly over th©
broneliial tubes in n healtliy chc^t.
The respiratory sound is raised in pitch in proportion as the tubular
•upplants its vesicular r|uulity. Tlie expiratory sound is always higher
in pitch than the inspir;Ltt>ry, its quality is more or loss tubul.tr, .:nd it
is prolonged. The alteration in })itoh and dunttion is in proportion to
the prcjiondemnce of the tubular over the vesicular quality.
Disease may furnish all degrees of broncho-vesiculurreapinition from
the normaf vesicuhtr mttnmtr to perfect bronchuU hrenfhint/, acconling
to the amount of consolidation.
This sign is due to the better trnnsntiasiou of the vibrations from tho
larynx, tnichea, and broucliial tul>es to the surface of the ehcst, in con-
Buqucnce of the eon soli da tint i of the air vesicles, making the imrcnchmni
ft bettor uonduetor of souud-nuves und rendering tho bronchial tubes
AUSCtriTATWir IN DIHEA^B.
45
more rigid, so that they transmit these wiive« from the apper nir pftssagea
vith less resistance.
The sign is obttiinod in ineipt'enl phfhui-if over the upper part of tlie
lung, and in ^JHfi/Hi«HiVr, uBually over the lower lobe. It is also he^rd
xaiomBcus^sotpuivumnnj (ijiOjikTtf,:\r\\\ oy&T n hing piirtiul]j collapsed
from any cnnse or whirh hiis been compressed for a considenible time
hj^uiif or (lit in the jtlcurat mf. It is luoet vuluiiUe aa a sign of incip-
imt phthisis.
Exceptional. — Occnsioniilly in c-isM where bronchA- vehicular rospiralion oo-
nntt ejtiior tlio inspiratory w t>x|>)rati)i'y murniur may Im> absent ; Then, an in
limiLir tn^taiifcs of bronchial respirution, its detection will depend on \\\f pitch
RDil qualHy ol the soumls which are preseotf and U|>oii concomitant aigna.
th
k
Bboxchul REsrtKATiox is one of the most important varieties of
the healthy eonnds, which may sometimes be iudicutive of disease. Its
nnlity uud its other elements excepting its intensity are mucli the same
tbo^e u£ nomiul trachi^al respiration'. The intensity of this sound is
DffUitlly greitter by far than that of the vesicular mnrmnr, bnt sometimes
very fevble; the pitch is high, the quality tubular, and the duration of
both inspiration and expiration is prolonged, the two being of uboiit
eqmil length. There is an appreciable iutcrvul between the inspiratory
and expiratory sounds.
£.rcf}4i<mal. — In bronchial rei^piration, either portion of the respiratoiy
murmur may sometimes be al>st^nt.
Loexmec taught that the bronchial pound was iilwaya prorluced in a
healthy chest, but that it was not usually h&ird because of the interven-
tion of air vesicles between the tubes and the chest walls. When ol^
tiiined in disease, he considered the sign due sinijdy to the better truns-
miesion of the sounds tu the surface. Skoda believed that consolidation
of the air Tosicles stirrounding the bronchus was necessary for the pro-
dnction 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 knov
that the sign always indientes consolidation of lung tissue (Fig. 27).
The tnbular sounds in tins variety of the respiratory murmnr are
transmitted for a considerable distance beyond the consolidated lung,
which accounts for the lict tliat the bronchial and the vesicular elemenla
are frequently combined in the regions immediately surrounding that
which yields simply bronchial respiration.
Tlte greater intensity of tha expiratory sound in bronchial respiration ne-
oounta for the fart that occasionally we obtain a venicular init|>iraton- and a
bronchial expiratory sound, as the intensity of tlie bronchiul sound drowns tlie
vesicular tn expiration.
Bronchial respiration is fonnd in greatest perfection, in pneumonia^
over the consolidated lung. It is obtained also in some cases of p/t/tit.\i%
but in this affection we are more apt to hear broncho-vesicular respinition.
46
PHi'STCAJ. DlAOyoS/S.
Exci:}itionat. — In rare cases cancer of the luog jrieldg bronchial breathing.
Pulmonary apoplexy sometimes causes the &\ga ; it is heard over ihe eotira
chest, tliougli more distant than in coiuoliJatioD, in a few cases of pleurisy with
ejctensive ettiuiioo.
CAVERN'ors HEsrinATlOJ.' has been likened to both bronchiul and
vesicular. We aro tolil by ouc uulhor tlmt it closely reacmblt'S the forniKr,
and by another that great care is iieceaajiry to distinguish it from the
latter. This discrepancy is probably due to confusion in theapplicntioa
of tbe term to different signs. Flint made the distinction cletir by in-
troducing the tcrui broncho-cuvemous to desiguntc those hollow, high-
pitched sounds which, although conveying the idea of a cavity, do not
correspond with true cavernous respiration. The iuteusity of cavuruoua
reapir»tion is usually feeble, so tbut, unless searched fitr carefully^ it will
be oTerlooked. The pitch is low^und the quality, instead of being vesic- ■
ular or tubular, is soft and blowing or puling. The expiratory portion ■
of the sound ia prolonged to about the same length iis the inspiratory,
and is even lower in pitch than tlie latter. The fiiiUire 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 niurniur as
just described, but 1 think it a very rare sign. It is iirodueetl in empty
pulmonary cavities, the walla of which are so flaccid that they expand
readily in inspiration and collapso in expiration (Fig. 16). It is a sign,
therefore, of any o£ those diseases which might eansc snch a cavity, vij,,
congtiinptioiitjmluionarif ab^icesSf or t/auijrenf.iiflhe lung.
Bro/icho-caivrnous rggpiralion is made np 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
ia not entticiently tubular to bo called bronchial, nor ret snflicicDtly gott
and puffing to hv termed cavernous. It la produced in pulmonary cav-
ities, surrounded by lung tissue more or less consolidated; the tubular
element being dependent upon the amount of consolidation. Somctimca
'the first part of the iuapiratory murmur may be tubular in quality and
the hist part cavernous; again, we may obtain cavernous inspinitiun with
Lronchial expinUion, due to the presence of consolidated lung tissue
bear the cavity. In the latter case the tuteusc expiratory bronchial
murmur probably drowns the euvernous sound wliich was heard with
the feebler inspiratory murmur.
Broncho-CJi-vernous respiration is the characteristic sign of the later
stages of coMumption, but it may also be produced in the cavities duo
to aftscejtjt or to yungrene..
Amphoric respiration- resembles tho sound prodnccd 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 respinitory act, but is generally most
marked in expiration. The expiratory sound ia lower in pitch than that
\
AUSCULTATION m DISKA^iE.
47
la brouchial ruspimtion. In this couiiection it is well to cmpliasizo the
Boceaiitv of stuilving Ihe pitdi uf the rcspimtor)- sounds, fur m some
iBiUnces thtre is abdolutely no otiier iiicaiiij of diatinguishiiig between
the sounds transniitteil from the bruuL-liial tubed iu coniiolidated lungs
lod thoflo heard over pulmonary cavities. The diatinclion in theso cases
hdeur if wc remembor that tlio expimton- sound in the former instance
isalvayH high in pitch, in the hitter nhvuya low.
Amphoric respiration occurs under the same conditions iis amphoric
nKiiianoe, and is frequently fonnd in connection with cnicked-pot reso-
■anoft. It IB due to the passage of air in and out through an opening
GuMUt.
a^M
r>fi>a»
Tto. 10.— PnTifni&
from a bronchns into a largo pulmomiry cavity or into the pleural sao
(Fig. 26). Tbo sign is obtained most perfectly in j/niittmoihortix or iu
pntumo-htfdrothorax. In the latter it disappears and retnrus again, as
the qnaniity of fluid rises so as to cover the opening or falls below it.
This sign is also heard in ]iht)iisis when the pulmonary carity is largo
and its walls are firm, so ihat tbey will not collapse In cxpimtiou.
Canities may exist wilbin the lungs without yielding cithur of tho
rarielies of respinitioii M-hich may be caused by » vomica; for example,
if a OHvity be filled with fluid, or if the fluid in the cavity rise above tho
orifico of the bronchial tube, none of thei?e sounds will be heard {Fig,
IC) ; but if the patient's jiositiou bt> changed or the amount of fluid de-
eraased by coughing, the signs return.
CHAPTEK IV.
METHODS OP EXAMINATIOX— CoH/»Hw«i.
ADVENTITJOUS SOUNDS.
The anscultiitory sonnrls wliich we have thns far been studying are
Buch as miiy be obiitineii, in more or less perfection, over the healthy
chest. Certain accidental or adventitioua sonnds occur only in disease.
These may acconipuny normal sonnds or take their place, and will vary
according to their origin. Those produciKl within the lungs are called
rdlefi or nmchi; tlioae upon the pleural surfaces are '.emied frtctiun
sounds.
Rales. — Rdles are na numerous and as different in variety as the
shades of color, but they may be grouped into a few distinct classes,
which are generally L-apuble of some peculiar iuterpretntion. All of thera
are either dry or moist; hence we may group the different soands under
one of these heads, according to peculiarities in their pitch and quality,
as shown below:
B&les.
or rhooehi,
Dry.
Moist.
Sanon>iiK rAles.
Sibilant r&les.
Mucous r&1» tlargB and small).
Suhci-epiUint rAles.
Crepitant riil*»s.
Gurgles (lurgfc and small).
Miirous click.
Rdles may originate in the larynx, trachea, bronchial tubes, air
cles, or in any cavity connected with the brnnchial tubes. They are pro-'
ducetl by various conditioTis which interfere with the passage of air
through the tubes and into the air Tcsiclee, and may be heard in inspi-
ration or expiration, or during both portions of the respiratory act.
Dry k.Iles 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 rnkx are nsually 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 aonnd which can be scarcely recognized to one which may be heard at
ADVENTITUiUS SOUNDS.
49
ice from the cheet, and their pitch is alwayu low. They nmy be
beard during both inspimtion and exptrution, but are most frequent ia
expiration. They wu produced in bronchial tubes esccc^ling one-eighth
of AD inch in diameter. They are caused by the vibrations of viscid
mucus ur by a fold of mucous membrane^ or by anything which con-
BtricU the calibre of the tube, iis pressure upon its cxtcrnul surfuco by
tuinore, bin<l8 of cicatriciMl tissue resuUiiig from former diseiises, or
coDinction of the circular muscuhir tihres causing a uniform narronring
of die tube (Fig. 17). These soundfi nre not removed by coughing, un-
lea ttust'd by tenacious mucus adhering to the side of the bronchial
lobe. Though in Ihc great majority of instances after coughing or
■fterdeep inspiration an individual rule may disappear, other nUes will
remain in some portion of (be chest. This sign ia obtained in greatest
• SoDoroui rilM
Snlonpllant rUes ■
Iboota rAlM..
■Slbllui rilM.
CraplUatrAlM.
FM. 17.— Bhokchui. Kii-n, l>Ry axo Hoiar. um SvacRKpiTurr RXun.
penection In the early stages of actiie bronrhitis and in a&thma. It is
also heard iii some cases of chronii: bronchttiitf occasiuually in phthisis,
and rarely in pneumonia, iM^ing in theso latter instances associated vith
other adventitious soandtt.
When obtained in phthisis, the dry rtiles are few in number and are
:iated with moist rales.
In the early stage of asthma, sonorous nllee may be heard in great
imbers over the entire chest.
Siftifnnf riihfi occur both in inspiration and in expiration, bnt are
heard mostly m inspiration. They are not so intense as the sonorous
Their pitch it! high, and in qaality they vary almost as much
>rous n'lles, being sonietimt!s wiiistling, sometimes hissing, and
sometimes almost creaking. They are caused in the smaller bronchial
tabes by the same conditions which give rise to rales in the larger bron-
chi (Fig. 17).
They are heard most frequently and abundantly in agthma and in
fiO
PHYSICAL DIAUNOSia.
capiUart/ hromhiti/t. In ordinary acute bronchitis they may bo lieardj
tboDgh iu limited nomberii.
Sibilant i-Ales are hearil ocouivaaUy tu phtbiaia, due ttieu to loculuKtl bron-
chitis or tu tubercttlur tW]K>siU. Tlicy are suiiii.*li)iK's, lhoiij;b itoL uiWn, buui-d
in pneuinoniu. Occusiouatlv, even in healtby or apiiaifiitlv lieallliy clursts, wo
Diay hear txvo or lUrcc of thew fine souodit ii«ar the bonlei-a of ihe liiug«.
Sibilant riiles may be altered, but tliey are seldoni removed by caugh,-
ing or by forced in8piniiii>]i.
Mol»T RALES are groni>od aa mncous, large and small, sabcrepitaitt
and crepitant, according to their characteristics.
Minous rdfe9,aho produced in the bronchial tubes, are large or smaU
according to the size of the tubes, and are caused by air bubbling
through fluid — niucuii, pus, 8er\im, or blood (Fig. 17). If the bubbling
bap{>cn to be iu u large bronchus, we get a largo, coai-se, mucous rale;
if in a smaller bronchus, the rale is much finer.
These niles are hriird during both tnajiimiion and expiration, and
Tary greatly in intensity. Sometimpa, like sonorous nilcs, tliey tn.iy be
hejrd at a distance from the chest ; they are at other times lundly i.ndi-
ble. Their pitch depends upon the condition of the surrounding lung
tissue. In simple inflammation of the niuouus membrane, the riiles are
luw pitched; but when consolidation surrounds the bronchial tubes, as
in pneumonia and in phthisii^, the pitch is high. These sounds are ob>
taiueil in greatest perfection in rfiruin'c hrtmchitis, but may be heard
in acute bronchitis after the dry 8taj;e has passed. They are present
in greater or less degree in nearly all cases of cnnxumpihni, in the third
gfny nf pneumoititif iiatX in pnlm'ninri} tfdeimt, trnd are humorous when
hi'inurrhfKjr has taken plaee into the bronchial luben until coagiihition
occurs. In phthisis they are found over a limited ^psce, due somo-
timea to associated bronchiiis> 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.
Siibcirj>it(tnl rtVea are moist sounds, which are prodnceil in the very
fine bronchial tubes, probably In the ultimate brouchi and lliuse a size
larger (Fig. IT). They are rauseil by air bubbling through fluid, and
may l>e hejird during either or both portions ot the respirator)' act, bat
are most fre<jnently heanl with insjiiration. They are of companitirely
feeble intensity, vary in piteh acconling to the condition of the surround*
ing tissue, and arc distinctly moist and crepitating or crackling in
quality.
Those rdles may be heard moat perfectly in rnfnllrtrtj hnmrhHis and
the third xtnge ofpneuuinnia. They are often found in asthma shortly
alter the paroxysm. They are present in conrfpsllon of the htw/, purn-
lont hroHchifiu, and pulmonary oedema, and are found over a limiced por-
ADVENTITIOUS SOUNDS.
01
*MXi of the lung in tnuuy cuses of jihtbisii^. They ocanr in brow^n indu-
ration of the lungs, and ure hciml after hemorrhage into the Bmallcr
bronchml tul*^, limited to the position of the huniorrhuge.
The Biilicrepitjint rale, due to circumscribe*! oiiiillary bronchitiB, U
a sign of great value in the early diagntittig of phthisis, in which it may
uf tun be found at the a{>ex of the lung before any other Bif^na can be
delected.
7'he rrfjiitani rdle is largely like the subcrepitaiit, bnt diflerB frxim
the latter in two rt-specta: it is not so moist or liquid in chnractor, ao
that it is sometimes dusked as a dry nile; an<I 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
■ouud produced by throwing salt ui>on a fire.
These rules are produced in the resiclee, iiiterceilular spaces, and
oltlmuLe bronchi (Fig. K). There are two hypotheses m to their
mode of production: one is that they are caused by ntr bubbling
tfaroogh fluid within the air vesicle, juat as mucous r.iles are produced
in the bronchial tubes; the other, that they are due to the sciwiralion of
llio agglutinated surfaces of the capillary tubes or of the air vesicles.
Which of llieye if true, or whether both are in part correct, has not been
decided, T(i nie they seem to be produced by sej>anition of the sticky
surfaces of the air vesicles, and the capillary hrunclii. In some cases of
pneumonii), for instance when associated with inflammatory rheumatism,
DO crepitant rdle can be obtained whicli may he accounted for by slight
Tueidity of the inflammatory lymph; for if the sounds were produced
liy air bubbling through fluidj they would occur regardless of the nature
of tliut fluid.
Ctwpitant Hllc^ are much morv nunierotis than tbo 8ii1>ci'v|Mlant. In listen-
tnf; to Bi(bci>'pii.'nit iAIt»s. »c ^cldnni spt>iii to tieni* murt? xUnn \i-u or fifliTn at
one* ; tvlnfreas willi tlie crupitatit rAlt* we seem to heiir a Imndi-fMl or moi-c with
«ttcli inspiration.
Crepitant rflles are obtained in perfection in the eaHy atatfe nf puev-
wH'mift. of which they are considered diagnostic. This Hti\^o lasts but a
Jew houre>: consequently in many cases of inflammation of the lung the
hUea hiive disnp|ieared before we see the patient.
A few crepiliiiil nilcs are ^tnielimes heard in congestion of the lung
'and in pulmonari' n>dema, and they are frequently found in phthisis,
in a small zone around the consolidation. In this latter case they seem
to n^ttlt from gradual extension of the pneumonitis, which often pre-
oetU*s tiilrercular deposit.
Crepitant rAlcs.snbcrcpitant rille8,and friction sounds arc sometimes
'so much alike that it is ditiicult to distinguish between them. If dry
crepitating sounds are numerous and heard only on inspiration, they
are crepitant nUes; but if dry crepitating sounds are few in num1)er and
PUrSlCAL niAtJNOiilS.
are heard in expiration or in both inspiralioii and oxpimtiou, they are
likely to be friction sounds. Subcrcpituiit riiles arc more moist and not
ne:irly ho numerous as crepitant nllcs, uud thuyaro usually hoiird in both
inspiration and uxpirutiou. The moist cliaraetor, the number^ and iho Liiuo
of occurrence of subcrepitant riUes witl enable ue to distinguish Lheiu
from the crepitant; and their deeper seat and their cionstiincy will nsu-
tklly emible us to distinguish them from tine Irictiuu tiounds — which are
still fewer in number — even when the latter are moist in character.
Crepitant n'llea are not much uiTt'etod by cough or forced rcspinitiou
wlien due to pneuinoniii, hut In nthur instances two or three full inspi-
rations will frequently dispel theui.
Exceptional.— Either oiP|)ilant or siibcropitant rAles may be someti.niM
licought out direclly after coiighinjj whew they ven absent a inoiiipiit pn*.
vlousJy. A tuntnd closely re-wmblins' tlie MiWri^pitant or tliR civpitjint rille mat
frequently be obtained owr ilit? tliiti border of the lifuiithy lung-; in these in-
8taac«s, unly a. ft^w oC the rales are beard, und tliey dUiappear after three or four
forced ioiipt rations.
GuBULKS rojiomble lar;fe mucous rdles, but aro generally higher in
pitch and possess a hollow metallic quality; though occurring during
hoth portions of the respiratory act, tliey aro most frequent in inspira-
tion. They are produced by air bubbling through fluid in cavities wliich
communiimto with the bronchial tuWs (Kig. 10). If cavities are com-
pletely filled with flnid or entirely empty, or if the level of the fluid
does not reacli above the opening of tli« bronchial tube, no gurgles will
bo producttd. These soiimls aro largo or small, according to the size of
the cavity in which they are produced.
This sign is usually indicative ot phlhinii, but may occur in any pul-
monary disease which causes excavations.
The siucora click resembles an isolated atibcrepitant rtlle, and is
heard during inspiration only. The sign generally consists of n singlo
click, or, at most, of two or tbrec clicks. It is a sharp crackling or
clicking sound, supposed to be produced in the smaller bronchial tuboi
by sudden se]mration of their agglutinated surfaces during inspiration;
it is not usunlly affected by cou;;h. Wlu-n heard over the a)'cx of one
lung, it is a *ign of L'onsiderable value in the early diagnosis of phOitjnn,
Such sounds are sometimes heard over a considerable portion of the
lung in acute tnfM^rrnhm.t, in extensiveMro«iV7>w(»MWOMtff, or in the later
stages of intcr^ititial f.r ratarrhol puenmonta.
Frictios Sounds. — Fi*iction eonuds are produced by rubbing to-
gether of the two pleural surfaces, which are either dry from diminu-
tion ol their natural aecretions or roughened by exudation of inflamma-
tory lymph (Fig. 18). These sounds are grazing, rubbing, grating, ra8i>-
ing, or crejiking in character: sonietimes dry. sometimes moist. They
may be simulated by rubbing the b:i(;k of the hand, while listening with
the stethoscope on its palm, or by rubbing the fingers on the iutegnment
ADVENTITIOUS SOUNDS.
69
»hen auacnltating the chost. They are usually fow in number and
transitory, being beurd for a few respiratious, and then disjippouring to
return again in a few minutes; thpy miiy be heunl just at the eiul of
inspimtion or at the beginning of expiration. This is thi- characteristic
sign of pleurisy. The gmzing friction soumi is only heard in tho be-
ginniog of the inflammation, and can be detected most frequently in the
circnmacribed pluurisv accompanying phthisis. Some one of the other
Tarietios, of whicli the quality is of no importanro, may be hoard iu the
first and third stigea of pleurisy. Care must always he taken nut to mis-
take for this sign the sounds produced by cnickling of the hairs beneath
the instrument, or by the rubbing of the slothoscope, the fingers, or the
THcMon.
PHldvot rMptnOory
oturmur uid iIuIbhu.
'^
f^
■sm.
rnspmiorr •outKis.f '
Tta. IBl— AcPTi PucTRHY. Tho upper partor the (uiiBiBlnji normal con'trtlon.oriheslroelto
■UghUrdlMMided, Tho k>w«T imrt of tlM lung la [wrtiaJly collapoML Tti<> uirper curtac*- uf Uie
llrid Is aot borisootal, but kt cootoi-ms luon or ka iNTfi>ctl; u> tlM> imtural ouUluv of ilie lung.
tlothingou the eurfaco, or of the clothing or fingers nn the iriBtrument.
Bounds closely rcBembliug the friction murmur aire often heard over the
false ribs in a healtliy cheat. They seem to be produced by slight
moveiuents of the shiu beneath the rim of the stethoscope.
Cnakimj or rrutHjtUmj sound«i are sometimes obtained over tho chest,
the Bigniticaiion of which is not ftilly nndcrstoocl. The creaking sounds
are most frequently heard at the lower part of the tliorax. and lUf siiji-
posed to bo due to old plt-uritie adhesions. Hoth creaking or craekling
and crumpliiig sounds are sometimes obtained orer the upjier portion
of the chest. The crumpling sounds which are heard in inspinition re-
senililo those M'hich may be produced by inflating a dried bladder, and
are supposed to be produced from similar onuses; that is^ the inflation
64 PHYSICAL BTAONOSIS.
of dry emphveematons air cells. Thompaou considers these sounds Jtt-
dicative of sypliilitic diseiise of the lungH. Vi'beu confiued to the apex,
they are nearly nlwaya nasocintt'd with phthisis.
Metallic; TiNKLiNfi is a clear, gilrery, tinkling sonnd, like that pro-
duced by dropping n pin into a glass. It seems to bo caused by the
fjilliiig of u drop of fluid from the upper part of a large cavity ou the
siirfjiee of fluid Iwlow. It can 8onietim*'a bo heiird over one entire si<3e,
but it is usually moei distinct ou a level witli the nipple. When llio
proper conditions are present within tlie chest — that is, a large cavity
contaiuiug uir and Huid — it may be produced by any a^t«tion, such, for
example, as sptviking, coughing, deep inspiration, or occnBioually by the
act of HwaHowing. The sign occurs most frefiuenily in the pleural cav-
ity in pneumo-hydrothonix; but in exfcptionul instances it is produced
in very largt) pulmonary cavities. A t^niiiid very eimilrtr to this may
sometimes be heard over the stomach when diet^uded with gas.
VOCAL HOUNDS.
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 speaking, an
indistinct, distant.and ninttled sound will be heard, termed normal vnonl
nmoiifince. It is due to the fact that sonnds produced in the larynx iire
transmitted not only outward througlj tlie month, but also downward
through evciy branch of the bronchial tree. Vocal re^orijince, like moat
of the other pulmonary sounds, varies greatly in different healthy indi-
viduals and in different portions of the same chest. If a person has a
low-pitchwl 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 (Turning from the mouthy and it is better to have the patient
count one, two, three, than to ask him questions and listen for the an-
swers. Ky the hitter course the examiner's attention is distracted from
the sounds within the chest iu the attempt to catch the piitient's reply.
The varieties of vocal resonance which may be heard o^*er different re»
gions of the normal chest are named from the piirts in which they are
produced; over the larynx and trachea we Imve laryngejil and traclieul
resonance; over the bronchial tubes, bronchial resonance; and over uir
vesicles, the normal vesicular or, as it is usually termed, normal vocal
resonance.
LAltTKAopHON'V 18 the vocal resonance obtained over the larynx, and
TnAcnEOf'iloN'V that obtained over the trachea. In these varieties the
words are imperfectly artirnliited, but the voicii is tmnsmitted to the
ear ** with a force and intensity almost painful.'' The sounds are con*
A
VOCAL SOUNDS.
55
rvDtrated or, in otber words, seem to be produced witliiu a small area
irami'«Iuttel y bciivuth the litetho&cope, and necessarily vary in pitcli with
the jillch of iho iudividimra voice.
XoUMAL iiROXcuopnoXT is obtftined while the person is apeuking,
by lieleuiiig oNt-r tlie broncliinl tubes, near the border of the sternum
from the first to thu third rib, ur more espeeially directly over the main
bn:>nehi on a level with the t«ecoud costid cartilages in front, or on ii level
with the fourth dorsal vertebra in the inter-scftpular region. Tliis
occopiea u position midwiiy between normal vocal resonance and luryr.-
gophony. The eounde thus obtaine*! are transniitted to the ear with
coneiderable intensity, thougli with miifh less force than over the larynx;
they appear to bo produced immediately beneath the etethoscope, but
the -words seem very imperfectly articulated. Whenever this sign is ob-
tained uver any other portion of the chest, it indicates consolidation of
the pnlmouary parenchyma.
NoBiiAL VOCAL RESOSANCE 16 obtained by listening to the voice over
,e vehicular portions of the Iniig. This sound, liaviug no ajtproacb to
ieulatiun, is di>it.int and diiTused, seeming to come from the deejier
portions of the Inng two or three inches beneath the sarface. As a
rtile, vocal resonance is always more intense upon the right side ihan,
upon the left, especially in the iufra-clavicular regions.
Bxteptional. — ^la a fenr instances over Uie right apex, even in liealth, the
re«ooance very naaily approaolies broncltophony. I( the foiindit havo this
chanu-ter upoD tnith sides, as lliey have la mre iostaaces, they will be found
mofttinlen&u upon the right side, but higlt«r in pilch on the lett — a disparity
due U> the difference in c;Uibre of tlic br<mcliial tubvn ; tlio»e upon tbe n^cUl siile
btttn^the larger niusl net.'esvarily ^ive the mom iuteose au*! luwer-pitcbcd 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
^oa; be cither diminished or increased.
K
Diminished. •[ Vocal sounds feeble or supprewed.
Increased.
Vocal sounds exaggei-utcd.
Resonance whicb 'fi termed bronchophony.
■ '* " (e^opbuuy.
*• ** pectoriloquy.
" " " amphoric voice.
'DrMixisHEn H7.<?0KANCE. — T)innniHhed resonance is usually due to
mncb the same canses as the diminished respiratory murmnr; that is,
eepuratlon of tbe pulmonary from the costal pleura by air or flnid, as in
pneumothorax or pleurisy. It also occitrs in cases of extreme i-Hf/iA/yw mo,
in jiulmontirif eedema, in bromhilis with free secretion, and occasionally
where there is extreme puhuonnri/ cutufoUdaliotu
M
PHTBICAL DIAUJfOSIS.
The Tocal sounds are niofitly Bupprosscd over fluid in the pleural sac;
but just libuve ihu level of the fluid the uir cells are [uirtiully eollapsed^
BO that vocal resonance h increased. For an inch or an inch and n half
below the level of the fluid the resunance is dimJuiAlied in intensity, and
A little lower it ia nwirly suppressed. TUlih we are able to ascertaia
the height of the fluid by means of the vocal resouunue as well as by
percussion.
This sign is principally of value in the diagnosis of pleuritic effusion,
by ennbling us to distinguish bi^tween it und CDnsoIldation of the lower
part of the lung.
Exceptionat.—ln some cases the vocoJ resocance may be lieard disLincUy alt
over the pleunlic elTusion, lliuiij;li llie (>outiJs ure dtstuut und iiioro ur \<^s* muffled,
iNcriBASEi) Vocal Resoxance. — Exaggerated vocal resonance differs
from the normal voice-sounds simply in its intensity. This sign de-
notes more or less consolidation of the lung tissue or coihipse of the air
vesicles, and ia usually iissoeiated witli broucho-vcsiculur respiration.
It is a sign of considerable impdrtanrp in the diagnosis of the early
stage of phthisis and in discriminating between pneumonia and pleurisy.
ExcejHivtial. — lu very run* caiws llie vocal resouuiice u exaggerated in pueu-
motltomx and in cniphy&fiiia,
Bronchoi'Hoky, as already noted, consists of more or loss intense vocal
pounds, usually imperfectly articulated, which have a itccujiar degree of
concentration, or, iu other words, seem to be produced immediately be-
neath the stethoscope, instead of coming from the deeper ]>urtions of
the lung. The intensity of this sign, which may be greater or less than
that of normal rcsunanuc, is an unimj)ortunt element; so also is the dis*
tinotness of articulation. Its recognition depends chiefly on tlie chorao
terislic concentration.
The significance of bronchophony depends upon iU location. If
board over the main bronchial tubes, it may be simply u healthy sound;
but if heard over vesicular j)ortions of the lungs, it is indicative of
COQsolidiition. It Is usually associated with a tubular resjunitory mur-
mur; but as it oci^urs with a less amount of consolidation than is nece»-
Barv- far true bronchial breathing, it may frequently be obtained with
broncho- vesicular respiration.
Exceptional. — Bronchophony ain.illy poMeeses the dtarax^tcristic coQcontra-
fion : but wi-ln^n Uie coiisolidat«!d lun^ is 8ei>arat«d from Uie chest wall by fluid,
it uiuy Kuuud distuiit.
This sign is of special Tolue in the diagnosis of the second stage of
pneumonia (Fig. 37). It is seldom obtained perfectly in phthisis,
because in this disettse consolidation, is nut usually complete.
Krw^ffoual.-^Bronchophony ftt occAsionally otttained fa narcinoma of (he
iung, though usually tlita diaeaso involves Um whole tissue, air vesicles and brou-
VOCAL sov^'oa.
37
ctilml tubcM alike, or It crowds the pulmoniu-y tUsue before it, thus IiindeH ng tlie
transmission of tlie voici;. But when ttie uir vusiclei uJoae nre lllled and the
broncliial tubes rtiiuain patent, vjt ocelli's in i-ure cases, bi-unchoithuny may be ob-
tauoed. It in aino present in liumorrliagic infarctioits which fill the air vuiolea
but tvave the brondiiai tubes oi>cu, and may therefore be a si^n ia pulinotiaiy
>£aoruoyY is a variety of bronchophony. It is u tremulous sound
which ImB been eomjNtre^ to the blfiitirig of a goat; hence the name.
Ijike bronchophony, it conveys to the listening ear the impression of
haviug boen produced within a very limited portion of the long; unliko
the lattor, it i>eeins to come up from a considemblc depth, and to trem-
hlti about the end uf the i)tetbosco{>e. Wlien present, it may be most
resdily obtained in the inter<Hcapnltir or uxillarv regions. This sound
t« generally iimluced in coiiMuliduted lung tissue nhicb is septiratcd.
trom the chest wjill by a tliin layer of lluid. Jt is a sign ot phitro-pnen'
v\OMi(t — that is, pnc'utnonia and pUnirisy with ettusion; but even in this
'lieease it is present only a short time, and is a sign of little value.
Egophony is most frequently produced when the pleural cavity is about
luilf Glled with fluid.
In ordinary pleuritic effusions, the lung just above the surface of tho
llnid is more or less solidified by collapse uf a jwrtion of the air vesicles;
under such circumstances regophony may bo produrcd providing tho
pleura-)ii)lmoni\lis and the pleuni-costalis are agglutimiteU just above
the collapsed lung.
Pectoiiiloquy differs from bronchophony in that the articulated
speech is more completely Iransmitttid. In broneliojihony the voice ia
lieard, 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 tar like bronchophony, but
arc heard over a consJdenible portion of the lung; and another in which
the sign is conBned to a limited spiice and has not the degree of concen*
tration found in bronchopliony. The first of these, which is high in
pitch and cbinging or metallic in quality, is frequently produced by sim-
ple consolidation of lung tissue. The second, whieli is low in pitch and
softer in quality, is always a trnstworthy sign of a pulmonary cavity
with smooth walls and a largo opening into n bronchtiil tube. Well-
deGncd pectorilminy is not a frequent sign, but when heard the first
variety is a sign of pUthistM or pneHinunUi, and the second of any of tho^e
diseases which cause vomicae, viz., phlhisigj pulvmnary alKicess or jraw-
grttU!fM%Ci brQiichierlasix.
Ampuosic voice is hollow and more or less musical iu character.
The musieul quality follows tho voice and is termed the amphoric echo.
The words are not articulated, as in pectoriloquy. This sign occurs
tindor the samo conditions as am[>horic respinLtiun and amphorio per*
cuMioii resonance; that is, over the pleural sac when containing air iui43
58
PHYSICAJ. DIAGA^OSIS.
commuuicattng freely witk a bronchial tube, uad over very large cavities
in the lungs.
Excvptional. — There ure j^ooit ivaaotis for belie\*ingr t!iat, in rar* cASttf »m-
plioric voice, as wdII o-s Liiiiplvoric iY^ft|iinLtion, may be beai-d over a layer of air
in the pleura) cavity wliicli cIo««t not commanicate with the bronchial tubes.
Amphoric voice is » sign ot jnteumo-hydrothunuy in which disease it
is associated with tympimilic resonance over the upper part of the che^t,
and ordinarily with the sueeussion sound. K'the latter sifrna arc absent,
the amphoric voice is probably produced ill a phthisical cavity.
Whisi'ERIXr Vocaj- Resoxaxce. — Flint describod the whisper reso-
nance witli ounsiik'rable niiuuteue&s. He considered the signs which it
furniithes of equal value with those from a loud voice; I find them uf
even greater importance.
Thk nokuai, uhon'CUIal tvniiiPERisa term applied to sounds of
a blowing or tulmltir chanicter, very closely resembling the sound of
forced respiration, heard in listening over the upper portion of the chest
when a penon is siteakiug in a sharp whisper. It4 modifications by
disease are classified as exaggcrate^il bronchial whisper, whi.tpcring bron-
chophony, cavernous whisper, whispering pectoriloquy, and aniphorio
whisper.
ExAOGERATED BRONcniAL WHISPER is more intense and higher in
pitch than the normal sound. It is pruduced in lungs which arc slightly
solidified.
Whisi'ER1s« iJKOscnoPiiONT is higher in pitch and more intense
and blowing than the preceding. It has the same characteristic concen-
tration and nearness to the car \\» bronchophony with the loud voice.
It may be obtained over lungs so slightly solidifiei] as to yiuld only ex-
aggerated vocal resonance Mhen the patient is sjteiiking aloud; therefore
it cjin be appreciate*! sooner than bronchophony with the loud voices
This (act renders whispering bronchophony a moat important sign in
the early stage of phthisis.
The cavernous whisper is a low-pitche<l, blowing sound, confined
to a limited portion of the cheet. It is produceil within pulmonary
cavities under the same uonditiuns us cavernous respiration. This sign
is principally of value in the diagnosis of phtlnRis.
WiiiriPEiaxo PECTORiLOQiiy differs from whispering br-onchophony
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.
AsiPHiiKic WH16PER occurs Under the same conditions as tho am-
phoric voice or amphoric resonance on i>ercuBsiou; that is, over the
pleural sao filled with air, or over very large cavities in the lung tissue.
Aphonic jtecloriloquy is a term which has been applied to the voice sounds
when th^ patieiil is Mpt^nkin^ in a low tunc. It has been stated that th^e
sounds caa be distiocUy heard Dot ouly over coasolidated or coUup»ed lung^
bat also even when the oritan Ln this condition is geparated from tbe thomcic
wall bv u collection of air or Ji<rrtii>i : however, these vihnitiotiK are not conducted
through jj«*. By studying I hi:* vuriely ot voeul rt'souiim-'e, it is clainieil that
may determine whether pleural ptTusions are of a serous or of n. purulent
character. I have been able to verify this statement in u Tow caites, but aoi in alL
TrssivB Sios s. — The reaonance of cough may Hometimes be stodied
with advantage, especiiilly in childron. Tlic act of coughing is often ol
special value in dislodging obstrnctions in the bronchial tube^ or ptil-
monury cavities, nnd also in causing u subsequent deep inspiration which
I will freely inflate the air cells, thus bringing out signs which might
^K4)therwi>te bo overlooked. Tbe ditlerent viirit<tie8 of cough are classified
^^mth laryngeal^ bronchial, oavernons, and amphoric.
W Labtkmbal cough is usually more or less hacking in char&o-
I tfir, and often spasmodic. [L is indicative of larytigitis.
I BROKcutAL rorr.H is quick, harsh, and bniasy. It is accompanied
I by a thrill or fremitus, and if severe is nearly always attended vith pain
^^a beneath the sternum or along the Inferior ribs, corresponding to tbe
^^P attachment of the diaphragm. It is generally indic-ative of bronchitis.
Cavernol'8 col'uh is produceil under the same circumstances as
cavernous respiration, and ia generally associated with gurgles. It baa
a hollow quality and is usually very intense.
Amphoric coron is more musical and hollow in quality, isgeneniUy
lower in pitch, and seems to penctnUo t)ie car witli less force than the
cavernous. It is heard over very large pulmonary cavities or over the
pleura when filled with air.
Sometimes largo pnlmonarycaritieeare traversed bytrabecnlte which
yield a peculiar twang when the patient coughs. This is of special
Talue, as these strings prevent cavernous or amphoric vaice>sounds.
Tussive signs are usually, though not always, transmitted through
consolidated lung, but seldom through collections of fluid.
We may obtain considerable information about the condition of the
lungs in children who cannot be induced to speak by studying tlte cry,
which ia subject to the same variations as vocal resoounce in adults.
CHAPTER T.
PULMONARY DISEASES.
PLEURISY OR PLEURITIS.
Pleurisy consists of an inflammation, more or leee extensive, of the
seroua mcmbrano covering the lungs and lining the thorucic walls.
There are three recognized varieties of this disease: the acute, aabacate,
aud uUrouic or suppurullve, tUso culled empycuia.
Anatomical and Patuolooical Cuauacteristics. — There is first
hyperwmift and reddt^ning ut the pleura with Urjiiesii from checking of
its normal secretion, tlieie is swelling from tnui'^udution of serum into the
perivAScular spaces, and multipliciition of connective-tissue culls vritb
loss of the normal glistening of the pleund surface due to degenerattoa
and exfoliation of superficial endothelial cells. Then follow exudation
of iuflaaimatory lymph uud Lfluslon of scrum to a greater or less extent;
the foniier clinging to the pleural liurfaoe presentji a rough, sbaggj
HppearHuct-; the latter gravitating tv the lowest part of tin- pleural sue,
UKually holds in suspension shreds of fibrin, leucocytes, and endolheliiil
cells. Thickening of thu serous membrane results from muItiplieatioDy
in it and iu the fibrous exudate, of new conncctive-lissu» cells; these
mature, ni^vr bluud-vetssels furni, making couuectiun with the original
vessels of the pleura, and organization of the exudate is the result.
Adhesions more or less extensive may form betwoeu opposing pleural
sarfoces, which become bound together closely by the plastic organiza-
tion, or more loosely by fibrous bands and false luenibrnnes.
Thejileural surface early in the inflammation may present irregular
spots of ecchymosis surrounded by the more dJtfused redness; later,
whitish spots of fibrous organization appear on the free surface. The
effused aernm 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
albuRien, and coagulates readily u|>ou exposure. In iUt'se respects it
differs from the fluid of hydtuUturax, which cuiitHini> but one per cent of
albumen, its specitic gravity being below 1,015. Tho amount of fluid
varies; iu acute pluurisy, it is nut utiually great, seldom occupying more
than one-third or at most one-half of the pleural sac, and U 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 iu acute pleurisy.
ACUTE PLEURISY.
ex
The proceases of pleuritic inflammation vary with the unuses aud
■everity of the ul!cction. The effusion takes its chnracterfrum the preg-
anco of serum, fibrin, endothelial eolls, blood, uiid pus in vwryiux quantity
nnd variously combtuud. The products of iDtUtniuiAtiuu. in mild rueeB
may be chiefly fibrinous with little or no serous effusion; hence Lhe so-
called plastic or dry pleurisy. M fibrinous exudute and pleural thiek-
«niiig i»re marked and serous effusion is copious, wo have the s^ro-M'nn-
aiiJi form. If infective innamniation ocnnr pus results, imil we CidI it
rinfit/rrna. The purulent uccumuliition in these cases swarms with the
clmructeristic streptococci ami staphylococci of stippumtion, und iu
some instances the so^4dlcd diplooooci of pneumonia and biicilli of
tultcrculoflis may bo fonod, though they are difficult of deinoustrutiou.
Hemurrhugic pkurisy occasionally conipHcates purpura hemorrhagica,
can<t*r, scorbutu?, mid tubt-milosifl, or may result from the lighting up
of * new iuflainnmtion in an old pleurttit<.
Seroufl pleuritic effusions after remaining for a time are usually
gruduidly absorbed, lint ]mrnlent accumulations never to any great ux-
ItMil. In tlie latter the lluid temls to perforate the surrounding wall
«itber to ap^jcar externally or to empty itself into an adjacent cavity or
»rgaii. The solid portion of an effusion may be absorbed after under*
^uiug fatty metamorphosis, but not infrequently, sooner or later it be-
comes the seat of tubercular degeneration; or it mayWconie incupsiilated
ind remuin so for years; or it may be the seat of calcareous de|KH!itian.
L'ases ore reported in which the Hbro'us exudate covering an entire lung
liad been the site of such deposit. Asiilu from tht'^e characteristics of
fcn inflamed pleura, certain pathological conditions result from the
rffect of the process upon iidjneent structures. Inflammation usually
entond^i to the lung tisbue immediately beneath the pleura, giving riise
to exudation which uccliideii some of the alveoli. It may also by ex-
i«naiDu eaiise pericarditis. The plenritie effusion may be sufficient to
otusc complete collapse of thu corresponding lung.
The compressed lung, npon disappearance of the fluid, tends slowly to
re-exiKuid unless pressure has been too long eoutinuefl, in which cose car-
Tiiflcntionof the organ results, and it remains as a small, compact, leatherv
moss, II suitable nidus for subsequent dispose. Its comjilete expansion
in any case is apt to be limitml by the formation of cicatrieiul bandsi
,And the great vessels may suffer serious compression.
ACUTE PLEURIsr.
For convenience of description, acutt- pleurisy has been divided into
fear 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 tbc three stages of j>neumo-
sia, calling the first the dry stage; the second, the stage of effusion; the
third, the stage of absorption.
la
PULMONARY DISKABS8.
Etiology. — Acute pleurisy may be primary, or becoudary to some
other dieeu^.
PredixfMsin'j fViH.<fjr.— It occurs ni03t frequently in w-iiiier ami
spring, iu adtiitd rather thiui childrcu, aud attnekei preferably tlit- male
sex. MidiiutritioQ and poor hygieDio conditions furor iUs uecurrence.
Estitiny Vavses. — The uioat coninicn causes are exposure and rlieii-
matiam. In a weak person mental depresfnion may be an exciting caniio.
It may result from traumatism, €!vcn (»f alight character. It arises
not infrequently from pneumonia, phtliiaia, pulmonary infarction, ab-
aceBS, gangrene, or tumors; other cauium are fuuud in hemorrhage into
the pleural ravity, pt'rlcarditis, costal or vertebral caries, absri'ss of tlie
nicdiastiuuTn, [H-riti>nitis, and hydatids of the liver; also in infective i\U-
eases, Urlght's disease, pya;mia aud septicfemia.
SvMiTOMATor.oov. — The usual symptoms of this disease are: A sharp,
cutting paiu iu the side, aggravated by general and respiratory uiovo-
nients; rapid nnil hicoroplvfc hispiraiioH ; a aliort, di'y cough and a
hard, rapid pv he, with more or less distnrbauco of (he digestive organs.
Pain is especially severe on inspiratiou aud apt to be located ju^t l>e<
iieath the nip))Iti, though in children frequently it is less circttnisi'rilied.
It is a more constant symptom in adults, but variable in dunitton; it
usually diiniuishcs as the general pyrexia appears, or vrith the occurrence
of effusion.
The tcmpcTftlure is usually but slightly elevated the first day, 09'' or
100** F. in adults, but in children 102'' or 103'' F. In pleuritic effusiou'
of children, surface thermometry may reveal on the affected side Jiigher
temperature by one or tivo degrees, rising aud falliug with the increase
and decrease of the efTneion. AVhile iu very mild cases the subjective ■
symptoms may bo bo slight as to attract little or lo attention, in rare *
case-8 they may be so severe as to suggest pucuuioniu. Pleuritic synip-
tomtt are apt to be less marked iu the feeble ami cachectic. When a
largo effusion occurs, nausea and vomiting are frequently present aud
(]yapn(i->a becomes a prominent symptom.
The most imfwrtant ;ft>//i5 of jileurisy are: short and catchinj? respi-
ration, friction fremitus on palpation, and friction sounds heard oa
auscultation. Over the collection of fluid after effusion has taken place,
there is flatness and loes of vocal fremitus and respiratory mnrmnr. Tho
upper line of flatness changes with the position of the patient (Fig. 18).
In the Jjri>t ntnt/e we have in the beginning simply dryneas of the
plenra, and ehortly afterward an exudation of inflammatory lymph.
liy inspection we obaeT%*e 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-
coitnl iu'Miral!.ria and in pleurodynia may l>e found similar muvemeuts.
patient is sitting or in a aomi-recurobent position, his body
Yfn be indined tovud the mffecied side. If reonmheat, h« u Uk«]T to
be lying on the anaifected side.
OocadbnaUT, e^iecullv io childiva. the patienl's effv-»ns to iw^iniiit ibe nk^T*-
~ at the affected skie result in t«iupo(miT spinal curvature t^^m-aixi tliat skK
On palpation, no signs irill be obtained in the early ]vtrt of thU
stage; but a little later friction fremitus may frequently bo detected,
and the Tocal fremitus may be found diminished. Pre^sui* usually
elicits deep-e^ted tenderness. Mensuration yields no additional $igns.
Percussion yields no signs at first; but vhen plastic exudation haa
taken place, dulness, in projwrtion to the amount of exudation, will
be elicited. The dulness i? always less marked at the end of forve*!
expiration than during normal respiration.
Auscultation early in this stage discovers a feeble respiratory mtir-
mnr with jerking or cog-wheel respiration, and in some instauoes,
just at the end of inspiration, a feeble, grazing friction sound. When
plastic exudation has taken place the respiratory sounds are still mor\'
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 nmy not be obUiinable except on congh or deep
inspiration, and will not be heanl if the inflammation is confiniHl to the
mediastinal or diaphragmatic pleura. At this stage the vocal resonanoo
is somewhat diminished.
In the second stage of pleurisy by inspection we still observe dimin-
fahed respiratory movements, but not the interrupted respiration noticed
in the lirst stage, perhaps also an apparent increase in size of tho
affected side; but sufficient fluid to dilate tho side of tho chest is excep-
tional in acute pleurisy.
In palpation the vocal fremitus is absent over the effusion. Itarely.
distinct fluctuation can be obtained. The apex beat of the hoiurt will
be found crowded to the right or left, according to the seat and amount
cf the effusion. If the pleurisy is upon tho loft side, tho heart is
crowded to the right; if upon the*right side, it is displaced in tlio oppo-
site direction.
Exceptional,— In very rare instances of serous effusion, the vocal frcniltuH in
not lost.
Percussion over the lower part of tho chest yields flutnesfl, extend-
ing upward to the surface of the fluid. Tho height of this surface ih
not altered by deep inspirations or forced expirations, but its relntions
are changed by alterations in the patient's position, unless the effusion
entirely fills the pleural sac or there are complete adhesions abovo its
surface.
Above the fluid the resonance is exaggerated, and in exceptional
cmses it may have a vesiculo-tympauitic or amphoric qtulity.
InvestigationB by Danioieean, of Paris, and more recently by the late
Dr. Ellis, of Bfwtoji, show th«t usually, when the pleural sac is no more
than one-fourth or onc-tUird filled, the upper surface of the Uuid corre-
sponds to a curved line knowQ as the letter S curve, termed by Ellis
the curved lino of flatness (Fig. 19).
O. M. Gurliind, in his monograph on rneiinio-dyuamics. describes
this curved line as folluws: " Its lowest point is found behind, near the
spinal column. From thia point it cnrves upward and outward across
the lateral region, where it is highest ; and from this point it jiroceeda
almost horizontally forward to the sternum," The experiments of
Garland demouistrate that, instead of a gradual rising of the fluid id
■ttrve; A, U,
Ci'RVBD LtiiK or PuTXiiM IK Plsdbibt, PoaTBiiiuK Vuiw (Uiiu.4)fD>. C. B, Lcttvr S
C, irtasRl* of dulMM.
the lower portion of the chest, carrying the lung above it. and main-
tuiniu^ a horizontal surface, as is usually supposed, iia upper line nearly
corresponds tu the natural outline of the base of the lung. This Is sup-
posed t-o be due to the elasticity of the lung, which holds the fluid in
this unnatural position. I refer thoao intcrcstod in this matter to Oar-
land's monogntph for a complete exj)osition of the Hubject.
If a line be drawn horizontally Ijjickward from the highest point of
tho curved lino of flatness in the latcnil region to the spinal column, a
flomewhat triangular spjtce will be loft butween it and the posterior p»rt
of the curved line of fljitness. Thi« space is ternieU by Oarland the
triangle of diihifM (Fig. 19). It is bounded l>elow and externally by tho
letter S cune, internally by the spinal column, imd above by a lino
drawn backwurd from the highest point of the curved line in the lateral
region. This superior boundary is not necessarily horizontal, but it
jirrr pif:rii*r.
65
mmT be so ctatBAtrtd for ibe akv of illiistnuon. In this trungular
■pttce ve hsTe oo fi&id. b=x tie 7«eoziuic« is :eii$ (has aVove i;. Thij
dalneu is dae :<• puml (x-nipresdos of the is::^ &pu::si ;he spinal
colnip"- In order W T^cc'gr.ixe ihe carriii line thiv^u^houi iis eiuire
extent, ve muft not c*L'ii:i«r« i^e aJected viih the so'j::d side pv^teri-
orlv, as it is not the distinciion tieiweea nesonanoe aiiu dalr.fss wh:*h
ve wish to obtain, bet the ui=tinet:*:.ii l-eiwe^n culness and £aice$«.
PeTtmseion should be m»>ie in perpendioclir lines at several placeis.
either from above downward or from below upward. By ihis mt'thod,
we easily distingnish between the dalness over the compressed lung and
the flatness over the fluid, and Wtween the chaRioter of the resonance
in these positions and that of the lung above them. Failure to recc^-
nize the true character of the percussion note in these dlffervnt localities
Fio- so.— CrKTD Lm or Flat^km in Plctribt, Anterior View (.ELLnt.
•Btcrbtr Ttew.
I<ett«r S cum?.
has caused authors to describe the appt-r surfuee of thr fluid ns corre-
sponding to a horizontal line. If we recollect that the fluid in the
pleural sac conforms itself more or less perfectly to the niiturnl contour
of the base of the lung, we shall understiuul why the line docs not iimlcrgo
greater changes with alteration in the position of the puticnt. Suppose,
for instance, that we find the level of the fluid, in front, at the fiftli rib.
when the patient is in the erect position; upon causing liiui to lie on his
back, according to the genenilly accepted opinion, the line of flatness
should still remain horizontal, and would then he found running longi-
tudinally along the latenil region. In fact, however, this never occurs.
On the contrary, the line of flatness is not likely to he dei)rcssi'd in front
more than one or two inches by this change in the patient's position,
and it will bo found running more or less obliquely downward and
backward, instead of longitudinally.
When the pleural cavity is nearly fllled with flnid, we frequently get
tympanitic resonance over its apex, especially if the patient is recum-
5
... . ,,, ,^p|aiu thfe phenomenon, we are onco more
;^ «t:kteiiienta tliiil tvmpanitic resonance u
,U vtutL lb w high piloheU. t'riieulzcl — who bfliovea the
..uutitHJ 10 bo low ill pitch^iu givhig the rcHSoua (or IbU
oiu WiulrJoh ami Truube, wha cluim that the pitch in
i.tit i» tli<pi*nilent upon two t^lctneuts: fir^t, the volume
.... p»»int pon.'u8sed; second, the tension of tho lung tis-
uUu that the pitch of tho percnssion Bonnd is directl}'
'..tio lit i\w tension and inversely proportionate to the tolume
;^Lillatliii{ oohinui of nir. lu other word^, u3 the lung i^ dimin-
wl tn vi>luuio tho pitch iamiHed; or as it again approaches the nor-
a\ h|ii<<, the piti'h Is lowered according to the amount of uir whicli it
iiilalh*; kihI i\b the tension of tiie Inng is increji«e<i tlie pileh is eli-vated.
'I'ltnrtiforo if Ihu dimination in volume which raises the pitch and the
illiiilmitluu in tuuBion which loweris the pitch be equally IjfllanccJ, the
pilt'h nill remain unaltered. It therefore follows tiiut in moderately
Ui'Kii pleuritic efTuaioiia which yield tympanitic resouuuce in the infra-
rhivi(!ulur region, the diminution in tension (htc jfihh) must e:[eeed the
dlniiiiiition in volume {!n'ijh pitch). Flint, and f)a Costa (Medical Diag-
lioniii IS'.fO, p. 205), who consider tympanitic resonance to be of high
pitch, bttlieve that thia sign in ph-urisy is due in great part to tlio condncte<I
ri'Honanoe from the trachea and the bronchial tulles. Both of these
reasons may be in part correct, but,iis 1 pointed out in a oomniuuication
to the Chicago }fe<lical Journal and JCxnmintr, Marcii, 18^ I, it is more
than prol)able that this sign results mainly from u collection of watery
vapor above the fluid in thepleur.il sac. Va])Oriz:ttiou of water occurs even
Ht ft low terapcrutnre, but at a temperature of one hundred and one or
two degrees Fahrenheit, under ordinary pressure, it takes i>lace rapidly.
This process must therefore bo going on constantly when ttnid collects
in the pleunti cavities, and as soon as ttie serous surfaces bocDDie so
altered by inflammation that they are iumpuble of absorbing the vapor
as rapidly as it is formed, it will collect above the fluid until the tension
becomes sufliriont lu prevent its further formation. A cavity so formal,
filled with watery vapor, must yield tympjinitic resonance. I am con-
vinced of the correclneJiB of this tlieory by experiments not only with
fluids outside of the body, but also on patients with the pleural cavity
almost filled with fluid, and in whom when recumbent tympuuilic refi-
mutncc was plainly discernible, just lieneath the claWcle, while on ill-
version of the patient so that the bai<e of the chest was the highest,
tympanitic resonance would be found over a small area at the base of
the pleural sac.
I
I
Bie^uski (Schmidt's Jnhrhnch, Auirust, 1889) calls attention to a new B(gn of
right-«ided pk'uriHV ; mcreo!»eO cardial- dulneM laterally appeani with effusion
6Ten in itiuall aniouDt, catued. Ik Uiinlu, bv ateleotaniis of tlie nitddle lobe of the
lung. 8u exposing more of t)ir> lieart, Tbi» idcreawnl dulncss u said to remain
[04- a year ur more alter absot-fttioD of Uie etTusiuD.
B)' auscultation the respiratory murmur above the level of tlie fluid
i» often found slightly cxaggeniied. The vesicular murmur ciuinot be
heard uver the ilul-i excepting in a small zoue ueiir its U])per level, where
ibosotinds are feebly transmitted from thu lungs. Over the fluid, vocal
n'ioiiauctj i^ either lust ur the voii;u-souiuls iire iudistiiict ami (listjint.
.Someiimes coiifolidjition uf the lower part of ihe lung euuges legoplionv
Tiear the upper Rurfane of the fluid. Often a few friction Bounds may
be beord in the same position, but none over the rest of the fluid.
[turiiirf Uu- third ifiii'je of pleurisy the signs denote gradual return to
hwlthy eundliion. Distention becomes less, respiratory movements
freer, and the voeal fremitus gradually appeiirs first at the upper
urLion of the ehest. The upper limit of the- liquid, as ascertuitie<l by
trra&sion, slowly fulls until tlte tluid is entirely absorbed. Sometimes,
rwlhe lower part of the chest, mure or lees dulness persists for a long
kime, or the resonance may not again become nurnial, uwing to the re-
aining inflammatory lymph or to thickening of the pleuni, which
^lD%y permanently aepamto the lung a sliort distance from the chest wall.
The respiratory sounds gmdually return, at first feeble and distant,
tiDt groning more distinct, until they finally become normal. Ocea-
tJoQaUy the respinitor}' sounds remain harsh and tubular in quullty. on
lUDt of the imperfect expansion of the air vesicles, and bronchial
ithing may remain near tlie vertebral column for some time, t'su-
SVf as the two surfaces of the pleura again come into contact, friction
waiidfiare obtained, which may continue for a short time only or for
eprrral months.
The heart and the abdominal orgims gradually return to their nor-
mal positions, us shown by percussion and auscultation.
in ioine rare coacs, howevor, wh^n tbe lieart is crowded to lite ri^ht of the
mill liy nil efliikiun into the left pletmil nnc. a()be!iion<t take place which i«r.
kdpntly retain the or^n in its al>iiorinul siluutiun. Sometimes the absorption
ta l»rge and luii>:^-i.'Oiilinued etTu.siuri in llio ri^bt &ac is fuHuwed by a pennanent
location of lb<! heart tu the rii^tit of tJic sternum, due tu thi> tetuk-ticy of the
nuTDundiri}; parta to fill theii|iace which should b« occupied by tlie unexpiuidsd
If the air vesiclps cannot fully expand, owing to the partial disnrgan-
tion of lung tissue from long-continued compression or because the
ig has been bound down by intlflmraatorj' adhesions, the chest may
again utuin its normal condition. There will be consequent loss of
>tion and retraction of the affected side, with more or less dulnesi
on percussion iind feeble or suppressed respiration. In the most pro-
tracted cises the ujiper portion of the lurj^ bt-comes oidy partially ex-
panded, and in this region there will be dulness upon percussion, with
I unLI1AV^14f
deficient vesicnlar murmnr and bronoho-resicitlar respiratory soands,
together Tith exaggerated vocal rosonance.
DiAONosis. — The essential points in the diagnosis of acute i)leunay
are: the iudistinct chills, the sharp pain in the side, friction frumitug
and murmura; flatuess on percussion with chaDgo in the lorcl of fluid
by changes m the patit-'nt'a position, with absence of vocal freniitng and
absence or great diminution in the iiiteusity of all respiratory and
Tocul signs over fluid effusions.
The differential diagnosis of pleurisy is usually easy, yot various dis-
eases have been mistaken for it. The affections liable to cause error in
diagnosis are pleurodynia, intercostal neuralgia, pericarditis, pneumonia,
phthisis, collapse of the lung duo to pressure on a main Ijronclius, can-
cer of the lung, aneurism of the aorta, and onlurgeinent of the liver or
spleen.
Pleurisy is only likely to be mistaken for jikurodynw or intercostal
neuralgia in the first stjigo of the acute variety, when the pain and con-
eeqnent impairment of the respiratory movements and murmur are the
same as in the latter affections. The distinction may be made by ro-
momboring that the paiu of pleurodynia is apt to be fugitive, shifting,
and often hilutcral, and is likely to be increased by slight pressure and
by muBciilar contractions. The pain in intercostal neuralgia is confined
to one, two, or three tender points along the course of the intercostal
nerves; the neuralgic diathesis is coumionly to he found in this ufffction
and fref|nently coincident uterine disease. On the other hand, the pain
in pleurisy is deep-sealed, and although there is tendomesa on pressure,
it ifl not fonfineil to isolated points along a nerve; and by nuFioultation
we deti-ct a friction sound wliiob is not obtained in pIeuro<h*nia or in
intorcostal neuralgia. In these latter there is usually no fever.
The diagnosis botwe»^n pericardilis and pleurisy affecting the left liido
is iMised upon the locality of the pain and the friction sounds, and the
relation of tho latter to the respiratory movements.
The pain of periwirditis is located in tho prseoordbl region; that of
pleurisy more laterally. The friction sound in pericarditis is hoard
most distinctly at the loft border of the sternum near the fourth costal
cartilage; that of pleurisy upually farther to the left and lower down.
The friction sound in pericarditis is independent of the respiratory
movements, and does not cesise when the patient holds his breath. In
pleurisy these sounds are not heard except during respinitiou.
Srce/idomi/.— The action ot the heart may raus« a friction Boun<) betwi-en
tite antoiior portions of the Ml pleura which will not fliiuppear when respiration
ceases, but tlii» is extremely uucoinuion.
The diagnostic points of pleurisy as distinguished from pneumonia
arc as lollovs:
A
ACUTE PLEURISY, 69
Symptoma.
PuuRisT. Pneumonia.
Chill absent or slight Onset with marked chiU.
Temperature low, rarely above 103° F. Fever high, 102°-105° F.
blitflit prostration. Marked ]irostration.
Cough hacking, dry. Cougli followed by tenacious, often
bK>ody or r\isty sputum.
BespirutioD jerking. Respiration panting.
Stitch-like pain, usually below the Pain iisually duller and less intense.
nipple.
Aspiration gives additional evidence
of effusion.
Inspection.
CouDteoanue notably pale and anx- Countenance apt to be flushed.
ious at the onset.
Decubitus often on the affected side.
Palpation.
Vocal fremitus diminished or absent. Vocal fremitus increased.
PeTCusaion.
Flatness and sense of resistance over Dulness rather than flatness.
the fluid.
Displacement of adjacent oi^pans. No displacement.
Auscultation.
Vocal sounds feeble. Vocal sounds exaggerated.
Inspiratory and expiratory friction Crepitant rales and later numerous
sounds prior to effusion. moist rales.
Bespiratory sounds feeble or absent Vesicular murmur feeble or absent,
over effusion. but bi-onchial breathing distinct in
second stage.
The moBt distinctive sign of pleuritic effusion is absence of vocal
fremitus over the a£Fected part, instead of increased fremitus as in pneu-
monia.
Pleurisy is distinguished from phthisis by the history and by the
same signs which ditferentiate it from pneumonia, also by the fact that
phthisis, affecting the greater part of the lower lobe of one lung, will
usually affect the apex of the opposite lung, whereas the signs of pleurisy
are usually confined to the lower part uf one side. In phthisis the signs
usually progress downward; in pleurisy, upward.
Many signs similar to those of pleurisy with extensive effusion maja.-
appear in collap-tp of n hnig from compression of its main bronchus, t!i^
loss of motion of the side, absence of vocal fremitus, dulness or flatness
on percussion, and absence of respiratory and vocal signs. When these
signs exist, the diagnosis must be based mainly on the position of the
heart. Moderate pleuritic effusions, where no adhesion of the pleural
surfaces has taken place, would be easily ditferentiated from the condi-
tion under consideration by changes in the level of the fluid. IJut
where the effusion is circumscribed, or when it completely fills the
:o
J'ULJlOJVJMr J)JiiJCASJCii.
pleural cavity, this eign would not be preeeiit. In pleurisy with consid-
erable eflhiaion, the henrt is more or less displaced toward the opposite
side. This does not occur in eollapse of the lung.
The essential difTLMi-'iiee in the signs of these two conditions may be
seen ut a glance in the following table:
PUJUBISV.
Ueart usually more or less dUplacvO
to opposjto side.
Side often tlistendeil. Side not re-
tracted excepting iu protracted oases.
Collapse of lvsh frum coMpnessioM
or THE MAIS fiKOA'CHUU.
Heart iioC displaced.
Side not distended, may he retracted,
and would always be i'<>lract«l cxr-opt
Uiat coUuptte of ttii> air vesicles t*auKeti
diminisiicit prosaurcoii tlieoi'gaii. Tliia
favors ditatalion of the btood-ve»«l»,
and sonietimes causes congestion wilh
oxudatiun whtcti fills the air vesirles
and distends Uio lung to its normal size.
Dnlness usually begins near the middle of the \x\n^ in pulmonary
cautery and progresses irregularly in different diroctions, leaving here
and there patches of normal reBoniince surrounded hy tlatness. In plpu-
risy flatness begins at tho base of thu chest and is uniform. The consti-
tutional symptoms of the two diseases are usually different.
The occurrence of empyema *vith perforation of tlie chest walU, jii the course
of the aorta, might cause a pulsating limior which would closely Mmulnte
an«urijtia of thf aorta. It would be distinguished from the latter disease by the
presence of signs of empyema iu ttie Iowkf part of the chest.
Pleurisy of the left side is distingnished from enlargemftU of the
9;if0«n by the following points. An enlarged spleen seldom encroaches
much upon the thorax, and therefore causes little or no distention of the
side, and no bulging of the intercostal spaces or displacement of the
heart. Upon percussion, dulness is found to extend in front higher
than behind, and the level of its upper surface does not materially
chnnge with changes in the patient's position. There isolso a largo area
of flatness below the diaphragm.
Even skilful diagnosticians have frequtMUly mistaken f.nlnrtjement of
the liifr for pleuritic effusions. The differential signs will be seen in
the following table:
Plkuritio EFnjsiONB. Htpertrofky of the lfvkr.
Inspection.
Frequently, bulging of the mterco»- There may be bulging of thecliest.
tol spaces. but the intercostal spaces are not espe-
cially prominent.
I
J.C'UT£ PLEURliiY.
71
PLKCRinc EFFnSlONB.
HVPEKTKOPUV Cf THE UVER.
PereuMtioK.
Dulnos extending higher behind
Uk»n fn front.
Tbe line of alnoliite Hatoom iiHttally
voriuit with chaii^e*i in the jxiAJtion of
tlic patient, and U not depressed or ele-
Lvated du ring' iQBpi ration or expiration.
Duln^ss extending- in froiil higher
ihau iK^hind, because the shelving U»r-
der of tbe lun^ (iditeriorly inlcrvenes
hetween tlie liver and tliQ ihoracio
The line of natnc«s is not materially
aiTect^id by ohangrei in the |>aticntV
l>OBition, hot ia depresGed und elevated
by inspiration and expiration.
Au»CHltatiun.
Ttw rwpirutory nmmiur is heard in The respiratory niurniuritt heard b»-
tront^at a lower level than behind, and hind at a. lower level tlian in front,
tJiis level is not materially afTceted by and this level is depressed during; dvep
dDepioKpinttion. inspiration and elevated in expiration.
pRotiSOBiH of acnte and snbncnte pleurisy. In ordiniiry esses of
aeuie plouriBj- recovery ueually occurs witliiii two or three weeks, but
t)iey miiy lupse into tbe subacute und chronic forms. A permanent
lesion usunlly rt-maius in some purt of theplcurul sac .iftcrstiro-fibriiious
pleurisy (Louiuts), frequently in. the form of thickening and adlit^sions;
these predispose to repeated attacks, resulting in greater pleural thick-
eningj connective-lisaue liyiierplania and t-ou tract ion, thus limiting tha
function of the lung and favoring attiu:kd of bronchitis und the inroads
of phthUis.
Diaphnigmutic pleurisy in tho dry form is cummun Jiud generully
resoUs in iidbe^ious, which may fijt the diaphragm uk high in some cuseti
a« the fourth rib, usually at the eovonth or eighth, thus greatly dimin-
ishing the vertical diameter of tho chest cavity, reuderinfr subsequent
thoracentesis, if necessary, dangerous, and favoring rupture of the dia-
phragm in tho sudden strain of severe bodily exertion.
Subacute pleurisy may be protracted for months, resulting in per-
maneat crippling of the lung from compression, and it may be in
emphysema of the opposite organ; or the Htiid may become purulent,
especially in children. Pleurisy complicating grave disorders such as
pyfcmio, septiceemia, or Hright's disease is obviously unfavorable. In tho
latter affection and in very acute pleurisy, effusion may be so rapid ond.
copious OS to cause death in a day or two.
Extreme cnmpreitsinn of the lung in any case invites sudden conges-
tion or o*<lema of \U fellow, and eonseipient death.
Danger of sudden death from compression of the heart, according to
Loichteustern {Deutuchet Arvhiv fur klinuche AMicin^ Band IV), is
greater if a large effusion occurs on the right side, prolHthly oving to tho
greater weakuees of the walls of the right ventricle, liowever, in chil-
<)ren a large effusion on the left threatena euddeu fatal syncope from iU
ejicet in twisting tbe great vessels.
PULMONARY DISEASES.
Treatuext. — The patient should bo kept quiet m bed,Hnd put upon
nn nnstimu lilting (3iet iinlesa great weaknetig demaud llit- oi>jH)sita
Talking siiould bo proliibitfd, and all volunUrj' motion uvuided. The
Tcspirntoiy movements may be restricted by strapping the side with
6Crii>s ot adhesive phister niniung diagonally, from above downward
and forward and downward and backward^ and also borizonU>11y; a
broad strip of rubber phistor applied during expiration, or u wide f laAtio
buiidiige, may be employed for th« same purpose. When these are nut
used, hot poultices iiuiy be beneficially «mpl(»ycd.
Opiates or some of the more recent analgesics, such as antipyrine,
ftcet-milide. or phenacetin, which are to be i>referred when there is
mnch fever and in most rases where the pain is not extreme, should be
given in suftirient quantity to relieve pain, l^omis recommends the
application of a constimt galvanic current to the affected side for the
rclii'f of pain, which continues after the subsidence of friction sounds.-
Souiutiutes the pleural i<uc rapidly lilU with serum, and the question
of aspirutiun will be suggested. With regard to this, the following
rule is important: Do nut aspirate in acute pleurisy until about the raid*
die of tho second week or until all acute symptonis luive passed, unless
compelled to do 8o to relieve great dyspntea. In the lliird stage of the
ditwaae, tonics and potsissium iodide, with counter-irritation by blisters
or iodine, are indicated. Absorption of the fluid may also be favored,
by free sweating brouglit iibout by the use of jabonindi, pilocarpine, or
the hot-air buth. and by such diuretics as squilU, comp. spts. of juniper,
und potassium bitartrate, acetate; or iodide. Sodium ealicyhite, or :<alni
in large doses, is* rcconimcndtHl ais sometimes iircdiieing prompt sub-
sidence of serous pleurisy where other remedies prove ursntisfactory (J.
Drzewiooki, Medical Jitfordj July, ItiSU).
SUBACl/TB PLBURI8T.
4
Subacute pleurisy, also called chronic pleurisy by some authors, con-
sists of a low grade of inflammation of the pleura, most fre<jucnlly char-
acterized by mildness of the symptoms, absence of pjiin.and slight con-
stittitionid ()isuirb:>nce with the effusion of an excessiveamoantof somm
often completely filling the pleural cavity.
ASATOMIO.VL AND pATHOLOttlCAL CHARACTERISTICS. — TheSB hav-
ing been already dcs<.Tihed under the geucnd title Pleurisy, it only re-
mains to be said that this is pre-eminently the "pleurisy with
L effusion." The morbid processes occurring in the plonri are less rapid
than in the arnto variety; the pleund thickening and formation ot
jlbrouA tissue is more extensive; tho effused liquid larger in quantity;
the results of pressure more gmve.
Etiology, — The causes are similar to those of the acute form, but
malnutrition and tuberculosis arc the most frequent.
BVbAVVTB PLEURISY. 78
Sykptomatology. — The priucipHl symptoms are dyspntNit Iob9 ofap*
p^itt, em/triaiion, vomUing, and more or leas cough.
Fever of from one to two dt^reea ia common. Pain may be slight
or altogether absent.
It is surprising how great the effusion may become in this affection
before the difficulty in breiithing beoonies noticeable.
The 8i</n» are thniie of the Hcrontl und third iitiiges of acute pleuriaj
vttb extensive effusion (Fig. ^1 ).
BroBcblal bf««lhlsf .*
i: ahwooe of nwpW <
Flo. 21.— 8i;BAi.-mt Putt'Kur.
DiAONOSiB AND Prooxosis.— The subject of diagnosis and progno-
lis of sulMicute pleurisy has bei'ii included in that of acute pleurisy.
Trbatmest. — TheindictUionsarefor imprvif/i nutrition and remoml
of /Ac rffusivn.
Very moilcrate catharsis, diuresis, and diApboresis, if employed short
of exhausting depletion, especially in the more robust^ are advisable, not
M much to influenoo absorption of the pleuritic effusion as to favor im-
proveuicnt of the general nutritive pr(M.>esiu.>s. >tild counter-irritation is
sImi useful. The diet should be nutritious, easily digested, and moder-
ttaly stimulatiug, composed uf animal and farinaceous broths, beef pre]>-
arations. eggs, and in some cases such spirits as slierry iiud port. The«e,
ssd hitter ionics, as the various ])repAriitions of liydrastis, calisaya,
columbo, and gentian, combined wiili ferruginons remedies, and the
employment of mercury and potassium iodide in alterative doees, beat
meet the first requirement.
If iu u couple of weeks the fluid has not materially diminiahed, it
should be withdrawn by an aspirator, providing there is sufficient to
more than half fill the pleural cavity, or even when the collection is
jmitll if il 'Siui-es dyspnim or dit-conifort in the side. AStienever the
rarity ia completely filled Vud the heart displaced, even though no urgent
74
PULMONARY DISSASB8.
a^'mptoma occnr, no time shoaM be lost iu {icrforuiiug the opcratiou.
Ill uusi'S of liilukTul etTudion, especially where ilicre is c^uoosis or great
tlygpniiii; wlieu erunt-iattoii occurs with iiuligeatiou &n(l feeble circuU-
lioii; wlifii plenrsil effusion complicutes periranlillii, he:irt disease, pneu-
monia, soTcre bronchitis, or Brighl's diacuse; or when the fluid beeumes
purulent— aperutive proce(inr»i must not be ilehiyed. In operating, it ia
most coDTenient to Iwve the paiient sitting astride of a chair with the
arms folded and rcwting uiion tlio buck of the chair, and the bodv in-
clined slightly forward; but if the patient h too wc«k to sit up, bo* may
remain in the recumbent postnro, lying clo«e to the edge of the bed.
(ieneral anspsthctic* are seldom used ; the pi^ rid may he thoroughly be-
numbed by injecting deep into the intercostal 8[mce, and jost beneath
the skin, with a fino needlo, a few drops of a two ]>or cent solution of
cocaine, or of the solution recommended for local amesthosia (Form.
140). It is well to tull the patient that he need have no fear until told
the plunge is to bo mjide, in order to save him much anxiety and enable
the physician to make his examination more deliberately. The surface
to be punctured should l>c surgically clean and the instruments aseptic.
I liml it convenient to dip the thoroughly cleansed needle into a mix-
ture of equal parts of carbolic licid and olive oil. Any of the uspiriLtors
in common use may be employed, but the simpler are usually the best.
It is generally best to use « medium-sized needle, and the cocks should
be closed and the air uetirly ex!mu8ted from the aEpimtor before it is
introduced. The puncture is best made near the angle of the ribs in
the sixth, seventh, or eighth interspace. It is my custom to make it
high. When the pleural sac is only partially filled with fluid, we aacer-
tain the upper surface of this, uiui nmke tlie puncture about au inch
below it. If the operati.m is at the lower part of the chest, the needle
is apt to strike the liiaphnigm, or, if this does not occur, as soon as a part
of the licjuid has been withdrawn, the diapliragm is forced npward
against the needle, causing pain and preventing further withdrawal of
fluid.
The akin should be drawn upward about half an inch by the ends of
two fingers, which are then pressed firmly into the intercostal space;
between them the needle is thrust inwanl and upward in the direo-
tion corresponding to the slant of the adjacent costal surfaces, to avoid
the danger of striking a rib. AVhen all is rejuly the patient should be
forewarned of the sudden coming pain, and the needle plunged in until
it enters the pleural cavity. The air cock is then opened and the fluid
slowly withdrawn. During this procedure, if cough, pain, or dyspnoea
or a feeling of constriction of the chest or weight upon the sternum
occur, the iispiration should bo discontinued at once, whether the fluid
has all been withdrawn or not. The amount of fluid removed at one
time is exceedingly variable, being from a few ounces to several pints,
and not infrequently rapid absorption has been known to follow removal
I
I
SUBACUTE PLEURISY. 75
of even a few drachms. The operation should be repeated within from
five to ten days if the fluid reuccumu lutes. Usually after these measures
the patient immediately improves, the appetite is better, weight in-
creases, and the fever may entirely disappear. Subsequent treatment of
the case should be of a tonic nature, and should include systematic and
carefnl exercise of the muscles of the trunk, and breathing exercises.
Recovery is sometimes greatly aided by a sea voyage or change of climate,
especiall;f to a high altitude when mountain-climbing will develop the
respiratory muscles and the air cells will be expanded. The patient
should be told that he must expect pain in the affected region on- pul-
monary and general muscular exercise, for some weeks or months.
CHAPTER VI.
PULMONARY DISEASES— Con/iniwrf.
CHRONIC PLEUKIST OR EMPYEMA.
The term empyema is applied to pleurisy when the inflammation is
protracted and pus instead of serum occupies the pleural sac.
Anatomical and Pathological Chakactebistics. — If sero-fibri-
nous pleurisy become suppurative, the plastic elements undergo degener-
ative changes by the action of various micro-organisms, and are found
to consist of pus cells and shreds and flakes of semi-purulent coagula
immersed in serum. If the empyema be primary, leucocytes, round cells,
and endothelial cells, more or less degenerate, appear on the pleural sur*
face, to be washed by the serum to the bottom of the pleural sac. The
lymphatics, cells, and pericellular spaces — in the serous and subserous
tissues — contain active micro-organisms in greater or less number. The
effects of pressure upon the heart and lungs in empyema do not differ
from those which occur in pleurisy with serous effusion.
Etiology. — Empyema, according to Bouveret, is most prevalent dur-
ing the first five years of life, and pleuritic effusions are more apt to be-
come purulent in children than in adults. Whether idiopathic or not, it
usually occurs in those of hereditary weakness or those who are debili-
tated by disease or irregular habits.
It may follow trauma or opening into the pleural sac of an abscess
in the liver, lung, or thoracic wall. Pneumonia and typhoid fever are
frequent causes, or it may complicate rheumatism, or scarlet fever and
some other contagious diseases, or pyaemia or septicaemia. More recently
influenza has been assigned as an occasional cnuBe.
Symptomatology. — The symptoms of empyema denote serious con-
stitutional disturbance. The most importantare: rapid pulse, dyspncea,
cough and pain, high temperature, dry brown tongue, hectic and night
sweats, with loss of appetite, vomiting, and rapid emaciation.
Tke signs of this disease are much the same as those of subacute
pleurisy, but usually the displacement of the heart and of other adjacent
organs is greater in proportion to the amount of fluid. Contraction of
the chest occurs when compression of the lung has so impaired its elas-
ticity that it cannot regain its original volume after partial absorption
of the fluid. The cliest is then flattened on the affected side, the nipple
depressed and nearer the median line.
VHHUJSHJ J'LUL'UISr. 77
Occn&ionally accompanying curvature of the spine may exist, wilh con-
Tesity toward the soiinil KiUe, ThU phettomenon rciultii because the donal
inuiK:te« of the sound utile are nu longer couul*.'rl)alunL'<.il by those of ttie aiTected
Aide, wtiicii iMcume purulyzvd by Uu* pcrsisU'Ut pn.-»stiiv.
Ordinarily the level of Ihe fluid does not vary with changes in Lhe
poaition of the patient, owing to the agglutination of the jtleurul Bur-
facos inimediittuly above tlie et!urtion. \n thi8, as in other varieLics oX
pleurisy, iluctuation is occasionally detected by palpation. iSumotimes,
irith large effusions, especially in the left pleura, pulsation of the side is
obsenetl syuchronously with the conti-action of the heart. This condi-
tion is callcHl pufstttinr/ empyema. If the pU8 breaks through the ohe»t
wall and appears beneath the integuments, the tuniur thus formed gen-
erally pulsates etrungly, and it might easily bo mistaken for an aneurism
if located in tho course uf the aorla inetoad of being at the lower part of
lhe chest. Tumors of thJH kind often enlarge with inspiration and
diminish in size with expinition.
E^fxptional. — Rarely, empyema, iDKtt^adof occupying' Its URual posJtioo otthe
Jbnm of the chest, may be contined to Uie upper part of the pleur.il sac, or to a
lull space about the root of the luQg, or it may occupy two diffe'rcnt aud widely
L'pttruled l^K-alitiea.
Uisgeaeratly cotusidert>d impossible to ditferentiate between serum and pus
in ^le pleural vim ; but Gnidu Bocelli. of Hotue. cluiniH that the dislitictjoD cau
btt made by atu-ntion to tit'.- whis|RTinjf vixrul resonance. Tlic wliisjK-r resonance,
bo ckiiiu»( may be licai-O at thu bioie uf serous plenrtlio clf iisiouti, but will not be
ooflduct^id through pus. In luakiuj; Ihia duilmHtoa, two conditions roust be
secured: First, iiiHiit:diute uust-ullaUun must be pracliHeil. (be var bein^ presiied
flriuly a^iiiKl ilie nukvd c)ic»t, ami all L-xt«rtml sounds excluded by clu^iu}; the
otiicr vnr ; Bvtioml, tJif patient must ho. &o placed that tlu; vibrations produced by
whispt-'ring shall proceed from his uiouth in a direction diametrically opposeil to
tlie listening: ear.
DiAUKOHts. — Empyema may be suspected from the physical signs de-
nying pleural effupion, together with the symptoms signiUcant of puru-
lent inflammation, but tho diagnosis can be made positive only by explora-
tory puncture.
Pkognosis. — Tliis is generally considered uufavorable. Chances of
rcwovery lie in spontaneous opening and discharge of the pus, a very
teaious process, or in its removal by operative procedure. Without such
relief, the dangers are : death from sepsis, pyemia, exhaustion, or from tho
efftn^ts of pressure upon the thonicic organs. In acnte empyema, death
moy result witliin one or two weeks, but in the more chronic forms the
patii-nt may live for months, or even three or four years, or posaibly
longer. Children recover much more satisfactorily after nperaiion than
ndultis but snccuDib more quickly without it. Lelch leu stem considers
tho es('a|W of piia in the empyema of ehildren as an ahntist infallible
indication of recovery, lie believes that the eases of Bii-ralled sponta-
neous cure in children can be explained by tho theory that the pleural
78
PULMONARY DISEASES.
accumulation in these oasee disappears by discharge through an opening
into a bronchus.
Luumis stales that when spontaneous opening occurs, abont twenty
per cent recover; but that when the pus has been removed by operative
procedures, only about twelve per cent recover; but I have seen quite a
series of cases in which evacuation of the pus by the methud here recom-
moudcd has been followed by recovery in about seventy-five i>er cent of
the patients.
Treatment. — Pns in the pleural cavity must bo removed. To this
end various operations have been advocated.
Aspii-atiou of the cavity repeated two or three times has In a few
oaaes proved sufficient.
L. G. Fiitteror, of Chicago, reported to me by personal letter six cases
perfectly cured by aspiration of the chest and washing out of tlie cavity
with a three-fourths of one per cent solution of clove oil in water that
had been filtered and thoroughly- boiled. This was injeoteii and drawn
off and followed by a permnncnt injection of a second quantity of this
fiolation nearly etptal in amotmi to the pus fii-st cvacuiitcd.
Another method of treatment ia by pkurotomy. An incision is made
in tho iixilUiry region between tho fifth and ninth ribs and pantlltd to
them; donble drainage tubes are inserted and u Listi^r dressing is ap-
plied. A convenient apparatus recommended by A. T. Cabot (Cyclo-
pedia of the Dist-asts of Children, Keating, Vol. 11, p. 715, I*it>*i) is
readily made from a piece of tuhing cut half in two, folded upon itself
and held in place through a shield by safety-pins.
.Still others advise rr»evtion of the ribs either subpenoslcal or not, and
performed with various iuoigious and mitior pointjt of ttvchnique.
Authorities differ as to the iuvariablo advisability of washing out the
cavity. Bowditch {Miiluiil yetcs, January, 18yu) claims tliat in two
hundred and ninety-nine o{>eratiou8 ujwn two hundred and fifty patients
he fouud it necessary to wash out the cavity only once, and he considers
Udangerons. lJcCerenvitIe(.y'//w)V//V./riArA«c/;<'r, Band 318, lleftl) re-
ports six cases of e])ilepsy in children, following mechanical irritation of
the pleural surfaces, as in irrigation, sounding, and probing. Equally
high authorities favor irrigation.
A. B. Strong, of Chicago, strongly favors resection of the ribs, and
reports thirteen cases {Chiratjrt Mr^iUral Iferord, October, ISHI) with only
one death. Of these, however, twelve were acute and eight were in
young children in whom tho prognosis is usually favorable, whatever
method of evacuation of the pus is adopted. Ue uses htrge drainage
tubes (Fig. a3) well iidupted for the purpose, readily made and easily worn.
W. JI. Striekler, of Colorado Springs, Colorado (Mcdiml Xen'»,
Mar. 1S8T), a(lvo(;ates rest-etion of the fifth, sixth, and seventh ribs,
thorough digital examination of the cavity, removal with the fingers
CHRONIC PLEURISY-
78
of all fibrinous nmsses, separation of fidheeions if necessary, and eopiout
hot-watt-r irrij^utioii, fuHowod by duily flushings, lie reports exceileut
rc(itilt« in Qvi,- uduU ciiscs.
ZimnierniiLa and olliera consider aiplum drninage as the must effeo
tiva A long, aseptic rubber tube is pa&sed into the cavity tbrongU tha
i^mm^,
. K— CuoT's nKAiNAOB Traoi.
Put, %— Stroxo'b Diutyiai Trscs. One-b&U siae.
canula of a large truc-ar, a clamp closing the outer end of the tube. Tlie
cannla ia then slipped out, the tnbe is clamped between it and the chest
wall, and the first clamp and the canula nro removed. Connected to this
tube is a glass one U-aiding through a rubber stopper t^ the bottom of a
bottle containing some antiseptio solution.
To secure a constant air-tight joint at the round in thin patients
where thetissucjt retract, the tube nmy |mss through a rubber shield bound
SL— IxoAU' Plat Tkocab. One-hAlt «tae. For totroduclBg draiUBfr* lubo In nDpjrnna,
cloHely to the chest. Powell {Ciinnilian Prarlltwner, 1887) successfully
treated six cases by siphon drainage, nsing Kt'Iaton's catheter }Kisscd
itirough a rubber bandage fastened around the chest, and irasbcd out the
cavity by alteniately niiaing and lowering the bottle coutaiuiug a weuk
solution of carbolic acid.
WithusinglcexcoptioQ, I have never found resection necessary. The
radical oiH-Tutiou which 1 have t'tnpluyi''l with much suttsfm'tionfnr many
years is i»c*rforincd by means of a broad, tlat trocar (Fig. HA) suftieioully
Urge to admit the ]>a6stige of two drainage tubes at once. If on ames-
«0
PVL3I0NARY HISEASBS.
Ihctic is tkonght necessary, iiitrons-oxide gas may bo advanbigeously
uscii, tis its effocta are quickly over; but it will usually U- sufficient to
inject ijoep into the iutercoelul tlHUues, us well u£ just beiioiitii the skiu,
% few drops of » :four-[icr-ccnt solution of cw»ino sucli as recom me tided
for local ana'slhesiii in tlieiiuuc. The skin having been mnde thoroughly
clean, it is punctui-ed by a sniull eicalpcl. which itiukea un iiiciaion ahout
a quarter of an inch in lengtli, the point of the trocar is entered into
.this incision, and then the instrument is plunged boldly into the chest.
Boon as the stiletto is witlidmwn, the thumb of thu operator is pkced
OTcr the mouth of the cuuala to prerent the escape of ]ms; and tbon tho
tubeSj which have been previously prepared, arc slippcfl qnickly through
the canuhi to the required dcjith, the canula ie withdrawn and the tubes
are left in tbe chest. A bit of she*^t rubber about three incbes eqaare,
with two bniiill u^jeningii near the centre un<l i-lo»e togoitier, is now
slipped over the tubes and down to the chest wall. Next* a section of
the same tiibiug about half un inch in length, thruugh which have been
tied two loops of stout thread each about uu iuch in leugth, is passed
over a canula and slipped down over the drainage tube to the chest wall,
where it i.s furceil off ujion tiki; drainage tube cluKt^> lo the Htirfuce. Both
tubes arc treated alike, antl tlirough the luops are iiiu-ised lung stri^w of
a4l)iceive plaster, by wliieh they are Infund firmly to the chest wall.
Tho drainnge tube is now perfectly under the control of the operator;
it cannot possibly sliJo into ilie chest, luul the udhesivc straps keep it
from being forced out a few ilays laU>r when the tissues about it have
retracted. The section of slieet rubber placed next to the cheat wall
acts as » valve prevcutiiig air from entering the chest at least for the
tirst eight or teu days; 1 1 Kit is, until tlic retractio]i of the tissue occura
about the tubing. A ruller bundagc is ujjplicd over the whole, the drain-
age tubes being allowed toprotrmie through it. In preparing tho drainage
tube, I take a piece of ordinary ptiregnrn tubing about two feetiu length
and one-eighth of an inch in calibre and cut It half ncro&i near the
middle; it is then folded upon itself, *oue of the tubes is perforuted in
sevend places extending about tliree incties from this cut cml, the other
in a eo[i]>le of place::, extending ubout one inch. About an inch and a
half from this end the two tulK?s are stitched togctiier at a single point
with strong Bilk. The stitch is nmde through one of the perforatious
and knotted within the tube; tlien, If by any meims it come loose, it is
likely lo be waslied out. When fo)ded ujnm itself nnd fiisteued in this
way, one of tlie tubes is cut about half an inch liliorler than (he other,
Ro that the operator may know snbseqneutly which tube is perforated the
greater distance from the end. Abovit Pix inches from the end of the
lul<c which is passed into the ehest, a bit nf thread is tied closely about
it as a mark, in order that during the operation the surgeon may know
how far it hns been pushed through the nannla. Finally, the outer ends
of the tuUa are tied tightly, and tlie whnle is made luteptir by soaking
in a strongly curbolized solnlton. By tiiiis cloHng the ends nf the tubes,
n-e Hjv cnablvii to slip tiwm through the cauuhv, w.iUulv;v\v the latter, and
•vtA vhcn th« chasl » mttdi dHtaadad, viAont
^ OMp* «r ■at* tkaa floe or KVD 4MUMH oC poa.
After tba di mi^fti «n eooiplvtcd, the drmiaa^ tebca may b« beat
ta ami Umb hcrawtimlljr, wbO* th* MMis an opcavil
lyfhortglHB tabes to loader nibber tabw* tbron^ wUiA
^nitj Baj be vaehed or drained acccvdmg to indJoatJona. It baa
ij ewton to vaeh oat tbe pteonU sac immedUtt^v with as aoti-
laahitwn^and to bare ibe wash-
ing Tvpsaltd afterward OBce «r ^'^
tvine dail J for a eo«{de of weeks, and
■alwBqamtly hai frvqaentlr antil
theoc is oUii«fat«d. Thissolotion
sboold be nsed at a teimperatttro of
101*" F. B«tw«cn the waahing* tbe
«iids «f tbe tabes nur be bent upon
and tied, or tbe j mar be
^*— f "g in a bottle containing
taatiaeptic solnlion, as thought
When the patifiit is able to
walk ahoai.I asuollr allow drainage
togooD consianclr inti^A bottle which
tbe patient curries iu Lid pocket.
In cases of empyema which have
lasted fur a long time, it is very im-
portant that ultoat the lifth or sixth
ireek after the operation the phy-
siciso shonld ascertain whether tho
carity is decreasing in size, wlitoli
can be easily done by measuring
from time to time the quantity of fluid requlrrd to All it, Usually tho
pleoral Shc rapidly rontnicte until it will not hold nion? tlutn fntirurllvu
<mnees; bat after this, especially in nduli cases of long standing, xUv mtn-
tnction may be very slow. Here it becomes necessary to nw> tttimutot-
ing injectinne, such as aqueous solutions of sine sulphstc, gr. ij, to iv.
ad z i-; ir<;>n sulphate double ilu^ strength; compound solution of iodine*
3 80. to3 i. od 3 i. ; or copper sulphate, gr. v. to gr. xx. ad ^ i. If
iodine is used it will Httnck the dntinago tubes so llnit they tnnst be
renewed every two or three days. Hydrogen |teroxide, the cununeieial
solution diluted with an equal volume of wutcr, has been highly recom-
mended to chock supi>nriitiou, and a solution of tho oil of cloves or
emulsion of i<Hloform may be tiaeil for the uime purpotw. AVhcn tho
CAvity lias so far cuntracteil as to hold nut niorii than two or thnio
draobms, the drainage tubes may be withdrawn ubouL half an ineh. lefk
in this position for two or three davi), tliHTi withdrawn its niiioh farther,
and 80 on until they are out of the pleural cavity, wluin tho extiirniil
wound readily cloaes.
6
(IiirTKiu. A, ia#M rtihlir: K rH*lnins
82
PULitOJfARl' DISEASES.
The aim in the trcatuiuut of enipyeniu is tu give free exit ft>r pus,
and socare oblilBnilioii of the pleiinil hic by agi^lutitiiiLiun of its wnlls.
llcnc© W0 eiicouruge as far as possible the esjwusiou of the lung, in
eome oases nlloving the rihs to fnU iu. by resection, aud bring' the pleiirr.l '
Biirfaec'8 together.
The importance of careful medical and geneml treatment adapted to
the iniproremeut of tho patient's condition need hnrdly be em])hafiizod.
PECCLIAB LOCAL POUMS OV PLEmiSY.
The following forms of pleurisy, though not entitled to he considered
as distinct varieties, need some special consideration:
CirciifH^criled jthurisi/ usually occurs during the course of phlhiais,
uud is responsible for nuiny of the acute pains sufTt-red by i-onsuniptives.
Tliia inilunumitidU is gfiiemUy limited to tho siii-il jiorti'in of pleura
in testing the lung where the lesiuus are superGL-ial. The signs indi-
cating this condition are sume varit'ly of friction sound, or a drj', ci*cak-
ing sound, prolKibly duu to old iidhesions.
Ph'itrUif of fhe Hjiex, unnssociated with phtliisis, is said by J. Burney
Yoo to be a fi-ctpient discjise, wliirh ho believes to be tho cause of many
coughs, usually called hysterical, or srumach coughs, lie li;is observed
it principally iu vronieu who have been accustomed to wcur lon-neckod
dresses. Its chief symjitoni is a harsh, dry, shidloii', or incomplete cough,
occurring in a person a])piireijlly iu good health.
The only physical gtffn to bo detected is friction limited to the supm-
clavicnlar region, or to the upper third of thy scjipular region,
Diaphratftitofir jihun'i'i/ or inlhininuition of the pleuni covering the
diaphragm is not easily detected. According to Noel Gueneau, the fuU
lowing symptoms render its di:iguosis more precise. I>c:jidcs the pain
elicited by percuasionoverthe liiiseof the client uu tliealTi-cted side, there
is a point of hypera-stliesia, due to irriuition of the phrenic nen*e, found
at the intersei'tinu of two lines, one of which corresponds to the bi rder
of the sternum, and the other, perpendicular to it, follows aud prolongs
the border of the ribs. At the same time there is liypenesthcsia found
between the sternal attachments of the steruo-cleido-masloid muscles,
and pain in the shoulder and in the iiifru-clavicular region of the eamo
aide. These are reflexes from irritation of the phrenic nerve. Nennilgia
of the last intercostal neno is also frequently present, and there is likely
to be increased obliquity of the hist rib on the afferted side, and immo-
bility of the h\'pocliondrinm. If the inflammation is on the riglit side,
the liver is usually slightly depressed.
Percussion gives a high-pitched note over a narrow space, correspond-
ing to the lower margin of the lung contiguous to the eltusion.
On aus<!uUation, the vesicular sound at the level of the collection of
liquid is usually feeble, and accompanied with crepitant or mucous
rdles. Weakness of the inspiratory sound and prolonged expiration may
PEVVLIAH FORMH OF PLEVKISY.
83
exUt over the whole Umg.due to cumpreii«ion of the bronchi bj enlarged
gluiiUs, which are iwid ordiimrily lo acfoiniKinj? thU diaeflaa,
MttltiUK'tihir pienrisy \a rarely objiervecl. lu 1854, Wintrich wrote
thut it was impossible to ilistiuguiah, in the living snbject, between ««i-
iacvhir, hihcular^ and innUilnrulnr plt-iirisy. und this proposition ik still
genonilly aocojitcd; but in a con»murirtit)on to the Auidi'mio de Mi-di-
ciue, of Paris, iu 1870, Jaccoud dt'flared the diagnosia jkoaeible when tlie
following ^oups of eijrns are found coiucidently with the ordinary
c<ymptom8 and signs of pleuri.-^y. TIp has observed (wo distinct scnieio-
logit-:;l types of the affection.
In the first, added tu the ordiiiiiry signs of complete pleuritic effu-
sions, tlie viical frtMnitua, tliuugh lust over every other portion of the
affected side, is found to be preserved along a line running forward from
the spinal t-olnmn, in ii more or Icb8 reguliir spmicinMiInr course, toward
llie stenuiin, at a variable height. Vocal reHoniince and bronchial respi-
ration are heard in the «nne Io«ility, tbongh wanting everywhere else.
Tills lino indicates the position of the band of i>leuritii' adhesion
dividing liie jdeural siic into two cavities. In these eases, ho has fonn*!
in the infra-clavicular region feeble and distant respiratory murmnr and
Toice-sonnds, with no tympanitic resonance;
In the second type, vulviI fremitus, Ihnngh more or less eiifeoblcd, U
obt.iined over the wliole effusion, excepting sometimes a narrow zono
of the brKidtli of one or two fingers, at the lower posterior part of the
chest. Marked bronchial respinition and broiicliophouy are aljio fuund
over the fluid, with perfect flatness ou ]>ercusBion, and no tym}tanitic
resonance under the clavicle. Iu txvo ciises he h;is been able to hi*: to
the fuudainentui partitions, by finding one or tv.'o zones where the
ribraiions were manifestly stronger limn in other locjillties. The value
of this diagnosis depends upon the proftosttion airpui-eiitly establish^I
by Jaceoud*6 observations, that Ihonicentesis is not well borne in multi-
lorulur pleurisy, but tliat it seems rather to add greatly to tlie patient's
danger. The essential points in the dilTcrential diagnosis between ei-
tensivo pleuritic efTusions of the unilocular, bilocular, and muUilocular
types are shown in the following table;
Uxir.ociXAH pLRumsv. Bu.ocrt.\B plecbist. 5liaTii.ocn.Att puccKiBr.
Lou of Tocal fremitus.
PullKitiim.
Vocal f rem Hub prtwcrved
OD a line corre^iiMJUtUn^
with the band of adhexEnn,
ttiou^i lt>st above luid be-
low this liae.
Vocal fr«mjt4iK, though
onfoplilwl, is prcHout ovvr
the wliolo of the alTei^lvit
side. exc<>pting' a small
tf.mQ nt the I)asft, Vnoal
frenritiij} is occaHlooally
we'll nmrkvd in one or two
limiteil KODtts cormspODd-
faig to bauk of adliofioD.
&4
PULMOyART DISEASES,
Usually tyn]|>an)tic rci^
onaoce under the clavi-
cle.
Abaeooe of respiratory
murmur and voc»l rv^f>-
nancc, «xr«|itin}(over Uie
oomprf^fUbHJ lung in the
upper part of tiie tbortuc.
BiLOcnaR pletbist.
PtrcxtMsivn.
Fiatnesa ov«r the whole
chest : no tyiupuniiini.
Anandtation.
BronL-liial respiratioD
and brom-hopliony licunl
over a linp corr*>spoi»ling
to the pleiiritio bnml, hut
waatinj; in other plac-es,
except over tlw ai«x,
where tliey are indistinct.
McLTUiOCCLjLK PLKCKtST.
Flatnoss over the whole
cbesl; do tympanism.
BroDcliial respiration
and bronchophony mai-k-
ed over the !>ettl ol tlie
whole effusion.
HYDROTHORAX.
Hydrothorai ia a term applied to the prMence in the pleumi cavity o!
a dropsif^al elTiiiiiou, which is non-iullammatory iii character, ihiu, clair,
yellow, or greenish. It haa a low specific gravity, contains relatively
little albumin, ami coagnlateH lesd readily than an inflammatory effusion.
The affectinn is uHunlly bilateral, but nmy be contined to one side.
Etiology. — Hydrothomx may arise from any condition wliieh im-
pedes venous circulation, producing extensive passive congestion, as heart
disease, notably mitml affection; diseitses of the liver or kidneys; pres-
sure of tumors and the like and venous thrombosis; it may also be the
result of malignant disease, chruuic blood-poisoning, exhausting dis-
charges, or other morbid conditions producing general hydra-mia.
I'ho symptoms, of which dyspnmi is most marked, come on insidi-
ously and are due to pressure of the tluid.
The /ligm will bo similar to those of an jn6amnmtory effusion.
Diagnosis will be based upon the sijins and symjJtoms of the cau-
sative disease, the absence of inflammatory symptoms, the character of
the fluid, and its usual bilateral position.
pROOXOsis will depend upon the cause.
Tkeatmext will be directed tn tbe primary morbid condition and to
the immediate relief of the lung by iispinUiAU.
PNEUMOTHORAX.
Pneumothorax consists of a collection of air or gaa in the pleural sao,
resultiug from perforation of the pleura or from decomposition of pleu-
ritic effusion'. (Fig. 2(i).
Etioi.ooy. — Air may enter the pleural cavity through a traumatic
openiu^ in the chest wall; through communication established with the
stomach or tesophagua hy ulceration or ruptnre; throujjh openings into
the lung from exploratory puncture, fracture of the ribs, or nlceralion
due to phthisis, empyema, abscess of a bronchial gland, or gitugrene; or
PNEVMO-H YDROTHOHA X.
85
through rnpturo of an emphysematous sac. Abont ninety per cent of all
iicaaes are of iiiltorculur origin.
SvMPToMATni.or.y. — The nsual *//JH/i/ot«« are sudden acute pain in
the eide^ with serere dyupuu-u uutl lividity of the lips and face; ^oat
prosirution, at-'Conipunied with anxiety of countenauce ; a chimmy aur-
,&ce, imlpitnlion, uccelemtrd pulse, and in some oiacs coUupfiu followed
by dejith witliin li few hour8. In other oases the symptoros are mani*
feeted insidiously, only becoming marked n-hcu caneidoroble fluid accu-
mulution l»aa followed the entmnoe of air. This ia the cjise in pneumo-
thorax from emphysema. If it re6ult from phthisis, the diyiuptonis,
especially pain, are very marked.
The most imjKirtaut fifjun arediminiHhctl niovt-ment and enlargement
of the allected side; tynipunilic rusonauce; re8]iiratory murmur feeble
or amphoric in character or wanting.
Inspection and mensuratioii reveal distention of the nlTected side,
diminntion or lo^it of the rei<jiiratory movements, with widening, and
nometimes bulging of the intercostal spaces.
Palpation shows the vocal fremitus feeble or wanting, and the apex
beat of the hourt displaced toward the sound side.
Uy percussion, lynipanittc or amphoric resonance is obtained over the
rCoUectiun of air. When distention of the side is extreme, the ndjucent
i»rgan« are displai^ed, and the tympanitic resonance, 8(m)e what muffled
l-iind motlified in (iinility, may be obtained for a considerable distance
"beyond the uorniul limit* of tlie pleura.
EixwpUonaf. — Occwiouully when the htiuioa is very f^i'eat. the pervussiuQ
Bote is M> nuiUliMl an to seem almost dull, The b^^ll i>otiii(l may be ohtameil by
fercuwiitiu witli two coins on odh eide of the cavity while the car U pliii;e(l
Apposite.
In auscultation; the respiratory murmur is feeble or absent according
4o the uniuunt of air. The vocal sounds arc nltered in like manner.
'Pbe respiratory murmur on the sound side is exaggerated. The heart
soundit are feebly transmitted through the collection of air. Bronchial
VreJithing may be heurd over the compressed lung, in the inter-scajiular
I'pftf'e, and nsuitlly over the apex anteriorly. Amphoric rettpiration and
voice are also oHiiiined when a bronebinl ttiW- connects freely with the
cavity of the pleura. The differential diagnosis between pneumothorax
and emphysemn.theonly disease with which it is likely to 1>ecoufounded>
will be given under the latter.
PKEITMO HTBROTIIORAX.
Pneomo-hydrothorax signifies a collection of both fluid and air in
the pleural sac. When the former beromrs i>urulent. as is usually the
case, the condition is termed pyo-pneumothorax. As the effusion of
ffuiil is almost sure to follow in u few hours after the admission of utr
I
iulo till? plcuru> the signs und symptoms of this disease and of pneumo-
thorax are usually coiisideitd together, but the prcseuco of both air and
fluid in the pieurul cuvity euu^es some signs which are not found in
piieuiuuthorax. The splushing sound obtained by suceussioti Is diag.
uoiiliu. MetiilUc tinkling is ulsu found in nniny inslanc:>H (Fig. 2(i).
Inspection, piiinition, and iniu:iiirutiun fnrnisli the s:(mo signs as
in pneuDiothurux or in extensive pleuritic effusions. There is absence
of \ocal fremitus, and displacement of the heart and adjacent organs,
with distention of the side and loss of motion.
On percussion, tympiinitic resonance is obtained over the air in the
upper, and flatness over the fluid in the lower, part of the chest The
Rlirht lunr (HinipiwMeil hy tir uid fluM. Heart crowded far
to the Mt.
line of flnlness corresponding to the surface of the fluid changes wit
the position of tliu patient. Tympanitic reoonance is not iufrctiuoull;
transmitted a short distance beyond the limits of tlie pleura, and even
below the surface of the fluid, so that if only a small effusion is present
this sign may be heiird over the entire cliest, and thus the presence of
fluid cscajie our notice. Amphoric resonance is sometimes heard over
the upper part of the cheat.
Upon auscultation below the level of the fluid, the respiratory mur-
.nur is absent ur very feeble and distant. Above this level it may be the
same, or amphoric respiration may be heard. This hitler may be limited
to a small space near the i-Dint of perforafion, Mhich Is likely to be
locjited just in from of the angle of the fourth or fifth rib. Amphoric
respiration may disappear an<l reappear apiin during the conrae of the
disease, in consequence of the variation in tlio amount of fluid from day
to day.
pyErun,rrTDRorHaitJT.
87
TTsiUilK broDchia] ni*pinitioQ u b«sirU over the compvvssed Inn^
-vhen* it lie^ against the fpinal column.
The Bigtii of phihisis, which in nine cwws oat of ten precede those of
rotithonu, are fre^nently found at the apex of the luug on the
te Bule. MetAllic tinkling is one of the sigufi of tbid disease. It
«ealt from agiution of the flnid in oonghing. The splashing
fioaud obtained on saccasjion is characterieiie. Voval resonance is feeble
or wanliug, or amphoric, upon the affected side. The percoision reso-
nance and the respiratory murmar upon the sonnd side are exaggerated.
I>lAOSOi-l5, — i'netimothnrai and pneumo-hydrothorax are not likt;ly
lo be mistaken for other diseaets, tbongh they are suid to be closolj
eitnaUtcd when there is complete catarrhal obstnictiou of the main
bronrhtis on one side. They may (tos»ib1y be mistaken for emphysema,
chronic pleurisy, or diaphragmulic hernia.
Comparison with tmphgntna presenta the following distinctive foA-
Uires:
PHEUHOTBORaX AKD PXKlIIO-KTMtO-
TBOBAZ.
Inspection.
Empbysou.
Ptomioeiuv or balfnatf of one sitl?.
with loaa of movemeoU e»pw:ially at
tiw luwer part MrHjeclitr!*!. but no fall-
iut; ID of the mfenor ribs or intercostal
Spaott duno^ nupiratioo.
Promiaenoe of the anterior superior
porliuQ of Uiecbeftt, tKUolly uftoa buth
!*i»li*». Willi A chanicl«ri»tic lifting
iiivv>;uient of the upper purt and lall-
iojj in ol liif lower ribs :inA inteivofttal
st«u.-vs durtu;; iospiraUon. witli fre-
tltieotly |H-i-iiiiuieiit c-ontrsction of the
lower part ol tiiu cbesL.
Pereuttion.
Tympanitic resonance over the up-
per port o( the cbes! «ith flatness ov^-r
the fluid, tlie line of (latnefis vao'*n);
with changes in the patieat's position.
TIte heart \a displaL'etl tu the riifhl or
I. acconiinip to the «eat of tlie ilfs-
Nearly always these sigiu are
found on one side only.
Auaetdtutitm.
Ve>iJculo tympanitic lesoiuuice over
the entire lung, but most marked at
ilie superior portions; no flatnen b«>
h»w. The heart may be covL'rcd by
lun^ tissue, but it is not greatly dis-
placed. The signs are usually found
on both sidesL
Renpiratory murmur feeble or ab-
•eot: irhpard. tlie expiratory mumiur
ia of normal ditratiun. unless prv)luiii;ed
coosolidaticn of tbr Inn;;, in wliti.-h
it will Ik> litf^h pitclied. Atii|th')nc
respiration and voice are observed if a
bronchial tube connetn* freely wtUithe
pleural cavity. Metallic tinkling.
Succuuion,
Splaahing sounds if fluid is present. No splashing sound.
Respiratory murmur usually feeble
and generally ikSvocioted with bronchial
r&leii. The expiratory sound is pro-
lunyed nnd low pitched. The re^pir*-
tun.' MiunilH lire sometimes harsh und
tubular, but never aniphonc. N'o mo-
tallic tinkling.
68 VViMONAHl' DIHEASEH
These diwiases can be easily difitinguUhed from chronic pteurUy by
tlie physiciil signs obtained on percuseiou nnd auscaltation. On iuspec-
iiou, jmlpation, and mensuration the signs are simihir.
PNErMOTHORAJC ANU PNEUMO-UYDKO- CHROKIC PLEURISy.
-tUUUAX.
Tympaaitic resonance over the up- Tyinpanilicix'aonuncv, if heanl atall^
per iwrtiou of tbe chest, tlatuuss over is liniiti-d to n Hiiiall s|Kice at. \\\n a[>ox
the Uiud. of tlie lung, usually inimediateiy be-
neatb the clavicle : llatneMt over thft
remuinder of the ulTecteU side.
Auneulitttion
Often amphoric respiration aud Never oinphoric i>espiration or voice.
Voice.
Diaphragmatic hernia is, fortunately, a rare disease. It possesses
many Bvmptoms and signs in common witli pnRumothonix, like which it
causes distention of one side, displacement of the heart, diminished
motion, tympanitic resonance, aud feeble or suppressed respiration vith
metiillic tinkling. The dlfffreutjal diagnosis depends mainly upon the
history aud the eym[>toni8, us seen from the foIlDwing table:
PKEtrMOTHORAX. DlAPHKAOMATIC HERNIA.
Uistory and Sgmptmnt.
Uiaally followtt phlhuisor&ccidcntal Often congenital; at times dyspnuea
perlorution t)f pleiim ; tlie ilyspnuta comes on Auildeuly, and us suddenly
may come on suddenly or gradually. diBappearB.
AuKuitation,
Amphoric respiration and metaUtc No amphoric renpiraHon, and th»
tinkling. metallic tinkLiu^ occurs independf^iuly
ol thi; i-espiralory niovenienis, and is
u»su(-ialetl niiti ruinOiinj; uf ga^ in itie
sloniacli or iiitor^tines. which usuiiUj-
fonn the contents uf Uic hernia.
pROoxosis. — I'nenmothorax without pleuritia is rare, but when it
does occur recovery not infrcriuently takes place. TI»e prognosis in
pyo-pucumothorax is very unfavorable. Death often occurs within a
few hours or at most within a week or two. Rarely imtients rtnrover.
Treatment. — Pneumothorax and pneumo-hydrothorax call for es-
sentially the tuunc treiitment. At first an opiate should be administered
to relieve pain. When flnid has collected and dyspuwa is great, free
drainage is ndvigabie, especially if the fluid hns become purulent; subse-
quently the case should be treated in the same manner »s emi>yenin.
Pntain recommends replacing the flnid and air by sterilized air, and
Tta favorably {Gazette d€s Uopitaux, April, 1889),
CHAPTET^ VII
PULMONAUY DISEASES.— C'y«/iHUerf.
BKU>CHiTI8.
BHON'CHiTia is au iuflanimation of the membrane lining tho bron-
chial tubes. It ufTec-U buth sides at tlie suinc timt?. and is therefore
(*alled 11 bilateral diiicusti. Five varieties of broucbitis ar^ recognized,
vis., Hcut«, subacute, chronic, cupillarr, and (ilustic bronchitis.
ACCTE AXD SrDAfUTE BItOXCUITlS.
Tiie syniptoma and the signs nf acute and subacute bronchitis are
BubBtantially tho siinie, except that in the latter variety thpy are less
marked.
Anatomrai. asi> PATaouKiii;Ai. Chakactekistics.— Tho morbid
peculiuriiies in aoutt* bronrliitis are those of ncute caturrlml iufiamnia-
tiuri affecti?ig the larger bronchi. There is congestion, tiiickcning. Mnd
softening of the mucous nicmbniue; slight exfoliation of 8ii)iern<-iat
epilliLdi:il cpUs, and bypci'seeretion of ibiu tnins|mrent niucns, frulliy
from admixture of air. This gnidualiy becomes translucent, and finally
yellow and vise-id as more leucocytes escupe from tlie engorged veseels.
Slight ccchymost'8 may iipiwar in severe cases, and theexpeclopalion may
show minute points of blood. This affection, usually confined to tho
larger tulu's in adults, has a tendency in children and the aged to involve
the capillary bronchi. The same conditions arc jiresont in subacute
brouchitis, but less marked.
Etiolody. — Old peojde and infants and those debilitated by disease
or vicious habits or subjects of the gouty or riieuniatlc diathesis are
most disposeil to attacks of bronchitis, especially if exposed to improper
hygienic conditions, whether of poor ventilation, defective drainage, or
deficient food and cli»thing. It is more previlent in climates exhibiting
frequent and sudden atmospheric changes in humidity and temperature.
Exposure to cold, especially when tho body is overheated, or to cxces-
eire heat lu a badly veuliluted room Is a frequent cause. Inhalation of
irritating gases, i)article(i of dust, or larger solid bodies frequently gives
rise to bronchial infinnimutiou. The Decisional occnrrem^ uf the dis-
ease in seemiag epidemics also suggests as the muse in some cases a
micro-org.inism.
SYMrrouATOLOBT. — Bronchitis is ushered in sometimes with a cbiU;
asaollj with pain in the back and extremities, attended by a Bensation
FUlSWyA R T mSEA sss.
iBas or constriction in the chest, soreness beneath the sternnm,
igh and frothy expectorition gometimos streaked with blood.
lost important /ii;;inf are absence of diilness and the presence «
smali, dry or moist rales on both sides of thy chest (Fig. 1*7).
)tion ill acute bronchitis shows the chest luuvemeuts uormitl
lat rtcoele rated.
)n palpfttioii^ the voc-al fremitus is normal. If tiiere is conside]
-etion in the tubes, brouchiul fremitus will be obtained, especial
Iren.
ptionai. — la a few caaes the movements axe deBcient ia those parts
supplied by broDuili ttmt ui-e [lartlally occluded by a coUectioo of t.^
secrelions,
ercussion, the resonance is normal.
rtional.—la some caws diilness is Tountl, especially over the lower po
e chest, due to accuniulnliuu of the Quid secretions. This dulnes
ttiay be removed by cuughiiig and free expectoration.
ascuHatiou in snimcnte bronchitis we frequently hear simply
lomcwhut bronchial sound without rales. In a<-ute, imd ir*
I of subacute bronchitis, sonorous and sibilant nilcs (Fig. 7^
lied in the early jiart of the disease, aud the resicnlar uiuf"
Store or less obscured by these nigiis. After from twenty-four tv
Igbt hours, the setrrelions from the mucous membraiiu become
it, and then the dry give place to large and small, mui:9t, mucous
he iutensity of these nUes varies; sometimes they are feeble, at
cs they nuiy bo heard at quite a distance from the chest.
jigns are seldom continuous. Often they are heard during a few
tiotis, and are then displaced by deep inspimtion or by forced
ion or cough. Mucous rales, even when numerous, may somtv
le entirely removed by free expectoration.
le of the brunchial tubes may become so filled with mucus as
0 diminish the intensity of the vesicular murmur, or even to
it in thoso portions of the lung supplied by the occludeU bron-
^foRo/.— If the dtftcase affect the smaller tubes, the vesiculartnurmur
.udible over the entire chest.
1 reaouance is not altered.
CHKONic DROjrcnms.
:Cal ,\no Patholouicai. Charac.tekistics. — Continned
;dn of the bronchial mucous membrane produces thickening
larity of its surface. The surface is occasionally (wler than
d of a grayish color, hut is usunlly of a deep pink or red and
■ of u purple hue. The congestion may be diffused or in
_ J
CHAPTER VIT.
PULMOK A RY DISEASES.— CoK/iVwrf.
BR0>*CHIT1S.
BftoxcHlTis is uu inflammation of the membrane lining the bron-
chial tubed. It affects both sidca at tlie fuiinc time, ami is therefore
called a bilati^ral UiHcase. Five varieticit uf bront-hitis arn rt»C(^iiized,
viz., acute, subacute, chronic, capillary, and plastic bronchitis.
ACCTE AND Bl'BACUTE BRONCHITlfl.
The syniptoma and the signs of acute and siibacnte bronchitis are
substantially the same, except that in tlie latter rariety they are Icm
marked.
Anatomical anu Patuologu al Cha«a< tf.kistus. — The morbid
pecnliiifitiea in acute broncliiii:^ are tliuse of ucnto catarrhal inflamma-
tion affecting the larger bronchi. There is congestion, thickeninjr. nnd
8ofl*ning of the miioons memhnine; slight exfoliiition of superficial
epithelial cells, and hypersecretion of ihin truiifiparent mucus, frothy
from admixture of air. This gmdnally bt-conics truutihicent.aud finally
yellow and viscid as more leucocytes escape from the engorged vessels,
Slighi ecchymoses may appear in severe cases, and the expectoration may
filiuw minute points of blood. This affection, usually confined to the
larger tubes in ailults, has a tendency in children and the aged to involve
the capillary bronchi. The same conditions are pre<*ent in subacnto
bronchitis, but less marked.
JCtiology.— Old people and infants and those debilitated by disease
or vicious liabits or subjects of the gouty or rlienniatic diathesis art
most disposed to attacks of bronchitis, eepecially if exposed to improper
hygienic conditions, whether of poor veniilation, defective drainage, or
deficient food and clothing. It Is more prevulent in climates exhibiting
frequent and sudden atmospherii- changes in humiility and temperature.
Exposure to cold. esj>eciany when the body is overheated, or to exce^
Bive heat in a badly ventilated room is a frequent cause. Inhalation of
irritating gases, pjirticles of dust, or larger solid bodies frequenily givea
rise to broucliial inflammation. The occasional occurrence of ihe dis-
ease in seeming epidemics also suggests ns the cause iu some cases a
micro-organism.
SvMPTOMATOLOOY. — Brouchitia is ushered iu sometimes with a chill;
nnialiy with pain iu the back aud extremities, attended by a sensation
lu other subjects of bronchitis, cough and expectoration are more
00D8tJiutIy preseiitr but ure variiible in character. In certain citiiea, aptly
termeil bnnieborrhci-a, exjiectonitioii is vory profuse, amounting soiue-
tlmc-s even lo two {juartB in twenty-four hours, more or letw serous in
quality^ but occasionally purulent. On the other hand, in so'called
dry catarrh, expectoration is Branty and viacitl; small, tough, tmiiB-
luceut nuiBses are expelled with extreme ditficulty during severe par-
oxysms of cough ac'cumpanied with great muscular effort, refiex laryn-
geal spiism, choking, venous congeetion of the face and neck, and perhaps
vomiting.
The siffus of chronic bronchitis differ from those of the acute affeo-
tion principally in the greater abundance of mucous nUes and in the
scarcity of dry rales.
Diagnosis. — Thti different varieties of bronchitis may be readily
distinguished from each otlier by the biati>ry. They are liable to be
mistaken for lutbma, emphyiteTiia, pulniouary beniorrhage, and phthisis.
Ki*om aftthtna, bronchitis is distiuguished by the «ymptomR and by
the hisUiry. Tlie spuamodic character of asthma, its sudden appearance,
the great dyspna-a, and tlie history of former attacks are sufticiont to
establish the diagnosis.
The physical signs in these two diseases differ rather in degree than
in kind, as shown in the following table:
Beoschitis.
lu the early staj^e. dry rAles, oompar-
atively few ia number. Later, cluhng'
the second or Ibird day, IhcKc i^ive
place to large and Hmall raucous rales.
ASTOMA.
Durln^^ Uie jMii-oxysm, sonorous and
sibilant i-Ales are ven- aliiintlunt. Tli«
foUowinff day eitlier tlic i-ef>piratory
murmur may be nortiml, ur an abun-
dance of moist rAles. duo lo tlie utl«a*
dant bronchitis, mcy l>e pi-esenU
nd \
Simple bronchitis can be easily distinguished from well-marked cases
of emphyaemn, but the latter disfuse is nsinilly ussociuted with more or
h'ss inflammation of the bronchial mucous membrane. The distinctive
points in the two diseaseii are as follows:
BRONcurrta Ewhtseka.
insjiKction.
Form aad movements of the chest Prominence of llie upper portions of
iiaturaU Uie chest, barn;I-<thai»ed. witli more
or less constant cxpnnhion of iIh; su-
peritir ril>s, whit-li are *«levaled In in-
spiralioii as thoiitrli united in asinela
burn'. DoT)n>s8ioii of tl»e soft purls in
iiLHpii-ation, n<.>tal>ly uliove ibe cluviL'l»fs
and viernnin and at the lowttr portions
of the eliest.
ACUTE jtJioxcmn^
£)3
BRONcmns. Ejcphtsema.
PerciU9ion.
Resooanoe normal. In exceptional Vesiculo-tyiiipaaiLic reaODaocemorfe
ln>itaac-es Blight dulnesH, especially or less marked.
over the lower part of the diest.
AttMcttitation.
Vesicultu* mumiur Rom^times incom-
plete. The expiratory murmur not
prolonged. Numerous rdies.
The respiratory sounds feeble, buv
expiration gro»tJy prolonged. Com-
paratively few rAles^
Bronchitis is distin^Uhed from pulmmwry hemnrrhage by the ])if--
tory »ni] churacter of tho eputa. The pliysiml signa are ideiirical, ex-
cept tho abseuce in. the latter of dry nUes. with the harsh qtmlitv of
rcspinitioii often found in bronchiti}!.
Before the days of auscultntion Hiid percussion, chronic bronchitlB
was often mifttaken tor phthixijt, bnt at present the physical si^s render
Lheir distinction com [»a rati rely easy. They differ in the following par-
ticulars:
Bao.NCHms. P11TUIS1&
Inaptction,
Pomi iU3(l movemenia of the chest Ver>' early in the diseaw more or
oaturuL less depression over \\w uffected re-
gion, with lessened expansion.
Rhonehial fremitus,
voL-ai fremitus.
ficBooance aormaL
Rale« found in ttiisdiseoAC are e<|uully
diffused ovvr both liin^. Expiratory
murmur not notably prolonged. Res-
oaauco natural.
Paljialion.
with normal Vocid fr«mitu» exaggerated.
Percu99io7t.
Store or leas dulness over the affected
regions.
Auae\dtation.
Kales and otlier signn of consoUdar
tion loc'ilized. tintiled to l\ve ixirtioo
of lung airected. Untnol 10- vesicular
respiration and exo^crati'il vocal res*
onaoce.
ifferowciintf.
No bacilli of tuberculosis in tli« spu* Tubercle bacilli ; elastic dbres.
turn, nor elastic fibres.
pROGSOSis. — Acute bronchitis generally terminates in recovery with*
in a few days or at most two weeks, even without treatment. It is
dom serious except in iiifnnts and the aged, or very feeblo patieutK in
whom it not infrequently develops into the capillary form. In tJ»e dia-,
ihetic or cachectic, oft-re|>eute(l acute attacks are apt to occur and leal
to chronic bronchitis. This latter form, though in itself rarely fatal, it
PVLilOyAHY DISEAfiES,
not easily curublc and groilnally tciuU to the derelopmcnt of bslbma or
more serious couditions, such us einphyscnin, brouchiecttwis, alclecUiaia.
and fibroid phtliisis. Kmphysemii is peculiarly liiible to reiiuU from
dry uHliirrh of the bronchi.
Tkeatmest. — In many cmscs the riru/e dlse^ae miiy be iiborted, if
Been early, by ;i bol HLiinulating dniugbt ut bed-timo and the Applicntion
of siunpisms over the chest; or ti ten-grain dose of Dover's powder,
quinine, or pheuacetine, eight gniius of untipyriue, five of acetanilide,
or a moderately full doue of jaburandl or its active princ;iple piluoarjiliie.
Failing in this, we may Ui^e nitli adv:tntuge smiil] Unscn cf opium ur of
aconite: or troelierf u( morphine, anlinionv, and ipecac fonipound (Form,
Hi); or aeomhination of morptiine, amiuouiuin chloride, and tjirutr emet-
ic (Form. 1); or troches of compound licorice mijcture (Form. 34) until
the exiiecturation beeonu'j! free. .Subser|nently for cough it will be
found beneliciul to iidminister extract of cauualia iiidiea (AUfU'e) gr. j|
to i, extract of hyoeeyamua (alcoholic) gr. i to i., extract of nux vomica
gr. ^ to i, f|uinine hydrobromate gr. i. to ij., mouol)romaled camphor gr. ij.
to gr. iij. every four to six ho[u>. Animonium earlMJniite with email doses
of morpliiue (Form. 5) h also U)<efnl. If the cough is not very trouble-
some, we may give poiiifiaium clilorate, 3 as. to 3 i. daily in divided doses.
Tonifa may be reqnircd until resolution is complete.
The subacute form of the disease is treated iu essentially the same
manner.
Chronic bronchitis is often dependent upon some constitutional dis-
onsf or diatliesia which should receive our firat iitteiition, together with
inipruvenicnt a^ far as jio^^iblc of the hygienic iturroundingK, and the
correction of vicious Iiabite. If it is due to the dnrtrou» diatht^ii;, ar-
fionious acid, gr. ^^ to gr. ^ three times a day, ia esjief-'ially in<]icatetl.
For the rheumatic or gouty diathesis, oue or more of the following
remedies uiuy be giveu from three to five times a ilay : Potassium acetsta
gr. XV., resin of guaiac gr. x. to xv., or its animoniuted tincture " ss. to
3i., polasaium iodide gr. v. to x,, tincture of colchinum ilix. to xx.
Even in these chronic conditions, salicylic- acid or sodinm Hilicrlate is
sometimes very beneficial, as also salol. In some iTistnnoes undoubted
bonctit is ilerived from phylolaeoji. In a large percentage of these cases
the digestive organs will be found at fault, ant) the greatest good will
follow a judicious use of hixatives and the administration of remedies
which will correct gastric and intestinal indigestion.
Many patients having the gouty or rheumatic diathesis are subject to
eructations of giis or sensations of weiglil and fulness of the stomach
shortly after eating, or to flatulence. The indications here are to hasten
digestion and prevent decomjMwition of food. To this end I have often
found of grejit service a c:ipsu]e containing the following, given before
meals and at bed-time or before and after meals according to the sever*
ity of tlie case :
CAPILLAHY BROSVUITIS.
B Capftici i;r. ss.
Uydi-iistinae hydrochlorat.. .- gi'- f .
Extmct. HMC\s voiiucu; tir. i.
AciJ. juilk-ylici. Sr. ij.
Pupain (Carku p:i|Miji-uJ gr. iij.
M. Incliwe in Oiipsule.
The liydru<.-ltlorutc uf hyilrajtUric here u«(h1 is tlie article comtuooiy kaovrn
ms ftiicU in modtcine. but in pbarmacy and cheinistr}' it is mure Lvrrvvtiy i«nu«d
bjrdrochlomte of bvrberine.
When the dipcrtive troable is mninly jpistrie^ the salicylic acid is
preferable to prevoot dccompositioa; bat if flutulcueo i« u jiruiuiueiit
sjinptum, sulol will be found efficacious. Of the digestive agi^iits, pa-
paiiit: ia tu lue must sitlisfactory, but somotimeif pepisiu, {»uncr(»iLiii. iiud
iiigluviu arc useful.
If tliL' iilTcctiuii ori^inute^ in syphilis, potiiRftiuni iodide in full doses*
with mercury hicliloride, will have the lw«t effect.
When the disesise ia of simple ciitiirrhal origin, potussinro chlorflte,
3 L daily in divided doses, ia one of the best Iniemal remedies. I'rej>-
arations of »c{Utll, senega, ye rba santa, and cncalyjilui^ are i^umelinies
beneficial. Vegetable and minenil tonics, cod-liver ui), and prejianilions
of malt are indirated for debility.
Peraiiitent' counter-irritation sometimes aids greatly in promoting a
cure.
LocoUji, inhalations similar to those recommended for diseuiics of Iho
throat {Form. fi2, ^3, 'it, 09, 72, and 73) aie beneficial, and in some
instances, particularly where there is free secretion, great relief is oh-
taiueil from the inhalation of thymol gr. ss. to i. to 1 i. of liqnid ulbolene.
Cou^'h niay i'c relieved by small doses of mori)hine and iinimoniitm
curboufite (Form. 5), by troches of morphine, or cannabis indica and
terpin hydrate compound (Form. 33), and often by setlative inbalaiious
(Form, 53--5i»). For dyspniiea, the nitrites in some form ai* specially
bencticiaL Great caro shonld be taken on the part of the piitient to
avoid damp feet, exposure to night air, cold drafts, overheated atmos-
phere, and the inhalation of irritating substances.
Wlipti pnu-tinable, chanjie of climate is often highly beneficial. When
the lironchiat secretions are profuse, the patient is likely to ohtitin most
benefit in a higher altitude with dry atmosphere: if the secretions are
scanty or t-enacious, a moist climate with an eqnable temperutnre like
that found at the sHtshore in .Southern California or along tlie coast of
the Gulf of Mexico is raoro salutary.
CAflLLAItV BROKCHITIS.
Capillary bronchitis consists of an acute inflammation of the mucous
lembrane lining the capillary hronrhial Lubes. It usually results from
"extension of inflammation affecting tlie larger bronchi, and it affects
both lungs at once.
Anatomical asd 1»athoia>oical Charactkkistics. — Evidence ren-
06
PVLitONARY DISEASSa.
:
dered by aatopsies indicates thtit capillary bronchitis without accom-
l>iiiiving inflammation of the air vesicles is very nire. In most cji8e« tho
inucuuB membrane of the larger tubes is tirst involved, and during tho
|trugrc8;3 of tho disease the small tubes becoino more or less blocked with
Beereliou; this bus ii valvc-like ucliou, which preventu nir from entering
aomu of the alveuli during inspiration, but aUuw.<i it lo escape in expiru-
lion, so that these air colls collapse, and as a result the cells in adjoining
Jobulcs are correspondingly disteudeil. The lung consetjueutly lias an ir-
regular mottled iipiieamnce, from interspersed sunken atelecljilic patches
and ele%-atcd distended air sacs.
Etiology. — The etiology of capillary bronchitis is that of acuta
bronchitis, it usually resulting, in childrcu and the aged, from extension
of int1:immation from the hirger tubes.
Symitomatology. — The principiil symptoms, in addition to those
found in acute bronchitis, are severe dyspno>a with lividity of the sur-
face and great prostnition, following marked febrile reaction and accom-
pauied by rapid respiration and a weak pulse.
The principal sujiut are: absence of duhiesa, iiccasionallv exagger-
ated resonance and sibilant or subcrcpitunt rllles on both sides (Kig
K).
By inspection, respiratory movements are found to be rapid, and the
countenance shows the effects of imperfect aeration of the blood as the
disease advances.
Palpation occasionally yields a rhonchial fremitus, dne to disease in
the larger bronchial tubes.
I'ercussion obtains a resonance normal or slightly exaggerated over
the lower portions of the chest. This exaggeration is duo to emphysema
of a portion of the air vesicles, which results from complete occlusion of
some of the smaller tubeii, with collapse of their terminal vesicles, and
consequent dilatation of the surrounding air cella.
Auscultation usually furnishes signs of general bronchitis, and in
addition to these, wirly in the course of tho affection, sibilant niles are
found iu great abundance, which a little later are n-phioed by aubcrepi-
tant rales. These subcrepjtant rales, when numerous and attended bv
the symptoms ah'eady mentioned, may be tjiken as a jKt^itive sign of
capillary bronchitis, but a few are frequently heard over the lower por-
tion of the chest, simply from gravitation of fluids, or of the products of
indammation from the larger bronchial tubes.
Occasionally a few subcrepitAnt r&les are heard, near the borders ot tho lung.
even In h<>altl).
Subcrepitant niles, when confined to the apex or to the base of one
lung, usually indicate that the capillary bronchitis producing them is
either of tuberculous or of emphysematous origin.
Diagnosis. — Capillary bronchitis is attended by signs similar to
CAPILLARY BROHrHms.
n
«uiiie of those fouiiil in ustlima, pueumoiiiu, or piihiioniiry UMlema. This
disease uiaj be Uistinguishcd from asthma by the history.
Capillary bronchitis cuunoi be mistaken for the first or uecoud etago
of M»rr /tiieuiHonitt if we bear in miiitl that ueither of ihese stages cauees
many sibiknt or suberepitaut riileti, which are abundant in bronchitis^
and tbut both sUges are iittcnUed by marked dnlness, while in bronchitis
resonance is either unaltered or exaggerated. From the tliird uUige of
lobar pneumonia this disease is distinguished by iho signs obtained by
palpation, pereussion, and aascnltation, as follows:
Capiuoay BRON'CHms. Lobar pkeumonu.
Palpation,
No increase in the roeal fretnitiiB. Vocal rrcmitus increased.
PervHAgion .
ND<]nlnes!i;occaaionaUyexaggerut«il .More or less duloess.
reAoaaot'e.
AiittcnUation.
Subcrepitant rAles over botli luogn ; Subcrapitant rAles conllDeil to one
4tiese rAles are of low pitch. Ktdv, uver the ulFected lunf; ; these rales
nre hijfli in |>ilch.
It is difficult to distinguish between c^ipilhiry bronchitis and hhtlar
ptuumoHWt with vbich it often coexists; but the diagnosis may be
made fairly certain by attention to the following points:
Capillary bronchitis. Lobular PNEiniONtA.
SymptoiiiB.
Moderate fever. Moderately accel- High fever. Very ra]>id respiration,
^erftted respiralioa.
Percitaion,
No dulne«s. but possibly exaf^gerated Limited unchanging spots of diilness
resooaiice. """y »'(im';tinit'« be delected, tlioiigb, as
the disease usimlly (Ktcure in children,
in whom dulne«s is diflicult to detect,
this sign is lialde to escape observation.
AwteutiaHon.
UiUtitudes of One dry or moist rAles The r&les are limited In area unless
over every part of the chest the two dtMOiies coexist. Bronchial
breathing can occitsionally be detected.
Capillary bronchitis is distinguished tram, pnlmoiiary isdetna hy ih^
following symptoms and signs:
Capillary bronchitis.
PtXMOSABY CEDEUA.
History.
Febrile symptoms.
Usually shows an antecedent acute
4trouchiT.is several days in duration.
No febrile symptoms.
This ulTeclion usually follows some
protracted diseaite, an typhoid fever, or
aflectious of tliu heart or Icidnevs.
9b
S'ULMONARY DISEASES.
Capillary bbomchitis.
PercvuaxoH.
Hesonance normal or exa^erated.
PrLMONABY UCI>EMA.
DutneBB over Ute loiter part of both
Lungs.
Atuscultatiim.
Usually aumerotu r&les in Uie larger Signs of general broacbitis Ire-
tubes, queatly absent.
Capillary bronchitis is distinguished from phthUis by the historj' of
thp case, and by the fact that the subcrepituiit rdles of the latter affec-
tion are liuiitud to u smaller portion of the ehest, which is usually over
the apfx of uuu luug.
pROitNusis. — This diseiise iu severe casea may j>rove fatal withiu
eighteen hours, but uaiuilly it extends over tour or five days. Tlie rate
of moitality, though difTerently estimuted, is extremely high, e«pecinlly
for the aged !*nd for infsints under one year. When following whooping-
cough or measles, or complicjiting any serious organic Trouble, or occur-
ring in delicate chilUreu, the prognosis is also unfavorable. CoUTalcs-
cenco in any event is apt to be tedious and recovery iucouiplete>
attended by more or less permanent crippling of one or both lungs by
collapse of the alveoli and hyperplasia of the connective tissue. The
prognosis should therefore always he guarded.
Death generally reeultg from ai'iihyxia, ariil its approach is indicated
by signs of extensive involvement of the kings, difticult e-xpeetonttiou,
cessation of cough, dyspncea, cyanosis, or the symptoms of collapse. A
temperature of 105" F. or more, if long continued, is very uufavgmble.
Tre.^tment. — Opiates should not be used in tiiis disejisc excepting
in very small doses. Early in the disease, ammonium chloride with
syrup of ipecac will bo useful; but after two or three daj's, more benefit
will be derived from ammonium carbonate. Inhalations of steam, or
steam impregnated with sedative remedies, have a soothing effect on the
ioflamod bronchi (Form. 5:^-20). Ammonium iodide iu snntU and often
repeated doses is sometimes a most eflicient remedy. Strychnine, gr.
■^ to •^, is a valuable remedy in this affection, as sonn as symptoms of
exhaustion supervene. Alcoholics should be used tostistain thestrength,
if the ammonium carbonate doe* not seem sufficient. Oongli and any
BpasnuHJic tendency may be relieved by camphor or the bromides.
In childi^u it is necessary to wutch carefully the secretion of urine
iu order to avoid a freqiicut cauue of dyspiuea: digitalis intenmlly and
cataplasms over the kidneys are usually effective in promoting free renal
aecretiou (Simon: Medical .»!/Tjr, January, 1800).
The most efllcieut remedies are ammonium rnrbonateand strychnine,
with large jacket poultices kept constantly warm and moist and cover-
ing the whole chest. The diet mnst be nourishing.
PLASTIC BUONVUlTiS.
99
PLASTIC BBONCHITIS,
Symmjvis. — Pscudo- membranous, croupous, exudative, or fibrinous
brouoliitis.
Broiicbitia issometltneacomplicHted by exudation of fibrinous mntcer^
with the formation of falsw mymbniiie or pluHtJc cadts in the smaller nir
tubes und their ramiticntions nud ocragioniilly in the larger brouchL
This affection may be acute or chronic.
ASATOMICAt AXD PATHriUHilCAL CUAnACTF.Rt^TICS. — The afTeCtlon
is generally chronic, and usuiilly involves the smntltT brouehi only. It
ta most frequently circumscribed, but may be diffuse in ucute csecs, and
is marked by exudation from the surface of the bronchijil nmcous mem-
br»ne *>f fibrinous nrnterial, forming casts, which have a laminated
structure, ilie layers being eepjimble wlien dry. Thi? pubstance is com-
posed of conj^hited alhnmin (soluble in alkali), ooittuining leucocytes
id fotglobulcRj fometimes octahedral crystaU, a few red cnrposclcs,
I and epithelial cetle. It is Urm and of a white, gi'ny, or yellow color»
occasionally spL'cked with blood. tSccmingly the mucous menibrane
beneath it is not seriuusly implicated, but may be either cougested
or pale.
Btu)I.o(iy. — The ultimate cause of plastic bronchitis is not as yet
known. Though poverty, exposure, and feeble health are mentioned as
favoring its occurrence, excepting diphtheria, no particular diseases or
conditions have been aseertuined to bear special causal relation to it.
Authorities differ as to its comparative frequency relative to age and
sex. Ac<-ording to I'eacook it more i»ften uffcctd meu (Transactions of
the Pathological So<:iety, Vul. V, Ijiiridoij).
SvMlTOSiATOLOOT.— The prominent symptoms are: hacking cough
with aciiiity expectoratiou, followed, after a varying interval of from a
few huurs tu several duys. by n sense of constriction in the chest, aud
dyspntea wbicli may be very severe. The cou^h gi'adually increases in
severity, the expectonttion becomes uiore abundant and perhapii tinged
with blood or accompiinied with profuse luemoptygif, and finally small
fmgnients of the fibrinous matter are brought up or, after severe parox-
ysms of cough, complete Gists of the bronchi. These ca^ts maybe solid or
hollow, varying in diameter up to half an inch and in length from a
fraction of an iuch to six inches, the counterpart of the bratiching bron-
chial tree.
The physical nignx are those of ordinary hronchitia. superadded to
which are the signs due to partial or eomplete obstniclion of w)me of
the bronchial tubes, via., weakness or ahsenue of the re8i)ir:itory mur-
mur, with dulness where portions of the lung are collapsed. These
signs may lead to an erroneous diagnosis of phfiriaif or of ptuumonia.
From the former, plastic bronchitis is distinguished by absence of catch-
ing respiration, pains, und friction sounds; by the speedy occurrence of
100 PULMONARY DISEASES.
dulness with loss of the respiratory mnrmar and vocal signs, and hy the
preRenee of signs of hronchitis in other parts of the chest.
We distinguish it from pneumonia by the absence of bronchial
breathing, and, when collapse of the Inng occurs, by the sudden acces-
flion of the signs of consolidation. The differentiation from ordinary
bronchitis rests entirely upon the expectoration of fibrinous casts.
pROGSosis. — The mortality in the acute form la about fifty per cent,
death occurring in from five to fifteen days. Though complete recovery
from chronic plastic bronchitis is rare, death simply from this form is
equiilly so.
Treatmext. — During the acute attack or during exacerbations of
the chronic form of plastic bronchitis, the treatment should be essen-
tially the same as that for membranous croup.
Stirling recommends inhalations of lime water, strong or dilute or
combine'! with a two to five per cent of sodium bicarbonate, in which
the casts are soluble. Turpentine, cubebs, and copaiba tend to render
them more plastic.
At other times, potassium iodide will aftord some relief. The gen-
eral health must be maintained and all causes of cold avoided.
A warm climate is advisable, and if possible a sea voyage.
DILATATION OF THE BRONCHIAL TUBES.
Synonyms. — Bronchiectasis or bronchicatasis, knife-grinder's rot,
filer's phthisis, cirrhosis of the lungs. It is sometimes termed fibroid
phthisis.
Axatomical and Pathological Characteristics. — Dilatation of
the bronchi is usually associated with fibrous induration of the lungs or
With vesicular emphysema. It is generally found in the smaller tubes
over the middle or the lower portion of the lung, more frequently on
the right than on the left side.
The affection may be general or partial, single or multiple, and may
oe fusiform, cylindrical, or saccular. The bronchus so affected may
continue of normal calibre on each side of the enlargement; it may be
narrowed or obstructed on either the distal or the proximal side; or
obliterated on both. The walls of such a cavity frequently show atrophy
of the mucous membrane, with its secreting glands, or they may present
H surface more or less irregular and granular. The submucous elastic
tissue is liypertrophied, the muscular coat normal, atrophied, or its fibres
widely separated. The cartilages may be thickened or may have par-
tially disappeared, but the connective-tissue elements are greatly hyper-
trophied, and the adjacent interstitial lung tissue is involved in the
flame process.
Etiology. — Bronchiectasis may arise from increased pressure within
the bronchi or from weakening changes in the walls or surrounding lung
DILATATION OF THE BRONCHIAL TUHES.
101
tissue. It may be the result of alveolar collapse or ntelectasU or stenosis
of the bronchi from any cause, but chiefly from chronic bronchitis, also
from phthisis uud occaniiouully from ohl pleuritic ttdhesious.
SYJirTOMATOLOOT. — Puticuts affcctccl with bronchiecuaia often have
the gcnenil ajtpc^iniuce and symptoms of phthi^ieui subjects. The prin-
cipal distinctive synijitom i^ the expectoration of opaque, purulent, and
extremely offensive sputum, which is very abundant, measuring some-
times three pints in twenty-four hours.
Theprinc-ipa! »r<7»>'nre: more or less duhiess.. and a hiirsh inspiratory
murmur with numerous nilcs, all of which signs may rapidly change.
Inspection shows imperfect expansion of the chest, prolonged, labored
expiralion, with more ur less lixity of the chest walls, and depression of
the intercostal spaces.
The signs obtained by palpation, perenssion, and auBPullation vary
greatly at different times, according to the amount of fluid in the tubes
or cavities. This variation in the signs is of itself almost diagnostic of
the disease.
By jHilpatioD, the rhonchial fremitus may or may not be obtained.
The vocal fremitus may be normal, but it is sometimes incretised, at
other times diminished.
By percussion, some dniness is usnally obtiiined over the affected
Inng. This is sometimes removed by free expectoration, and may then
b« followed by vesicnio-tympanitic or perhaps a craclced-pot resonance.
Dulueea is apt to be located at the middle or lower part of the lung, and
is most common on the right side. Light percussion nsunlly elicits dni-
ness. when a more forcible stroke would produce a somewhat tympanitic
sound.
On auecnitation, M'e sometimes Cinl the respiratory munnur sujv
pressed over a considerable portion of the Inng, while round nljoot it the
iiounds may be harsh and loud. A little later, free expectoration hnving
eraptietl the bronchial tubes and cavities communicating i\ith (hem,
reapinition may become hroncho-vesicular and intense. M-here at tirst it
could not he heurd. The respiratory murmur is often associated with
numerous ndventitions sounds of every variety from the dry, sibilant
rdle to gtirgles.
Vocal resonance is subject to similar changes, and from the same
DiAONosis. — Bronchiectasis is most likely to be mistaken tor pHthma^
from which it can only be distinguished by attention to the expectora-
tion, and to the mutability of the physical signs. The distinctive
feAtordS between the two are as follows:
Bronchiectasis.
Fremitus changeable.
PHTinsis.
Pakyation.
Elxuggerated vocal fremitus not unl-
rei-)ial, but when pi-ewnt uyuatly con-
itanU
102
PULMONARY DISEASES.
BRoscHiecTAais. Phthisis.
PercuMion.
Dulness, orvesiculo-lympanUic reso- More or less dulnesis, which remaitiB
nanoo, often clianfiiDjr tvoiu one to the constant.
other during llie «.xaniinalion.
AitJKuItation.
The signs aw usually found over the Tlie signs for several months are
toweror middle i)ortioD» of one or both
lun^, and chansf vapidly as the re-
sult ot deep inspiration or cough.
UBually confiiieU to tlie upjwr portion
ot one lung. They are not loalfrially
altered by cough or by deep inspira-
tion. They are confiiittl to a inore
Ifmittid splice than Iht; signs of dilata^
lion of the bronchi.
Prognosis. — Bronchiectnsis rnng a chrouic conreo, and, though not
£Eite] in itself, is iuductivo of other pulmouarj disease, especially predift*
posiug to putrid bronchitis, and gaD^reno or abscess of the liin"^. It i«in-
rurnhle and, Ixting secondary to fhronic bronchitis, old pleuritic adhe*
siondiuid thickening, ateleccasis or libroid phthisisjit^proj^uoeiti depends
npon that of the associated disease.
Hectic, rapid ptdso and {>rogres8iY3 enmciatiun with uight sweats are
unfavorable i<yniptoins, but thustj syni]itoni(<, aLteuded by must abundant
fetid expector.ition and great aathenia, giving thfi iippeamnce of the hitit
stage of consumption, sometimes disajipear in a partial recover}*, ro thut
the patient lives iu fairly good health tor a year or two.
TaEATiiKNT. — In bronchiectasis, cod-liver oil, calcium cbloridf, and
vegetable tonics are generally demanded. Some of the preparations of
eucalyptus globulus or griudelia robusta are opcaKionally beneficial, as
are also copaiba, turpentine, senega, and stjuillR. Potjiaaium or ammo-
nium Iodide aud arsenic aro also useful. Inhalations of turpentine,
caniphur, iodine, aud carbolic acid uro frequently useful in checking or
altering the secretions (Fomi. 60, UT, 68, 70, 71, 73). Counter- irritation
should he tried.
ASTHMA.
Asthma is a spasmodic ailcction of the respiratory apparatus, chieflj
characterized by paroxysnml attacks of dyspnoea.
Anatomical and 1\vthological Cji.\.kactebistics, — There arc no
recognized morbid changes peculiar to a^tthnm. It is a functional dis-
order or neurosis dependent upon some physical condition not yet thor-
oughly understood. Many hypotheses luive been advanced to explain
the mechanism and ciiuse of asthmatic dyspno^t.
Though none of them have become entirely adecjuate theories, tha
bronchial spasm hypothesis in the one most commonly accepted. Ac-
cording to this, the dyspncea is due to spasm of tliu annular muscular
fibres of the bronchi which narrows their calibre aud obstructs the pas-
ASTHMA.
lOS
eagfl of air. That bronchial constriction occurs m asthtna ie proved by
the constant presence of sihilant niletu
Som«>, with Wintrich, cougider Bpasm of the diapliragm ae acconnt^
ble for tho diftimlt brenthing.
Weber and othera hold that it is due tt) vasomotor relaxation pro-
dncinjT congestion and tumefaction of thu brouuhiul uiiicaiiij mL-nibnnio.
Crystals and ejiirals found in the sputum by Ijcydfii ami Curtu^'limiinn,
and supposed to lie causative, as irritants to the bronfliial nincous inein-
biiiiie, have be«n tisoertained to be present uot alone in afthnia. but also
in many pulmonary disorders.
Etiiilovy. — Altliougli tho nltimatf cause of asthma is unknown,
certain predisposing conditions aro recognized; according to Sidter^
horfdity is to be traced in forty per cent of all cases; others claim
a etnitller {wrcentage (Lazanis tn Deutsche tnediciHt^iir ZcitHtigt
Tho neurotic temperament seems to favor it, jMirticularly if coupled
with plethora; also the rheumatic ami gouty diathesis. It is common
to all ages. Its victims are most often males, those preferably of tho
npper class. Soltmnua thiuks it especially common among the Hebrews
<8hattuck: Cyclopedia of Diseases of Children, Keating). Asthmatics
nsually suffer must in wiiit4?r, ami the attacks occur generally at night.
Its exciting causes may be considered iw those acting directly a£ irritants
to the terminal fibres tif the vagtit^ or sympathetic? in tho hroiichial
mucous membrane, and tluise acting reflexly from a greater or leas dis-
tance. Bronchitis is the most frequent exciting cause uf :LSthma. An
asthmatic attack may arise from itdialation of dust, smoke, fog, and
other vnpors, pungent fumes, odors from certain plants, pollen, and
emanations from animals. Indeed, the list of substances capable of
exciting an astlimatic paroxysm is long.
Different patients are affecte<l each in his own peculiar way, one
by the pre^ienee in theatmosplien'of one substance or condition, auuther
by one totiilly different. The diseases and conditions which by reflex
impression upon the bronchial nervous mechanism excite the asthmatia
paroxysm are also very numerous and varied, Not infrerjnent imuscs
are found in irritation of the upper air passagoe by impalpahle particles
diffused in the atmo^^phere or by such deformities as septid detlectioDj
exostoses, naaid polypi, and hypertrophy of the tonsils.
Asthma has bec^ii attributed to the pressure from a hypertrophied
thyroid, an aneurism or other tumors, or from enlarged bronchial glands.
]t is frequentlydueto somo disorder of thealimeutiiry tn!<;t. such as (gas-
tric indigestion or neurosis, duoilenal catarrh, hepatic torpor, constipation,
intestinal worms, or hemorrhoids. It may be duo to abdnminal tumors
or derangements of the gen ito- urinary system, as for example calculi,
prostjitic enlargement, enuresis, 3pemiatorrh(£A, sexual abuse, and. in
women, ovarian, uterine, and vaginal disease. Diseases of the heart, of
lOi
PVLWMfdRY DIfiKASES.
the kidney, or of the brniii may cause iisthiiia, as iimy also cerUin iskiu
diaeasea — eczema, iirticitria, miJ bur[>c*ti, fort'xaiiiplo. Puiik't ile»'i-it>e.>iau
epileptifonn variety of luthnia {Journal de Midecine de Paris^ IbbO). It
8oeni8 somciimes Co occur from j>re$i-itce in the blood of poison, such :;»
the CI ramie, gouty, rheuiUHtic, or iimlariiil (Hobinsoii, McUU-al yvK'n, IWI'O),
or certaiii ehtMuieaU presumably at-tiug through the circuUriun upou
the respiratory eenti'eg, Uut back of all these favoring conditiouH uiid
exciting cnuses is something, as yet unknown, which is nn iniportflut if
not the chief otiologioul factor in the production of the disease. Cases
occur iu which the most careful examination fails to Gud any predispos-
ing or exciting cause.
SvMPToUATOLOGT. — Asthuia is characterized chiefly by jKiroxysms of
dyspncRa, with striduluus respinition und the evidences uf deficient uen>
tion of the blood. In some indtamrcs ati attack may l>e foretohl by sen-
sations of mental deprcjwlon, drowsiness, or iiritability, or iheir oppo-
ailes; or by byperfusthesia, heiuliiche, a sense of constriction of the
throat or chest or frequent desire to gape or sneeze. Some attacks begiu
with coryza. which may develop iuto bronchitis. Usually the onset is
sudden: llie jmtieut awakes from sleep, wheezing and perhaps gasping-
fur breath, with a sense of thoracic constriction, and if it be bis first
attack he fears inimiueut suffocation. Brejithiiig becomes more laborei1„
accompanied by venous turgeacence, congestion of tlie face and neck,
bulging and suffusion of the eyes, dilatation of the nostrils, and profuse
perspiration. The pulse decreases in strength with the severity and
duration of the paroxysm. The ])aroxyem8 usually last from two to
four hours, but the attack sometinicii terminates iu a few minutes. It
may occasionally continue for weeks. Recurrence of the affection re-
sults in some patients only from certain exciting causes, in othei's more
or less poriodienlly — daily, weekly, monthly, or yearly.
Diurnnl attacks arc rare. Frequently the paroxysm terminate* in a
mild bronchitis, iietween attacks the condition of usthmiitic patients
varies in degree from a conditiou of apparent liealrh to the state of
more or less constant suffering from the disease or its sequelie.
The principal ."I'yjf.f are labored and wheezing respiration, attended
by numerous sonorous and sibilant rules, which may b? heard, and
often felt, over the whole chest.
The imtient is usually found in the upright position. Respiration is
labored, inspiration being short and jerking, and expiration j)rolonged.
Thedyspncon is chiefly expiratory. The respinitory motion of the chest
is greaitly diminished. Severe cases show the signs of deficient oxygeuih-
tion of the blood.
Inspection, palpation, mensuration, and percussion yield no distino-
live signs. The resonance may be normal or slightly exoggomted.
Uy Kuscultatiou we obtain jerking or cog-wheel respiration, with a.
groat variety of sonorous and sibilant rAles. The respiratoiy murmur
AUTHJIA.
105
u usually harsh and more or lesa tubular, tirn reeicalar element being
auppresaed. Vocal resonancu ia normal.
DiAONOKis. — ^During a imroxysm, astlima iriav Ir' miatnkon for
eardiac ilygpntpa, capillary brouchitU, or spui'iiioilif laryugeji! iiirectioiis.
From the first, it may be distinguished by the lii&torv, hy tlie al»ence of
cardiac signs and by the preeeace of a grejit number of ijonornug and
eibilunt riiles.
Asthma differs from rnpiikiry broncbitiH in its history, and in some
of the eigne obtained by inepection und auscultation, as shown in the
following table:
ASTHIU. CAPILLASY BROXCDITU.
Snmptom$,
A sudden attack, willi usually a hU- Dyspaceu comes on ^-adually, usu-
tory of former jtaroxysras. Febrile ally preceded by acute or subaouto
symptoms not nmrkeil. bi'oriubitis. Febrile eymptouis pro-
nouiici^d.
Inspection.
Re&piraUon labored, but not greatly U^spiratiou not only luboi'ed, but
•oMlerated. also rapid.
AuKuUatioH.
Sonorous and sibilimt r&les, usually Mucous rdles likely lo precede tha
followed by large and small mucous sibilant i-dle?>, niul tlic silijlaot to bft
rAlefl. followetl by ibesubcrepitant.
Spa^f/wdic affections of the larynx are distingniehed aa follovs:
Asthma. Spasuodic labynoeal AFFEcnons.
Dyspnoea expiratory,
Rdlwi.
No loral lorynjreal signs.
No cliango m voice.
Dy^pacea inspiratory.
No tiles.
Laryngeal si^s sometimes positive.
Voice a1teii*d.
After the paroxysm, the signs of asthma are tike those of bronchitiB>
bttt tbey last only a few hours.
Asthmatic symptoms often occnr during the progress of pulmonary
iphysema; but these two diseases may be easily distinguished from
''eAob other by the history. In ertipffyAeutti,tiS in cardiac disease, dyspnoea
is permanent, and aggruvntod by exercise; while in asthma the dyspnuea
usually ironies un during the hours of rest.
pBO(tso8ii% — Aaliimatic paroxysms arc very rarely fatal. One at-
tack predisposes to others, and the disease is usually obstinate. Hope of
complete cure is good in jiroportion to the youth of the patient, absence
of organic disease, short duration of the attacks, infrequeuce of recur-
rence, immunity from distressduring the intervals, and the presence and
discoTerT of a removable cause. Chronic asthma tends to the develop-
ment of emphysema, chronic bronchitis, and dihitatiou and hypertrophy
of the right cardiac ventricle.
106
PVL^ONAHY DISEASES.
Tkbatmbnt. — During tlie puroxysm, the most efTcctual iuieriial
treatment cunsi»U uf the udniiiiistnitionof uiorpliinetiiKl chlonil (Form.
2) reiiwite<] every half-hour or overy hour tinti) relief \a oblained. Thia
may be comhined with half u ilriu^hm of 11. ext. uf ^riiidelia rohiista^
which issometimoa bcncticiiil. The nitrites in the form of nitroglycerin
gr. jjjf, or nitrite of amyl "lij. to v., reneatcKl evory twenty minntos for
two or three duses, or iipouiorpliiuf gr. 7^,, internally every two houre,
frfqaently provu efleutive. Weill {Irtt Frnmre .Uifliaile, March, 1889)
through experiment)!, confirmed hy others, found tluit inhahilion of car-
bon dlaxi<Je greatly relievwl iiongh und ilyKpna^ and cut the paroxysm
short.
Two or three cn{\8 of strong hot collee will frequently abort an
attack, if taken when the first Bymptoms are noticed. The seTority of
the paroxysms nmy be greatly moilitied by small doses of belladonna,
hyoscyamus, or hyoscyamino gr. ^1^ to yjs Iiypo'lcrmically; or by po-
tassium bromide or camphor. Fuming inhahitious of arseuious acid or
potassium nitrite alone or eombinL-d with other autiBpatimoiJlc:i such u8
etniinonium^ Iiyoscyanius, or tobucco, give 8p«?e*Iy relief in some cases
(Form. 132-138). Galvanizing the pneumogiwtric nerve, with the poa-
itire pole beneath the mastoid procoBs, and the negative pole on the
epigastrium, will promptly relieve aome cases.
If either bronchitis or pneumonia supervenes, it should receive treat-
ment similar to that recoinmeudcd when it occurs i\a a primary disease.
The general treatment of asthmatic patients should be supporting. Be*
tveen the {MiroxyBins an effort should be mudo to prevent their recui^
rence. The most effiracious remedy for this purpose is potassium iodide,
but in some cjises aninioiituni iodide, grindelia, eucalyptus, arsenious
acid, or resin of gnaiac will be found useful.
In all cases a complete history should be obtained and a thorough
txamiuatiou made to ascertain, if possibh', the existence of any disorder
which might cause a reflex brouchial spasni. Such disorder should
be correctoil ; thus, it will often hei possible to prevent or care an attack
by attention to the alimentary canal.
It ahonid be remembered that asthma may result from the rhcnmatio
3r dartroug diatbesis, and that it is often caused by bronchitis or emphy-
sema, as well as by purely nervous affections. The treatment must
therefore meet the conditions of each case.
If all nicJicinos fail, a change of climate should be tried. The cli-
inate of Colorado is perhaps the most frequently beneficial to these
patients, but very slight changes tnay be sufficient to prevent a re^.-tar-
rence of the attacks ; therefore "each patient must be a law unto him-
gelf " in this reganl. By repeated trials, most cases will find localities
where they will be free ^m asthmatic attacks.
PULHONARY EUPUYHEMA.
107
PULMONARY EirPHYSEMvV.
Fnlmonary einphyBemu is an abnormal inflation of tho lung, due to
over-ilidtention of it^ air vesicles or acc'uniiilatiou of air in tho tissnea
nbont them; in tho former cases it is commonly termed vesicului', in.
the lalti-r uxlru-vestoular ur luterlubutur uniphyeuiuu.
Ktiologically it is also called primary or secondary, comjvenKiitory
and vicHricins.
A.vATuwicAL AND Patholooical Charactekistics. — I'ost-mortcm
opening of the che«t in a welt-markeil ease of genera) emplivscma re-
reals the Inngs abnormally p:ile, much iliitteiided so as to meet or over^
Iiip anteriorly, their surfaces bearing the imprint of the ribs, their bor-
ders rouiideil. They do not collapse. The heart may be displaced down-
ward and toward the uiediaii line. The lunj? feels softer than iiurnml
and pufly to the touch. Indentation mado by digital pressure rumains
for some time.
There is loss of elasticity, diTuiuished crepitation, and greater buoy-
ancy in water. Dilat«d air sacs may be seen proti-nding from the sur-
face as ronn<led, hemispherinil, or spherical elevations and of a grayish
line. Air may bo presided from the distended sites, which upon section
appear i\& cavities scattered through the lung, rarying iu size from a
millet-seed to a hen's egg. In mild or beginning emphysema there may
be simply extreme distention of the aUeuli, with little or no destruction
of their walls. As the process continues, two or more air cells coalesce
by the rupture of their common aejita, forming cavities of vnriablo size.
The walls <if. these are hero and there constricted and roughen ?d by
ragged projections which mark the location of former alveolar purtiliona.
The capillary plexus is conaetiueutly partially destroyed. In the inter
lobular form, secondary to vesicular emphysema, uir escapes from tho
vesicles into the interstitial connective tissue forming other cavities.
The process may extend along the blood-vessels of the interlohnlar septa
to invade the mediiuttinnlj, cervical, and finally the subontancons connec-
tive tissue.
Probably rupture of the alveolar walls is dependent iu moat cases
upon a primary fatty or fibroid degeneration. Senile emphysema, so
called, results from atrophyof lung (issue: here the lungsare diminished
in sire and generally pigmented. Kmphysema is gonendly bilateral, but
may be confined to one lung or to a single lol>e. When due to forced
expiration, with obstruction in the trachej*. larj-nx, or glottis, it is moat
marked along the anterior border uf thenpper lobes. In addition to these
morbid changes, the bronchi communicating with the cavities are the
seat of more ur leas bronchitis and bronchiectasis, Vireliow, as reported
in 1889, had never seen tubercles in an emphysematous lung and uidy
me case of pneumothorax {Bertimr kliniache Wocliejixhrift, 14^811).
PULMONARY MSEASES.
But both these conditions may accompany it. Pnenmonift oecft5ioiia!lj
compUcutes it^ and dilnt^itioii aiul hypertrophy of the heurt, with re-
Bulling cbuiigofl iu ihe lungs, lircr or kidneys, iire not uncommon.
ETiOLOfi\'. — Emphyseiim may occur at uny ugc. It is, liowever,
most coniutou in those heyond middle life, uthI more frequent in men
than in women. Heredity seemn to play an important part in the eti-
ology: but whctlier tlic ilisoiiso is largely dne to hereditary transmission
of u special weakness ot Inng tl^ue, or to primary maluutritive cliauges
of a fatty or fibroid nature, is an open question. It occurs iu the aged
from natural atrophy accomiMinying geiicml senile decline. Forced in-
spiration may cause over-dlstention or rupture ul air vesicles, whose elae-
ticity is alreaily inipai.v^d. Tlie usual cause is the exertion, after deep
inspiration, of ]ii)werful expiratory efforts with closed glottis or with
more or leas obstruction of tlie respirator}- passages from other ciiuses.
Uonco, the disease not infre<jnently complicates asthma and the cough
of chronic bronchitis or pcrtnssis, and may result from oxccfisiro nse of
certain wind instruments, or from straining efforts as iu lifting, child-
bearing, or defecation. Local conipensjitory emphysema occurs in the
air Tcsicles adjacent to lung tissue that is collapsed or consolidated or
whose larger bronchi have been olistructed. Obliteration of tlie iiir vesi-
cles of one lung wholly or in large part, from pneunumia, phthisis, in-
farction, and the like, or from prossurc by pleuritic effusion, may produce
compensatory emphysema in the opposite organ.
SvMPTOMATouinY. — The proitiiiteut symptoms are constant dyepnona,
increased on exertion, associated often with the symptoms of bronchitis
or asthma, or of both.
The prominent signs are: lifting of tho sternnm in inepiration,
barrel-shaped chest; vesieulo-tympanitio resonance, and prolonged ex-
piration.
Inspei^tion jn well-marked cases finds the countenance dusky, the
eyes prominent, the nostrils dilated, and the sterno-cleido-mast-oid mus-
cles standing out like whip-cords in their efforts to aid in respiration.
The shoulders are elevated and drawn forward, the neck is apparently
shortened, anil tho individual seems to stoop, which gives hlin the a]>-
pearaucc of old age. The margins of the scapula; sometimes stand out
like wings, and there is an increase in the anteru-puiiterior diameter of
the chest, giving the rounded barrel-shaped appearance. During inspi-
ration, there is no expansive movement of the upper ribs, but they are
elevated as if the chest walls were composed of a single bone. In marked
oases of this disease, there is with inspimtion fulling In of the soft ]iurts
of the chest above the clavicles and sternuui; the intercostal spaces at
the upper part of the chest are wider and more distinct than usual; and
there is retraction instead of expansion of the false ri1>s during inspira-
tion. Early in the disease, these signs are not present. Vouous pulsa-
tion is sometimes seen in the jugulars.
PVLMONARY EMPHi'tiEMA.
lOU
Oocaaionally omon;^ old people, in cases known as atrophous emphysema. Ui«
inter^''>8U:ijl»r itepta are dentroyetl hy atrophy and the vesicles coalesce. Th|
volume of llie luc)<; is tb<>reby more or less diminished, !io that the duwase cnuMsl
no dlatentioa of tho I'liesl. In ^ucli otues. no sit^s wotdil be obtained oit in>
vpecliou, except f»crlia|»s retraction luid an increavetl obliquity of the lower rih»,
Willi conRidpniblu diminution ut tlie Hpace between them and the cre«t of the
iltum.
Rt palpntion, the apex beat of the heart ii freqnentlj fonnd btilow
its normal position, and nearer the median line.
Vocal fremitus may be e3cuj^«;Qrated, diminisheil, or normal.
Mensnmtion shows us the exact increase in theantoro-posterior diam-
eter of tho chect, and the deficient expansive morcmcnt in inspiration.
Percussion yields Tcsicnlo-tympanitic resonance, nsurtHy most marked
over the ui>per part of the left lung. Percussion over tho pnccordia
may show diminished urea of siiperfici:*! cardiac dulness. or the entire
region may yield pulmonary resHuiuuce, due lo tlie expansion of the
border of the left lung, so that it completely rovers the heart.
Deep inspiration or forced expiration will not materially affect the
pulmonary resonance^ as it wotild in he-alth.
On auscultation, the vefiienlar murmur is impaired, the inspiratory
ind being deferred, and con8c<|nently shortened, and tlie exjdratory
sound being prolonged, so that the ratio between the two may be ru-
versed. making the expiratory sound espial in length to the iriHpiratory,
or even three or four times as long. In typical, uncomplicated niees,
both sonnds are low in pitch; but hnrsh, blowing sounils from the bron-
child tabes are often beard, especially dnring ins^n'ralion. A peculiar
dry. crackling sound, closely resembling fine pleuritic friction, is often
heanl jUHt at tho end of inspiration or at the beginning of expiration.
It is produced in the walls of the air-vesicles.
Gerhanlt iBfr/iwc r klintsche WoehtH«chrift, 1888), in four cases of einphy-
semu, li«ai-d flne bubbling, crai kling KOuads in the cardiac region synchroaous
with tlie heart-beat, eridpotly from displacement of air in the mediastinal
coDoective tis^uo by the cardiac impulse.
In rare ca^^es, especially in tlie u^fed, the inHpirutory and the expiratory^
ids are of equal duration, exajjgeratcd in intensity. hurEli and tubular ia'
quality, and high in pit<^i. Tliis is probably due to atrupliy of a portion of the
lung tiKwie.
Vocal resonance may be either increased or diminished.
The heart-sounds are usually feeble, and thoee at the apex are dio'*
placed downward and inwanl, by the intervention of the emphysematons
luug between this organ and the surface of the chest. The cardiac
sounds and impulse are often abnormally distinct in the epigastrio
region, due tu displacement of the heart and to dilatation of the riglit
ventricle. Dilatation of the ventricle may cause tricuspid regurgitation
with a valvular murmur.
DiAONtisis. — The iii8«u!c« likely Ui lie mistaken for einpIivKema
are: ililatnlion of the Iiiiig from acute titljerniilosis, uud imeiuno-
thornx. When confined to «ne Inng, fni[iliytfeinii niiiv he niiMiikeu
for any of the dieeasee which usually causo foeble respiration. In
Buch cases, the normal ninrmurof tht> tiound si<lL< is liahleto bo mistaken
for exaggerattid ret^pinilion, and llic ft-eble niurnnir of ihe enij^hyiiouin-
U>U8 lung fur the normal sounds. Error may be avoided by remember-
ing that tho feeble respiratory murmur of emphysema is chnracterized
by prohriffcti expiration, and that resonance over the affected lung la
more marked than tliat of the soimij i^idu; whilo in nearly all diseases
eau.sing feeble respiration, from obstrni-tion in the iiir paiu>ages or frum
inti-rferenco with the free expansion of tlie lung, the cspiratory sound
is jfhorlrr than the inapinuory, unrl ihe resonance i« less intense thiin on
the sound side. Emphysuraa of one lung, or of a single lobe of one
lung. 18 a rare nffeotion; but when it does occur, great care is necessary
10 avoid en-ors in diagnosis.
Bilateral emphysema \$ differentiated from pnetumlkornx by the signs
furnished u])on inspoction> percnsMon, and auscultation, as foUows:
<
I
EUPKYtiEUA. PKEITIOTHUEAX.
Usually bilateral. Very rarely bilateral.
Promjueuce of both sidos, especially Uaiforni distentiua of one itUie, no
of th^ anterii-ftuporior portion of the sJnkin? in of the soft parts during in-
chest, witb fulling in of tlio soft partA spimtion.
during inspiration.
PercuMitm,
Vcsiculo- tympanitic resonance on
botli stdc^.
Tymjtanitio resonance on one side
onlv.
AiiseiiUation.
Tho ro»pimtor>* murmur vesicular The respii-atoi-j' murmur feeble or
In quality, and expiration prolonged. sitppreti»ed, or amphoric.
Kmphysema of u single Inng is distingnished from pneumothorax bj
the following signs;
EUTH^-SEMA OP OlffE LDKO. PKECTtOTHOBAX.
/VrcuMtoN,
Vesicado-tytiipanitic re«oDancc Tt'inpanitic re&onunce more or ieoA
int«nfte, willi atisence of the veslcul&r
quality.
AlttcttHaiion.
Theinspiratory murmur delayed, the Tlie vesicular murmur feeble or
expiratory Butind pi'olon^'ed. absent, but, if tieunlt reiTular io
rhj'tlim. Tilt* respiration may W am-
phorie,
E. Thompson states that in acute tnltfrrnhms, as numbers of the air
PULMONARY EMPHYSEMA. Ill
-vesicles become filled with the tubercular deposit, the adjoining cells
become distended so as to cause physical signs, especially in front, al-
most identical with those of emphysema. The distinctive features of
the two diseases may be seen in the following table:
Emphysema. Acute tuberculosis.
HUtory.
AffectioD gradually developed. Comparatively rapid accession.
Syviptoms.
Constitutional symptoms often slig:lit. Constitutional symptoms similar to
those of typhoid fever.
Inspection.
Cyanosis ; labored expii-ation ; chest Pallor ; respirations rapid but not
enlarged. labored : chest not enlarg^ed.
Percussion.
Vesiculo-tyrapanitic resonance more Vesiciilo-tympanitie resonance in
or less marked over whole chest. front, but actual duloess behind.
Auscultation.
Expiratory murmur prolonged and Expiratory niiu-raur not much pro-
low in pitch. longed and higher in pitcli than normal.
Some signs produced hy fibrosis or fibroid disease oi both lungs are
liable to cause it to be mistaken for emphysema. The distinction may
be readily made from the following signs :
Ehphyseha. Fibroid disease of both lungs.
Inspection.
Fixity of the chest with bulging, ex- Fixity of the chest with flattening,
bept in the atrophous form.
Palpation.
Vocal fremitus usually diminished. Vocal fremitus markedly increased.
Percussion.
Vesiculo-tympanitic resonance. Usually dulness, but occasionally
resonance approaching tympanitic in
quality,
Beart covered by lung tissue, as Heart uncovered, causing increased
shown by resonance. area of superficial dulness.
Auscultation.
Low - pitched respiratory sounds, Absence of respiratory murmur at
though sometimes considerable harsli- times. In other instances, rude res-
ness from affection of the bronchi. piration.
Emphysema and bronchial asthma are not likely to be mistaken for
each other, especially if the following points are remembered :
flMFHYSEMA. ASTHUA.
History.
Dyspnoea constant. Dyspnoea paroxysmal.
119
PVLMOSAHY msEAHsa.
Chest barrel-- bui>etl.
Heart displucutl.
Emphvsema. ASTIIIU.
CliP-st normiil.
Hvnrt not displaoetl.
AntcHlUiiion.
Few rAUfi |iri.>HVRt imli^ss t>roiicliilis Abundant ili*)' r&les, tubilant and BO-
compliciite, when rales are moist. mii\ju^.
pRoaxosis. — A lung onoo cmphjsomutoug never recoTcrs. Mih] cases
dejietiilent upon causes which may be eiirly removed may be gretitly re-
lieve<l ))y tlie geneml improvement of tlie patient nnd the comjwnsa-
tion offere<l by the remaining normal hing tissue. Though in itself not
a dnngerons dificase, wcll'mnrkod emphysema insures the patient muoh
distress, unfits him for ftctive life, and ^roatly jiredisposes him to more
serious disease. Bronchitis, though frequently a c'tm!>e of the disease. Is
a eummou effect. Bronchiectasis, asthma, and pleurisy are likewise fre-
quent complications.
Heart disease with disorders of the liver, kidneys, spleen, andalimeu-
tary tmct which are its common sefiuolae, naturally resnlts from chronio
obstruction to pulmonary circnlatioii, and is therefore an important cle-
ment iu prognosis. Pneumonia, tuberculosis, and hemorrhage arc rarely
observed in emjihyscmatous foci, but may occur 'u\ parts not so affected.
Treatsien'T. — As the changes iu the lung tisane iu this disease are
due in part to general malnutrition, our first aim in treatment must be
to improve tlie general condition. Ttemedics of most sen'ice for this
pnrpose are tincture of iron, cod-lirer oil, and occasioually small doses
■of quinine and strychnine.
Chronic bronchitis usmdly coexists, and should receive treatment
similar to that alreaily mentioned under the head of treatment of pneumo-
thorax and pneumo-hydrothorax. Potaesinm iodide is the most eerriceo-
ble single remedy in this disease. It should be given in doses of gr. r.
to IX., three or four times a day for a long time. Arsenioua acid long
continued has been found beneficial. Asthmatic symptoms are to be
treated as spasmodic asthmsK Cough may require anodynes. Expira-
tion into rarefied air has benefited »ome cases.
The patient must avoid all causes of cold or asthmatic attacks, and
should live if possible in a climate where he will be most free from dysp-
iicQfL High altitudes are not to be recommended for those cases.
CHAPTER AMir.
PTILMONAUY DISKASE8.— Cfe«/m««f.
PNEUMONIA.
Si/noutfmx. — Peripnoumoniii, peripneumonia vera. Popularly known.
as king fever or inllaniniiition of the Inngs. There are two rw-opiiizeii
Tarieties iif this disease: /oM/-y);i«»mDnm» in which the greater partorlhe
whole of one lobe, or the whole lung-, is affected, and lobitlar pnr»ritontft,
in which the inflammation is confined to « single lobule, or to groups
of lobules scattered through the lungs. According to tho origin and
character of the disesise, Ita various manifestations collectively have also
been termed prinmry or secondary pneumonia, or bilious, gastric, ty-
phoid,latent or walking, intermittent, hypostatic, tubercular, scrofuloua,
rhenmatie, gouty, puerperal, or metastatic pneumonia— varieties, ao
called, which require no special description. Though different cases vaiy
more or less in their origin and anatomical charactcritttics, as well as iu a
few of theirclinieal features, to attempt to differentiate between them hy
their physical signs would only lie confusing. I shall therefore consider
at length only lolnir and lobular pneumonia, and but briefly mention,
nnder their respective headings, special variations of the disease, and
the signs which are accounted valuable in enabling us to differentiate
them.
«
LOBAR PNEUHONU.
Sj/nontfms. — ^Acnte pneumonia; croupous pneumonia; acute sthenio
pneumonia.
Lobar pneumonia consists nf an inflammation of the vesicular struc-
ture of the lungs, with accumulation of inflammatory exudation in the
air cells, whereby they are fille<l and rendered impervious to air.
Anatomical and PATHOLOfjirAL Ciiaractekbticb, — Croupous
inBnmmation of the lung is e-hiinioterizcd by threo stages — first tuf/orye-
went, second red hnpfttizfr/io/i, third yellow or ffrny htpnthntitm; it may
terminate in reaolntion, in suppuration iliffuse or circnmflrrilied, in gan-
grene, in chronic pneumonia, or in tuberculosis. \)wT\t\fi fugorgctmnt
the lung is incrensed in size, is of a dark red or bluish color, with per-
Imps faint patches of subploural occhymoscs and the affected tissue does
not collapse. It is dougliy in coiinistency.pitaon pressure, and is lic:-vier
tbftu normal. From the cut surface oozes a reddish sero-albumtimur
8
lU PULMO^'AHY Dl HE ASKS.
fluid, with darker blood from tlte CHpillarios. Microscopuafhf the vefi^ols.
liuing the alveoli are foiiiul oron-ded nitli blood corpusrli-s and so uia-
tcnded a^ to encrouch upon the Innitn of the iitr »ir^, whieli contain
serum, oorpuscles, and n few epithelinl cells.
lu tht' Btflgo of ffii hrfintizaiioH the organ is darkly mottled, in coloi
reaemUliug tho liver; the serous snrfuco may l« markedly crchymotio
Hnd tiic 8eat of fibrinous exudation. The lung is larger, heavier, and
firincr than iiunind; it sinks iu water, is friable, uou-crcpitant, uud may
show the iui}jritit of tho ribs. The cut or torn surface ifi Ixithed in a
re<Idish s^Totii! Uuid. and appears granular from the projection of small,
dark red masses uf coagiilum from the alveoli. These become more
prominent on pressure imd are easily removed upon scraping tho (-urfacc.
Micro»coj}icnfhf iXwse masses are sc-eu to oonsitit of granular epithelial
cells and rod and white corpuscles, lu-hl within a tlbriuous coagulnm.
In tho third stiige reil hepatization gradually given plat^o to ifelfnir or,
iu markedly pigmeiite<i lung», to (frai/ hepatizaiion. The rwi colnr of
the former stage ili^ippeard owing to fatty degeneration uf the alveolar
contents, to amemia produced by the pressnro within the alveoli, and to
breaking up of the red corpuscles with some ak^iorption of their hasmatin.
The lung in this stage is stiil larger and heavier tlian in the preceding
stuge, it is more mottled with gray and yellow, more fragile, and is uon-
erepitant. Section reveals a surface more uniformly gray or dirty
yellow and less granular, from which exudes a viscid fiiiid of like color.
Microscopic examination shows pus cells, fat globules, pigment,
miero-organisms, and a detritus of librin and rod corpuscles. The
morbid conditions causing thesi* appcaranuea are loc-ated chietly in the
air sacs. In addition, the nuu-otts nienibrnue of tlin smaller hroneln is
usually congested and not infrefjiieutly these are the scat of plastic,
fibrinous casts sometimes extending to the larger tubes. (Edema of the
|wrt8 adjacent to the inflammatory focus is usually present and may also
involve the upi«>sito lung. Acute oompensjitory emphysema is likewise
occasionally present. The bronchial glands enlarge and aometimea
Eiuppurate.
IMeuritis occurs if the pneumonia is superficinl. Pericarditis is most
common in pneumonia of the left lung, evidently from direct extension,
but it is not an uncommon accomi>animent of right-sidod pneumonia.
Inlliimmiition or at least markeil congestion of more remote structures —
the alimentary tract, liver, spleen, kidneys, brain, and spinal cord — are
not uncommon associate morbid phenomena. Under favorable condi-
tions, resolution oconrs, incident to rapid fatty degeneration of the
idveolar contents, which become more fluid and disappear larliy by
expectoration, partly by absorption. Gradually air re-enters the vesicles,
which resume their function, congestion snbsidee, and pulmonary a^dema
slowly disappears. In unfavorable cases suppuration may supervene
upon the third stage; the lung then becomes more uniformly yellow,
boggy, and very fragile, and the llnid from the torn surface is decidedly
I
LOBAR }*NBUMtiNlA.
II.')
purulent. There is also more or less |Hirtileiit innitnition of (liu peri-
Tesieulur tismmK. Reimltition inuy slowly fullow tbU difTuee siipiruratinii,
or niiiiierut:.s iihscei?}te!< iiiuv form 1>y rupture of tliti iiitemlvuDbr wpta
Htid furniiition of limiting walla of granulation tituiie. Tlit^se in turiii
l.y progrefflive uliieratton in tho line of least resistance, may t«>rmi[uit«
in perforation of tlie plenra or pi'ricanliiun, <»r may empty themselves
into the bronclii and cinge hy cicatrization; or their content* remaiuing
encapctulateil may nndergo cascons change and roceiro enlcareons deposit.
Diffuse or circumscribe<l ijitni^renf oe<'nsionHlIy occur*, invited in some
cases by nnteccdent Ijronchi ectasia or pntriil tirnnohitis (Orth, l>iagiio«is
iu Pathological Anatomy, J). 145). In rare cases arnte pneuninnia termi-
untes in a chronir fonn^ eharacterized |>athologirally by large increase in
tho interstitial connective ttssne which oblifcrutes the alveoli and smaller
bronehi of thealfecteil part, making ir firm, denstt, and airless. Kinaily,
the pneumonic area is liable to infection nith the ttiben-le Ifacitlue, Jn
order of comparative frequency pneumonia afTects the right loner, the
left lower, and the right upper lolw. Arccrding to Miiuft, the disease
in children originates oftenest in tho right upper lolic-. least frefjuently
in the right lower. Double pnenmonia occurs in from tire to fifteen
per cent of all cascA, but most frcfjnently in the aged { Ldomi?' Practifal
Sleilicine, p. Ht'i; fyelopiedia of Disetwes of Children, p. ,^sii).
Ktiolooy. — (.'limates and soasons most subject to sudden marked
changes of temperalnre, occn|uitiona subjecting the individual to abrnpt
changes from heat to c^ld, and such hygienic conditions as bad ventila-
tion and sewerage, poor food and clothing, and habits which enervate
are all favorable to the occurrence of pneumonia. Though robnat health
anil a fine physique seem at times to offer to it no Ikarriers, yet most
diseases which exhaust vitality and diminish local resistance predisiinso
tu pnetunoniu. In this category are included a previous attack of pneu-
monitis, the acute infectious diseases, alcuholisiu, nra>mia, acnte rheu-
matism, and disorders of the blood. Diseases of tho hciirt prodneing
chronic pulmonary congestion, and severe traumatic injuries to the
cfaeet, are also predisposing factors.
Kec^nt InvMti.iraiJotut by Fraenkel, Weichselhaum, FrMlAnder. Netier,
Sleriiherir and many otli«r careful ot»<ervers suggest that pneumonia i!4 an ia-
feetioii» disease, tho priiimry exc;itin^ cause of wliicli isa specidr iiuci-«>^'rtpuiii-sni ;
and titui in most iastanoei^ Uie diplococcas pneiMUonin-* of Fraetikel i» timt >ronu.
Ao(*«ir(liiiK lotbesewHlerR, it can be proved lOt_'xisl iiiovpr OOpor centof all ert.se«,
io ttif tUftucsand dotikof Uie loml pubnotnu-y inHaniniation ; and it has alto
liecnfiiuiiil ul Ibeiu^'it of ceniplicatiiig lueningilis, plenritU, peri(^rdiUs. synovitis,
and utilis. Frieillnntter'tt microi-oi.'cus ibe lyplioid )incillu<i. and other spei'itlo
ffeniu may a\^*t in some oawts excite pulmonary* uiflamnintion. DeJafield <,NfW
York ifed. Jour., 1890) re^rds pneumonia as an tnrective iDdainnuvtion de-
pendent upon individual euscvptibility, a primary er^cciting; cause of iaflainmatioB
and a palttofranlc bacterium someonr^ of whioh facton; takes precedence at differ-
«Bt tint«i>. FaLts r«cor<lea by Wolff iZtUgchrift rfer Bakt. . 1900), Jaworak!
116
PULMONARY DISEASES,
{Jour. Am. Med. Am.. Dec. 1S»0>, Kiihd {Berlin ktin. Woeh., April, 1S89),
JiniUetutn {Brooklyn Med. Jour., April. l^Hft). Wii^Tier {,(4711. Jour. Med. Hci., ItwO),
Wells [Mfd. Itegiiit.. Feb.. 1«1KJ : y. Y. Mrd. Jour.. March, 1800), Moslcr (/it-iiJ.
med. M\Kh.. Nos. 13 tiud 14, 18O0 ; Mt:d. PrtM tmd Circ. Hv\>\. 23. 1800). luid
others stronm'ly suggest iU contajfioiis ohumi.'U'i' uiuler Htiine comlitions.
SYMPTOMATrtLOOY, — The chief ayrtiptnms jire ii severe initial chill,
folldweil bv fever which attniiis ji;reat intensity in a few hintrs and hb
sudtk'ulv subsides Itctween the tifiii kikI the tenth 'Inya; these wre iiBiiiillv
alti'udeil by paiu in tho sitie, dyspjui-n, congh with eler»r teiiaciona and
subfiequeutly rusty sputa, great prnittration, and frcfjuenti} delirium.
lu some eiises these active fetimres are preceded eeveral days by dull
pains in the he»d, back, and Hmbii, dizziness, hissitude, iind perimpe ali-
mentary disorders. Usually the onset manifests itself abniptly by scvore
rigors, which may lust for two or three hours. In children tliere may
also be initial convulsions, ilGlirium, aud gastrio disturbance. The tem-
perature in uucompliciited pneumonia is uliaracterized geiiei-ally hy a
riw) to 103" or 105" F. at tlio invasion, followml hy slight morning ro-
missiong and evening exacerbations till the day of crisis, when it either
declines gradually or falls suddenly to normal or one or two degrees
below. The highest point is commonly reached on the second or third
day, but may occur just before the final fall.
The pulse ranges from 100 to 130 bents per minute, or much lugher
in serious coses, and is the most important index in pneumonia. It
becomes rapid and feeble depending upon tlie severity and dui-alion of
the atUick, and may be intermittent, especially in old age.
Sharp lancimiting pain below the nipple, increased by cough and deep
inspinition, is a common symptom, probably due to concomitant pleuri-
tis. It may be absent or slight in old age and when the pneumnnia is
dee]) seated. It tends to diminish and disajipear by the third or fourth
day. Very severe headache during the fifRt two or three days is an ah
moat constant symptom. Pelirium, uHvially of themild, int^oherent type^
18 most frequent in old people, chihlren, and drunkards; in the latter it
may take the violent form. Muscular tremors are common in oonvt^
lescenw. Convulsions often occur in children either at the beginning
of the disease or just before death. Ho^piration is shallow and increased
in rapidity, in severe ca?e8 even to sixty or seventy counts to the miunte.
Dyspnu'tt is usually an e«riy and prominent symptom, bnt may l»e absent,
even with greatly accelerated breathing.
Cough of a short, hacking character is commonly an early symptom,
but is exceptionally absent. It may disappear just before death. The
expectoration, at first frothy, Iwcomes translucent, tenacious, and viscid,
and later of a red or browniah-red brick-duat or rusty color from ad-
mixture of blood. In some grave cases the sputum is more watery and
dark pnrple. like prune juice. Uusty sputum commonly appears within
the first two or three days, but may bo absent till the tenth or twelfth.
LOBAR PNEUMONIA.
iir
ami thtu prcsuutiu but slight degree. Barely, it isfntiitly ubsenl. Dur-
in;: rciaoluliou the sputum \i inure prefu9e»ud yelt(»w or greenish. Diges-
tive tliatjrdcrs, vouiiting, aiul ilturrhu'it ocotir suinetinies at tlie invaainn.
The esscutittl aujttti in the order of their occurrence arc; diminished
movement of the side, some duluess and crepitant rdles, followed by
marked dulueHa. bronchial breathing, and broni'hopbony. These signs
are succeeded in fnvornble cases by suburepitaut rales and a gradual re-
turn of the healthy signs (Fig. 37).
HonnftI slfBl. '
BiDDChlAl bTMthlng )
anil imjuubopboojr. f
Subcrepuuit riUes. ..
x,,*^:
Tmk ST.— The upper lobo iaAicm* bMlihr lung Uhq« : cb>e ntddlo lobe ropreMOti lh« atoood
ilaC« of pneiiinopU (red bepaUxaUon), Mid tbo lowvr lobe lUuaAfmtKs Uttt third «ta^ (CTOT b^p-
bMlOB>.
For convenience we describe tlie signs in three groups corresponding
to the three stages of the disease. l^\\e first stage, beginning with the
inception of the disease, continues until the air vedicles are completely
tilled. From this point the sku/k/ stage continues throughout the i)enod
of consolidation or nn\ hepatization. The fhir// stitge, that of gray
Itejiatization, continnes from the beginning of resulution until couraleft-
rence is complete.
As signs o^ ///p /iV.*/ Wa*/e, inspection Gnds the niorements of the
chest soiuewhut diminiitlietl over the affected organ.
Pal|Nttion in tlie early part of this stage yields only negative resnlts;
later, the voc«l fremitus is increased.
Poreuesion early in this stage elicits slight dulncss. which gradually
incroases as the ^tugc advancci<.
Ou auscnitatiou, while there is congestion only, before inflammation
bos become fairly established, the respirator)* murmur is feeble. As
GXtidiition takes place, crepitant rules occur iu great numbers at the end
of inspiration. When tlieso rdles are well roarke*! and persistent, they
may be regarded as pathognomonic.
Wlien pneuinoDta is Associated with inQainmatory rhcuniatifim, the crf^pilaiit
ledoes twt ovcur. Siilioiepltant are sonwtinMS associated with the crepitiint
"iNUes, but the latter greatly predominate.
As conBoiidfttion progresses, reapiratiou b«:t>meH broncho- vosicular
and finally bronohial.
As ((/'//(j< f;/" ^A<r «*(■'>'«/ «/rtf/^, inspection anrl palpiition slinw that the
moveniQiiU ure still de^cient on the uflucted side, und cxiiggemtod oa
the u)>i>uBite side. Vocal fremitus is exaggerated.
Exeeptiamtl. — Consolidation ia rare inslancea iUmiQisbi>s the vocal fremitus^
in conseqiiencti at complete occiuHion of the bi-oacbiol tubes.
lu percussion there ia marked dnlnesa over the affected area, with
«xugnuniled resouunce over healthy portions. The lina separutiug dul-
ness from vesicular resoiiiuico ustuilly corresponds to the position of (he
interlobular fissure, and is not altered by changes in the position of the
patient.
/Cj'ceptionui.—la i-ai<a cas«s the density of the lung- h so great timt tlic per-
tius^tun suuiid cuused by vibruliun of air in llie broncliiul tubt-s is tnirisinTtli*<l to
the Burfatw with such pet:uliiLi-ili!iliui:tue»s as lo Jutttify lh<> itp^KrUulinii of tabular
resonnnce. In some Jn^laiRVH of f xtr«,'[ne consf>li(irtliini. tlin ivsoiiiinti! w^enw al-
iiiustutnpboric. In such Ciises Ihe-iohd soiimls wuiiMof twuessity be mistaken for
hollow !«ounds, were it not for tht<ir pitch, whiih it nl w.-iys lii^li instead of low
like ihu proper re&ouiiuce of cavities. In nu-e coses, flatness is found instead of
dulueSs.
By auscultation there are fonnd no crepitant rdles, but in their place
we (ind brouchiul or broncho-vesicular respiration, varying in degree
with the amouui of cousolidatiun. There is alsu coexisting bronchoph-
ony and whispering bronchophony. A few moist and dry bronchial
idles ure upt to bo heard in tliis stage.
Excrptional. — In rarecosps a f»w crepitant rfllen itwiy bo hoard tn IbissLige.
In other instanctiS, tiie bronchial tnbos of Ijirger Hize may be tilled by the intlamma-
tory lymph, so that the vot-al reMinanc^ tsdimini-itted instead of being* iDtensitled,
and all respiratory sounds may be suppi'esaed.
Early in thfi third stage, the signs are the same as iu the second stage,
with the addition of a few subcrepttant nlles. As the stage advances,
vocal fremitus becomes gradually lessened, dnlness diminishes over the
inflamed portion of the lung, bronchial breathing slowly gives placi; to
broncho- vesicular breathing, and this iiually to the nonnal respiratory
mnrniur. Subcrepitant nllos appear early in this stage, and continue,
often associated with mucous rales in the larger bronchi, until resolution
is nejtrly complete.
The crepitant nile also occasionally reappears; it is then known as
the crepitant nile redux.
bronchophony, which was present ju the second stage, gradually
LOBAR P^TEVMomA.
119
gives plm.*e lo cxuggeruteil vocul rc-soDanco, iind thia, in tiiru, to tbe
uorniul suuihIs of the voice.
I>iA';si>sis. — rneumonia is to be tliagnosticntod from |ileiirodyuia,
iiitt'rft«stiil ueuralgin, pleurisy, pulmoimry unleina, colliipse of the iiir
vesiclM, liydrothornx, pbtliisis, iiiul bronchitis; also, in c-hilUrcii, from
ineninxitis on account of the delirium, ocoasioiiul otiiunictionB of tbe
posterior cervical muscles and other convulsive plienoincna. In tlie aged
or debilitated, ou account of thu fypboid syniplonis and ocrational
absi'ni-c nf the usual symptoms of iiiHauimatiun of the Uing, it may be
mistaken for typhoid fever.
It is not likely to be mistaken ior phnr<Hhptia or inkrcrmtal neuraU
gift bv any one fumiliar with physiciit diagnoiiiii, ua thosi3 diseufles yield
no signs excepting those duo to piiin.
Ttovd. pieurUi/ it is distinguiabed by the following features:
PNEmoNIA. PLEITHIBV,
SjfmptomB.
Beep-seatc^d, comparuttvelyduDpiun, Paia superflciul, and lonu'lnn tins',
marked chill, hii;h temporatiira, coiijfh usually absence of market) ctiiti and
vitb \*i9cid or rusty spnttini. hi^li teuipeniUire, absence! of rusty
and visdd Mputuro.
Signs,
First Stage. First Stage.
federate diilness n'ith Te^^hle n>Hpi- ResonutK-t; □orniit). Respiratory
ratioa. Nunieromtci'vpilaiit r&lesualy nntrniur tt.>cble or ub^enl. Ordinarily
on m«]>iratioQ, ami cxag'^rated vocal ^nizin^ or crenkin;; rnction »uunda,
wMaance. Itntli in«pirnlaiy nnd oxpimton,' ; but
oeco^iioitally traiutilory cr(>|ii1atinp
friction Tnurmurs few in niiniher as
C'ompittvi) witli crepitant rAleti dso*
ally l>ear<J during ttin.*« or four iostpir^
tions Ihen disuppearing', lo return id
a few moments.
Second Stage.
Vocal ri-pTiiitiis absent. F)ulne»9 in-
Mend of duliicss. Tliolinc of llatness
chanK^'*^ with changes in the patient's
post I ion.
UBiiully ftl)8eti<'*> or marked feeble*
ooaKofnll i-PApirulDni'nnil vitcalaounda.
Third Stage.
Friction freiuittis and murmur ; ab-
fteni.*e of Hilcty. Ri;Hpii-atory and vocal
Ki^'iis ffHilite or nearly noroial. More
or less dulness.
Second Stage.
Vocal froroiltu exitggcrated. Dul-
Bess iDurked with no change of th<> np>
per limit by cliaiigeit in the poKition of
the pnlir-nt.
Bronchial n-spiration aad bron-
chophony.
TTiird Stngt.
Subcrepilarit iaU*s in iidditioo to tbe
bnrsh respir.vlion. ex.ig)r»?rated vocal
fremitus, and rt>iK»nnuctf, anddulnessof
the second stage.
There is a liability to mistake puhmmary ivdema only for the first
luid ihird stages of pnetunouia. The diagnosis is generally easily made
FUUlOSdRY If IS EASES.
if we recollect thut oedema is usually u bilateral, and pneamoDiu a uni-
lateral disease. In cetlcma, thedalneasiBeligltt^aud occurs ou both sidoa;
while in pncutnouia it is marked, and commouly found only on one iiide.
Crepitant niles arc few iu u?dcma and nearly always associated with
larger moist niles. In the first stage of pneumonia crepitant niles are
very abundant, aud seldom associated with other moitit iiouuds.
Sulwrepitant niles in o&dema are heard upon both sides, and are not
high in pitch or motalHc in quality. In pneumonia they are found only
on cue side, and arc high in pitch and usually metallic.
(Edema usually follows some protracted disease, as, typhoid fever.
Pneumonia is generally u jjrimary affeiJtiou, and is attended by marked
febrile symptomH which are absent in a-deraa.
Pneumonia is distinguished from pulmonary collapse or atflectasii by
the history and ensemble of physical signs, rather than by any pathog-
nomonic c]iaract«ri8tics. The points of distinction are shown in tho
following table:
Psat/MONIA. PmjIOKAKr COLLAPSE.
Hittory.
Usually a primary affection inrolv- Generally a sequel of broachitia,
lag ooly one luag. oftea involving both lungs.
PereuMion,
Harmed duluess. M(Nict-ut« dulness. frequently vesicti-
lO'tympooitic resonance in the vicinity.
AuaenUaiioH.
Id the first and thlnl stoees. crepitant Few if any crepitant or subcrepitaat
and subcreiiitant rAtes. rd]e!i.
Second sU^;e, bronchial brcathiug; Tlrouchial br&atbin^ over collapsed
J
exaggerated respiration over healtliy
lung.
RAIes and other abnormal signs usu-
ally conflneil to one lung or one lobe of
tliat lung.
lung; prolonged emphysematous ex-
pimtioD near it.
RAles due to bronchitis over both
lungs. Other signs due to collapse
more apt to affect both lungs and not
likely to involve an entire lobe of
cither.
The distinction between pneumonia and hydrothorax is shown below:
PXECMOKIA.
Unilateral duln(»». and the respira-
Xavy aud vocal signs of cousoUdaUon.
HVDHOTHORAZ.
Bilateral llutiinHi, with absence of
respiratory and vocal signs.
To distinguish pneumonia trom phthisin, a knowledge of the histori-
aud the symptoms is frequently essential. Many jihysicians. where the
aigne of pneumonia have continued for more than four or five n-f»ek8»
consider the case one of consumption; but this ntle will not always hold
good. The distinctive features between these two diseases, as they ordi-
narily present themselves, may be seen in the following table:
LOBAR pySUJIO^flA.
ISl
Pjteuvonul
PHTBinti.
An acute airecUoa usually involviog
(lie g-reut«r porltoQ of the lower lobo
of uiic lung- and giviii>; rise to the sig'o»
of ct'iDwlJdatiou.
A prolniclcHl diMiiuM) coming' on fn-
Hidiuusily, newly ulwayn Utiginnmg at
the 0]iex of th« luii^:. iintlut lint In-
vul%-in{; only u limitvO amount of
tlHsu>< : (giving' lisp, ni-xr. lo thv flifibft
of »liKhl uml )tiih<w.-(tuuiiily to tbuHc of
grvator coiiMiliiJntion.
StfmploniH.
Breathing paoUng. Harked pyrexia Brvailnujf hurried hul natural. Ir-
terminating in crisis. r<>pularundint«rmitli'nt temfMrature.
Pneumooucci.
iiitroMOpie.
TubenMii bucilll.
Phthisic following upon pneumonia will be distinguished from pii/-
longed cases of Ihe siifi|il« iiif1J4mniution by the history and by Ihe
phvi^trjil signs oblaint'd ou r(.>|M.-utt'il uxaniiuiitioiis, and in most cases bj
finding tulHTcle bacilli in llie i^juitum.
Any one funiiliar with jdiysint) diagnueis cannot mistako brouvhtiis
for the early Htngeit of ]>neurnoniu. Tliu t&Xh* of tim resolving stage of
pneumonia inigltL U? mistaken for thoau of brondiitis; but thcriMK no
danger of «rror if we remenibor that the latter is a bilatfral disvafi' and
caiisvti littlo or no diilness ou jiercuesion, and tlial, Sf\wu dnlneiM duu_
occur, it disapiK^urs after cough and frett expectoration.
Though in some traces the eyniptiims of pneumonia are like tho
symptoniii uf mcninfjitis and ii/phoid fever, the diugnu«is is readily niadi}
by careful physical examination.
pBOciNOsis. — Uncomjilicated pneumonia usually runs its artlvo
coarse in from five to ten days. The eymptoiits increase till the day of
crisis, when they suddenly remit or sulfide by lysis. The crisis, usniilly
occurring anywhere from the 6fth to the ninth day, is murkM by a
■udden fall of temperature, often to one or two degrees below nornml,
accompanied by decrease in seTerity of the other symptonis, and Cnllowetlj
by sleep, or in children by »tupor. There U also not infrerjuentlj
SI critical hemorrhage from the kidneys, bowels, or nasal njurouA mem-]
brone, and usnally a profuse perspiration occurs. In the feeble or age
the critical discharge may occur as diarrhiPa.
The mortality in pneumonia ranges from ten to twenty jwr oenc,
varying in different aeaeons and yean, bot in the weak and aged averag«j
ing mnch higher. The prognosis is worse for women than for men, U
infants than for adnlta nnder sixty. In persons over sixty, and in tboae
addicted to the exoesiire nse of alcoholic stimnlante, the disease is ex-
ceedingly fatal. In general, fatality is pro|K>rtionato to the extent of
Inng tisBoe involred and to the severity of the fevtr. Doable pnea*
Bioaia nsaally terminates in death, and pneamonia n( the apex is said to
FVUIOXAHY niHEASES.
be vspociull)' nuluvurublc iu tho aged uud iti children. Complieatiug
|H>nc&rditis, valvular dis^eose of the heart, Rright's Jiscme, dialx-ics,
pleurisy, tiibiTculosis, eiupliystiua, and pnlniunary abscess or guugreiio
greatly lessen thechauces of recovery. The most jirooiiueui iiufavurable
symptoms are m follows: A pulse iu adults above liO beau to the
minute, in children above IW, or marked irregularity in its rhythm;
rapid respiration with low temperature; fever above 104" F. for more
tliaii forty-eight horn's; a gradual rise of lfiu[>t'rature after thr fourth,
or eontinuwl fever beyinul the tenth day; delirium and ronia, or in
children convulaionit occurring late; signs of collapse at any stage of the
disease; haemoptysis or eopiond prune-juice expectoration; suppression
of t)ie s)mlum iu the third s^tuge or its becoming fetid. Deatli occurs
from ufipbyxia or more frequeutly from heart failure.
TitKATMEST. — Within the first ten or fifteen honra from Ihe incep-
tion of the tittiick, a blister will sometimes prevent further development
of the iullammatory process; but patientd are seldom seen by a physi-
cian early enough to allow of the use of this agent. Calomel adminis-
tered in grain doses every hour until its purgative effects are produced
is 9aid to abort some eases, but it should not be given to debilitated
patients.
For the first two or three days, small doses of aconite or reratrum
viride are very useful. They should be given often, iu just Buflieioiit
doM*s to keep the pulse nearly down to its natural mte; they must not
be continued after the third day. During the aanie period fluid est. of
ergot, in doses of n^xx. to xxx, every three or four hours, is often very
nseful, relieving congestion and checlitng the inflammation.
After the second day quinine in doses of three to five grains every
three to five liours is the best antipjTetic. In the inception of the dis-
ease, phenacetine, gr. v. to %., or antipyrine in similar [loses are often
productive of the beat effects iu relieving fever; buta« soon as the heart
begins tfl weaken, they should be emjtloyed, if at all, with the gresiteet
caution. It is unsafe to use them continxionely, and seldom desimhic to
administer more than three or four doses of either in the beginning of
the disease, or more than one or two small doaes during any twenty-four
hours after tho second day of the attack. It should be remembered
that iihenacetine is less depressing to the heart than antipyrine, but
apparently possesses only about one-half the antipyretic power.
During the active stage of inflammation, large, hot jacket ponltioee,
enveloping ihe wh(de side, are beneflciid if they can be kept constantly
and thoroughly applied; otherwiae tlicy do harm. When poultices can-
not be managed satisfactorily, an oil-eilk jacket should be eniployed, with
warm clothing. The constant application of heat or oold prodncea the
same reaults in acute inflammations; therefore, in some instances when
the temperature is high, excellent results may be obtained by tho appli-
cation of cold over the affected organ ; preferably by means of the coil
LOBULAR PNEUMONIA.
in
of rubber tabiug through which » cnrrent of ice- water is kept uirciilat-
iDg. From the very rirst, the pjitienl should ke«p perfe<?tly f]iiiet,
neithiT mo^'ing nor speaking excepting tvlien nbanhittOy nccesgary.
Very small doses of opium or nioUenite doaea of chloral are soma*!
times necessary to reHeve puin tiiid restleganess, hut eith'er mnst be gJTOsJ
Vci7 carefully, uiui opium 13 espe<'ial]y ohjectionabic when the evidence
of imperfect aerntion of blood Is distinct. 3fany patients ImvcTindoubt-
edly been linrried to t]ie gruTc by the injndiciona use of opium in thia
disease.
Where there is much prostration, and the heart is weak, fttryohnise
gr. ^ to jij or tincture of nux vomica in full doses with or without tinc-
ture of digitalis every three or four hours is very important. Alco-
holics or amntonium carbonateare required in the same condition ; and if
oedema of the lungs ap]iear8, alcoholic stimulants in large and oft-
re|»fale4l doses are of the utmost, importance.
The ammonium salt is evanescent in xU effects, but acts promptly.
Auimonium iodide, ammonium chloride, calcium chloride, liquor
pot:Ls&H5, ur potassium acetate :u'C Utsefui in the later stages to favor
rusolutiou and prevent ea^eulion. Lute in the disease counter>irritatioQ
is beneticial. Cuthurties and hluod-letting should not be employed ex-
cepting in rare instjtnces, in robust patients. When patients are much
prostntted and delirious, great care should be taken to prevent them
from sitting up or getting out of bed, for this will aometimes cause im-
mediate death.
Liquifl diet should be given regularly during the height of the at-
tack ; as n rule, a half piut of milk or ita equivalent being given ever;
three hours.
The ex|>crimenUof G. and F. Klemperer ( Berliner hliui»ehe Wochenaehrift) on
tJtR riinitive <>(Tf>ct« oT the hlood-Keruin oT ittiniuni' animals, or anti|tneumoU>xm,
are extremely iuteresUog, but aa yet the results are Dot uuUieDlicaled.
LOBrLAB PXEUMOSIA.
Synofiymit. — Catarrhal pneumonia; broncho-pneumonia; dissem-
inated pneumonia. Ohronic, interstitial, or interlobular pneumonia is
often included in this term.
Lobular pneumonia is an inflammation of single lobules or groups of
lobules scattered through the lung, preceded and accompanied by bron-
chitis.
AXATOMICAL ANU PATHOLOGICAL ClIAU-lCTEEISTICS.— The SUrfaCO
of a lung, which is the seat of catarrlial pueumouia, if the disease ia
superficial, pre«euts rounded, isolateil, reddish-brown or gray spots, ofteo
slightly raised, varying in size up to that of a walnut. The^e may be
coDfinod to a lobuto or may be scattered over ono or both lungs. At
these poiuta crepitation is diminished or absent, the lung is more fria-
PULMONARY DUSEAHES.
ble and cjinnot bo inHuletl. Section reveals a Dioitlod appenratiCi: due to
isolutcd dark brownish areas of consolidation, intersperBedj iu advanced
slagca, with others of u lighter line; from the former, thick, reddish,
scvretioii e8caj)e8, from the latter, it \\i\i more of n milky upjHmnince;
pue may also be preHsed from the bronehiolet!. The gnmular formations
characteristic of the red hep!iti?Jitioii of crou|iout) pneumonia are ab-
Beut in the catarrhal form. Here the nuclei of consolidation are com-
posed of scattered groups of bronchioles with their immediately related
Teiieles. Iiiflaninintiun comnieneing in the brnnHiioles involves the air
Tnaielcs by direct pxtensiou or by aspiration into them of irritating seci-e-
lions. The microscope i«how« some of the alveoli collapsed, but the
majority are more or lees tJlleil with serum, leucocytes and epithelial cells
with varying degree of fatty degeneration according to the duration of
the disease. The local effects of this intlammation are similar to those
of croupous pneumonia, t-xccjit tliat the prtMlucts. of catarrhal pneu-
monia contain much leas fUjrJn and fewer red corpuscles. The walla of
the brunchioles are thickened and infilt rated witli i-ound cells, and their
epithelium is largely exfoliated. Their Ciilibre is in some iduous con-
tracted, in others diluted. The small tubes are always blocked with
catarrhal accretion. There is also usually present more or less neri-
broncliitiij. The alveolar walls are congested.
The alveoli adjacent to these areas of consolidation may be emphy-
aematous and are often the seat of congestion and o'dema. The pleura
over them may be inflamed. The pulmonary lymphatic glands are com-
monly enUrged. Catiirrhal put-umouia terminates in resolution, suppura-
tion, gangrene, or in chronic tibrciid Indiiratiou, or the products may un-
dergo tjiseous or tubercular degeneration.
Etiolooy. — Lobular pneumuiiia is most common in infancy before
the third year, and in advtiuced age. Bad sanitary comlitions, poor food
and shelter, and debility am pretJisposing factors. It is always second-
ary to affections of the smaller bronchi, and hence arises from exposure
to the exciting causes at bronchitis. It is apt to follow influenza and
the brunchicis which complicates contagious diseases, esiKcially meaitles
and whfxjping-cuugb.
Symitmm.xtuux.y. — The eaaeutlul symptoms are rapidity of the pulse
and of respiration, usually with lilgh tomperature and troublesome cough
and emaciation, occurring in the course of a bronchitis.
The pnlse, at first strong, frequently becomes feeble and compressible
and runs up to from 140 to ItlO per minute, and the respirations from
60 to SO. The temperature gradually rises with irregular exacerbations
andtfemissions to 104" or lO.V F., anil in fatal arute cases may go trro or
three degrees higher. The cough loses its bronchial cliaracter and be-
comes hacking and painfid, and is followed by but little expectoration
which may be streaked with blood.
The most important *iyj<s are deficient respirnt^iry movement*, slight
LOJiULAR pyBt'MOS/A.
ViS
and occusioimlly "patchy "dulncsfl, with deficient vesicular nuirmtinnKt,
on forccil inspiration, Dtimerous poorly dcilMed loucuus dicke. Wlicn
only H limited number of lobuk'» iire nfTei-ied, a flia^osia cannot be uc-
euratoly mndo; but if several lobnlea are involrpil, the signs bpcomo
quite distinct.
By inspection we slml! ueually observe rapid bnt imperfect res-
piratory movements, with very slight expaueiou of the ribs during
inspiration, but considerable elevation of the chest walls, I'spe-
cially at the upper part; and at the aarae time falling in of the sufl
parts of the cheat and retraction of the lower ribs, as in pulmonar^'l
emphysema. The inspiration is often shortened and the expiration
prolonged.
When several inflamed nodnles exist, eBpecinlly if they are locritc-d
near the surface of the lung, palpation will discover exflggerate<l vooul
fremitus.
Upon percussion, dulness will be found, varying in degree with the
nmount of coiisoliiliitlon. Thi^ h nearly always limited to the inferior
and posterior portions uf tlie chest, and usually occurs on both sides;
bnt the disease may be confined to one lung or to the upper lobes of
the lung?.
By ausonltution more or less broncho-vesicular or bronchial resplm-
lion with exaggerated vocal resonance and moist high-pitched rAles will
uenally bo found over the lower part of the lungs. Likewise, over the
upper auil anterior portions of the eliest we ordinarily tinU the signs of
pulmonar}- cmphysetna, viz., vesioulo-tympanitie resonance, with a pro-
longed and low-pitehed expiratory murmur.
After protracted or repeated colds, the occurrence of a feeble vesicu-
lar murmur, with several illy di'tined mucous clicks on forced inaplni-
tion, should cause us to suspect lobular pneumonia. The mupoiis clicks
in these cases are due to retention of the catarrhal pniducts in the ajf
cells.
Uigh-pitched bronchial niles are uldo significant of coui>olidatioii.
lu children, some of the alveoli are often oompletoly choked, so that
few rdles are produced. In adults, the iunumiuatory products are mora
fiuid, and conse<piently rales are more abundant.
Dl\oko81b. — The diagnosis of lobular pneumonia is very difticnlt, un-
less a considerable number of lobules are affected. Even then, the disease
ctuinot always bo deteeted by the physical signs alone, bnt, as in some
rases in other pulmonary affections, the history and symptoms must bo
weighed with the signs, before a positive opinion can be forme4l. For
example, in a i^hild sutTrring from bronchitis, if the respiration sud-
denly becomes accelerate*!, the temperature elevated, and the cough,
which may previously have been loosw and ea^', becomes dry, hacking,
and painful, we have good rea^mn to think that the vesicular p>ortion of
the lung h*s become involved in the intlammatory process. If, in addi-
l-Zi.
VVimtNARY D/SEASSS.
tion to these symptoms, thesij^'-ns of consolidation which have just bccu
enumerated are jireseat, tbti Uiaguoeis may be considered certain.
The disttnetivo feutiircs ln-tween iftfiflnrt/ brour/iifin and lobular
pneumonia may bo found under the JttTcrential diaguo»is of capill:iry
bronchi titi.
Tiobulur pneumonia is often prect-ded and accompanied by collajise
or atelectasis of many of the air vesicles; for this reason the si^jns of
the two diseases arc nsually considered identical. If any considerable
amount of tissue is inrDlved, and the two conditions are not eomliined,
a difrercutlal diagnosis can be made by attention to the following ityntjH
toms and EJgns:
LODCUkR rsETMOia^.
PtTUIOSAHY COLLAPSE.
SymjitoTHK.
Tem]H;ratiire suddenly incre.isod
cough becomes dry and paroxysmal.
The elevation of tempe ratine, nnd
llie cxiuyh. wliicli are incidental to the
.iMoci-ativl broarhitis. ar<* nol mate-
rially utTected by collapse ot the air
vesicles.
Inspedio}}.
Fatltng in of the lower portious of Tlio inverted aclion of the Inferior
Ihechesl. wliich may liavt^hoen tiotioetl ribs is increjispd in pro|H>rtion to the
to bronchitis, partialty disappears. exteat o( atelectasis.
Palpal itm,
Tocnl fremitufi It increased.
The vocal tremitus is not likely to
be iacreaMed. but, on the coalrury, it
luav be dimiaiitlied.
Percunion.
Cnironn dulncss. or distinct patdbos
of dultiess, usu.illy marked over the
lower portioDK of tbe cbest.
The dulness tit not »o distiuct, aud
there i& occasiouatly ve^iciilo-tym|ia<
nitic resonuuce.
The dulne^ usually occurs flrel nt
the l>order of the left \\mg. where it
overlaps the liearl ; anil shortly after-
ward al the base of the lungs. From
tlie latter |Kisition it has u tendency to
spread upward ia an elongated, sonie>
what pyrontiilal fonn n.Inng' the hn&t
of tiic intervei-tebraJ grooves, in which
poRition it may reach as hif;h as the
apex of the lun^,
Au»cvitation.
The respiratory sounds >renerally
banh or broncho- vesicular In quality,
never wholly tubular. The nmcoaa
r&lr« of bi-onctiitis usually heard over
the entii-e chest ; but, in many in-
■tances, Hner moist rAles are obtained.
Tlie respiratory sounds uiuaUy
feeble. The rAles of bronchitis are less
likely to be pre-sent tlian in It^ular
pneumonia, and are seldom heard over
the collapsed lobules. Sometnnes deep
inspirations may bring' out a few crep-
LOBi:iAH PNSVittiXIA.
137
limited to a small spnce ininie<ltalt>)y
ever the iaOiimeil lohiilen. When tlw
finer bronclii are tlilatetl. a$ suniutiiiiea
bappens in thin (lifteas«, the rdles be-
come foarse and nomewhat motaltJc if
the dilatations aro siirrotiniied by con-
Aolidnt^ Itins*.
itant r&)««. which are heard with three
or four iusph-ulurjr aou, aud then dia-
appear.
The difforontini <)ingno8is between lobular pDonraonm and hbar
pneumoniit appears below:
LOBITLAR FNEUMUNU.
Begina with a bronchitis.
No cbiU.
No crisiA.
LODAK I-NECMONU.
Symptomi.
Bc)^ns with ihill.
Pain in the side.
Terminal crisis.
Signt.
Usually conflDed to one side and to-
one tai-£e unuL.
Duhiess iiiurkKl.
CrepiUiul am) Rubcreiiitant rflles.
Bniiii-iiial voice u ml bi-eatJiing.
Orten over boUi 1ud>;s but in siaall.
Bcatten^t) areas.
Duliu-vi not markeil.
UucouH with Ktiialler rAlus.
Bront-liy-vesicuUir vuicw «iu1 breath-
ing.
The following is the differential diagnosis between lobular pnen-
moniii and acute tufKrcuIar phthisis:
Acute ttberocuar pbthisis.
SjfmjUotna.
Id youni^ adults.
Initial pyn.-.\ia precedes Itie phj-alcal
signs.
flsmioptysis common.
Emaciation less rapid.
very
LOBCUkR PXEUMOXU.
faclkildreu and the ajjed.
Initial bronchitis.
Uaemoptj'Bis not common.
Emaciation and exhaustion
rapid.
Signt.
Most mailed in lower and posterior Most marked at apex.
parts.
No tubercle bacilli. Sputum sometimes contains tubercle
bacilli.
pHUUNOfiLS. — Thia disease may termiDate fatally within two or three
days, or uiay extend uvcr muuy weeks or uiuuths, ending in re^ulutiuu
and recovery, or in purulent infiltration, or in cheeriv or tubercular de-
generation and death: or the intiamuiutiun may cauBO exteuaive new
connective-tissue fornmtion in the inleralveolar septa and about the
broucbial tnbea, eventuutiug in fibruiil phthifiitf. which may extond over
aeveral years.
The disease is most fatal in infants, eetpecially when following whoop-
ing-cough or tneasles, anil in aged or greatly debilitated subjectt^. Death
results in from '^0 to 40 per cent of all casea. M>me authors placing the
mortality even higher. Among the grave Byn:.ptoniB ore: e.\teusiuu ul
138 PULMONARY DISEASES.
the bronchitis aud increasiag cyaDusiii; irregularity of the reBpimtiooi
and inefficient, feeble cough with cessation of expectoration; a nipid,
feeble pulse ; temperature exceeding 104" F. , and stupor or conrnldions in
the later stages of the disease.
Treatment. — Lobular pneumonia is nearly always a secondary affeo
tion, due to extension of the inflammatory process from the bronchi^
mucous membrane in consequence of debility. Bearing this in mind,
we avoid all depressing remedies such as antimony, aconite, or Teratmm
viride, and very early commence the use of stimulants.
Quinine is the best remedy to moderate the fever. Alcohol shoold
be given according to the amount of depression. The rule is to give aa
much as can be borne without causing head symptoms. Ammoniam
carbonate or ammonium iodide are very useful, not only for the stima-
lation which they afford, bat also for their beneficial effects ia removing
the products of inflammation.
Sedative inhalations are useful early in the attack, and at a later
period stimulant inhalations and counter-irritation are beneficiaL If
the patient emaciate, calcium chloride, tincture of iron, and cod-liver
oil are indicated. A change of climate is advisable if recovery does not
take place within eight or ten weeks.
PECULIAR FORMS OP FNEUMOKIA.
Several somewhat peculiar forms of pneumonia merit passing consid-
eration, though they are not distinct varieties of the disease. These
are: interstitial pneumonia, typhoid pneumonia, bilious pneumonia,
pneumonia due to cardiac disease, and pneumonia from BrighVs disease.
The treatment of these forms is essentially the same as that for
the diseases with which they are associated, combined, as occasion may
eeem to require, with the resolvents and expectorants indicated in lobu-
lar pneumonia.
Chronic OR interstitial pneumonia (sometimes termed catarrhal
pneumonia) will be described under the head of Fibroid Phthisis,
Typhoid pneumonia is a term that may be applied to a certain
complication. If pneumonia complicates typhoid fever, or vice versa^
the symptoms of the one disease are associated with and somewhat
modified by those of the other, and the resulting prostration is marked.
The secondary pneumonia is here indicated by increased rapidity of the
pulse and respiration, with signs of consolidation. Cough and sangnino-
lent sputum are rarely present.
The expression typhoid pneumonia also refers to pneumonia of a
sthenic and usually fatal form, frequently epidemic among soldiers and
others subject to unhealthful sanitary conditions. The chief features
are extreme exhaustion and constant tendency to collapse, although the
4BSCS:i:S OF TUB 1.UN0. 19a
IooaI jmlmouary aigiia nmy be but slight. Symptoms liko those of sep-
tic-wmia mny be prolonged for months.
Peculiarly viscid gubcrepitjmt nilos may be heard, few in number
and found irregularly at (he Ixise or apex of the lung.
' BiLiova PNEUHoxiA, which is most common in mftlarial districLa, is,
in addition to the symptoms of typical croupous pncunionia. chanicterized
by jaundire, greenish, rlseid, and inodorous stools, with other evidences
of liepatic and gastric disonler, and a fever record interinitt«nt in type,
the febrile exacerbations being sometimes preceded daring the early
part of the day by chilly sensations and coolness of the ends of the nose,
fingers, and toes.
Pneumonia arising from disease op tub ueart, especially from
marlted mitral lesions, presents many features similiir to those of lobular
pneumonia. The iuvusiuu is usually slow, seldom pr^retled by rigors.
There is a chronic cough, with experloration which seldom becomes
rusty or tenacious. The signs may appear in scattered palcbes, which
change their seat from day to day, but are usually found over the lower
lobes of both lungs.
There is some exaggeration of the vocal fremilus, slight dulnees, and
blowing though not strictly bronchial respiration, with exaggerated
i Tocal resonance.
Pneumonia from Rriuht's disease mnynot differ mnterinlly from
ordinary iicute pnewniouia, or it imiy begin in collupsi' of portions of
the vesicular s-tnicture, and present characteristics similar to those of
lobular pneumonia.
AaSCESS OP THE LONG.
Ahflcees of the lung consists of & circumscribed collection of pus
within the pulmouury pareucliynia. It is usually characterizwl by pain,
rigors and fever, and later by expectoration of a small amount of blood
•miuediately followed by a large quantity ot pus, which escapes within a
few hours. These nbecesses are rare excepting when secondary to tuber-
culosis, pyiemia, or embolism, in which cases they are usually multiple
and muBt bo considered as incidental to the primary disease. They may
also result from the entntnce of foreign bodies into the air passages,
obstruction of the bronchi by tumors, or from suppuration of the bron-
chial glands; also from perforating abeoesses from below the diaphragm
or from the mediastinum. The pulmonary ali^cesses which chiefly
interest ua are those rt^sulting from acute pneumonia.
Symptomatoloot.— The abscess nsually follows within a few days,
upon some exposure, and occurs during the acute st&ge of the infiaroma-
tion. being preceded by the chill and fever of acute pulmonary intlum-
mation; but aometimes it occurs after the pneumonia has subsideil.
The formation of pus is commonly attended by rigors which are followed
9
pvutoSjkMT »nr§9Wt
IB* 4lf tVO
ISC
IW
in«f«tar ciulit. tm
tfciwacpitt. la
fqcpwted m thtf coone «C « fr«
t'okM ikc yriit dia of
wtUkb lea ta tnsl^ <§?•, th»fraft»
Wing pnenM by « fr* dnfB a< UMd c
a peat to a piat of raBovMh or gn«iiii|
pctt u tipTloratoJ witkia a tern IwaiL
fWTgr**** or abnv it
OooMBBaU J the ftbana Ta|«am xat* the
The ipataM w—anly eoofena aaill nOeviih
laag tans Tinfafe lo the naked eta, vfciefc apM
tiflB are fionnd ta fwiteln eJMtie fttft.
Tltf jifaf an: itnlnfii vith toabhnua or afaanwe «( the nspintorj
amraar orcr the afaena^ cwlaaeJ vith indisltnei lAle* and niwiliiiiiii
branchial hrwathiay ia tha fau^ tiane abont k, and a&er caca^ of piu>^
forachort time the sgna oi a csritj.
DiifiKiaf*, — ^Th3 afWtion it liable u> be ■iiraVea tar fannu^il
pnaaiaita, cr aent* or ^raaie pteorisf . The Bflai iapenant fieatni
in the diagaoM kki tbr «jmp«o«a of aeaie pnrnmonia ftilWved
inegalar chilb and feTirr: dalneM laoR cr Ich circMacribcd, bat a|
to be mon dialiact than tha*. of paeanonia and Um than that iif plea-
riff ; atjptc inspiratory aad Tocal sipw, and ftaatir adden ^xpccunatiun'
of a large qnaotitj of poa in vhid macf be fonnd dastie ftbre.
BnaekUia b diatingaiihed faj abnaoe of the initaal chill aad sabaa-
qmint ngen, lUght fercr, aim ma of dolaeH on |wrnnrifm, and the
ftiatnce of faSatMal rdba; and by the character of the expectovatioii.
Pmenmemia jiehie Terr dmilar rfnptoms and qgaa, bat aeldoro
nniri the bn^alar ehilb aad ferer. In {itwaiaoaia the dalncMB ma^
be loB or son sariEod aecording to the atse of the aboecBi aod the
amount of healthy bug tinoe between it and the aniface ; but erentaallj
tba dnliw in caae of abaees beoomea noK dtcttnctij ciirtuascribcd.
Jn pTwuiafftita dtttiiwi crepitant and aabcrv[MtaBt rAles or btonchinl
breathing are praetieally alvars preeentt while orer a polmonary abeoee
there maj be a feeble aomtal mormnr or abaence of ravpitaionr aouuda^^
or there maT be irregular broDrbial rAIes, which are lielj to be
duitinct in a zone sarroonding the abetsen.
AruU pUurisy maj be difliBTeatiated br the pnanoe of fncti«
BnandM and fremitu, but absence of rocal fremitos. In it there ia mt
decided dolnem. and leat distinct re^tratorr and rocal sigaa than ii
abooMi, and there i« do hectic ferer. TMien there ia mach effnaion,
duage of the terel of flatneas by changing the patient's position and
ditplacewent of the heart differentiate it fnnn afaeoeeB.
Chr^uie pUmrUjft or empyema, when general, ran be easly dlsiin-
A
ABSC^S OF THE LVNQ.
131
guished from u))6ce88 of the luitj?, btit tvlan circumscribed the Eigns are
not characteristic uutil u niicrus^-u^tic t.-xuiiiiiiatiuu of ilic ptis reveals
elastic tibru in tho case of abscess but none in oiripycnm.
I'KooNosis. — The affection may prove fatal within two or three
weeks or may be prolonged for mouths. If the abscess opens spontane-
onsly it will usually do so within tlin-e weekB. Many cases die of ex-
haustion, Honie by infection of other parts, und still others by rcjiealed
pneumonias developing about the purulent c&vity; yet b considerable
uuml>er recover. The cases caused by pytemia, gangrene, tuberculosis,
eiubulisni, are necessarily grave.
Treatsiekt. — Commonly the profession favors expectant treatnieut
with tonics and uiuple nourishment, hut when the aliscL-ss can bo located,
especially if near the che^t wall, the question uf surgical interference
ptust be couaideretl. Knowing the danger of the operation and remem*
tering that many cases recover spontaneously, I believe that the greutoet
good to by far the greatest unni!)cr will be obtained in most casus by
pursuing the expectant plan for at least tlirce or fonr weeks; but when
Ke have rcaaon to believe that there is a single abscess near the surface
of the lung, when sufllcient time has been given for BpoutaneouB ojieu-
ing, and when progressive emaciation and hectic fever indicate the
retention of pus, it is sufer for the patient to open the abscess from
witbont.
Aspiration alone or combined with wustiiug out the cavity with a
disinfecting solution will prove curutive in a considerable nnmher of
cases and should bo tried first, but if it fails the surgeon, with antiseptic
precautions, should cut down and resect a portion of one or more ribs.
If the lung is found not adherent to the jjlcura it ehonld U' drawn up
and stitched to the external pleura, where it will become firmly attaclieil
within a few hours. Then (or at once if the two surfaces of the pleura
vtv adherent) an opening should l>e made through the lung tissue to the
cavity by means of the thermo-cautery, and a large-sized drainage tiiTjo
introiluced. Strong's tubes spoken of in treating of empyema (Fig. 33)
»re well adapted for this purpose. The cavity shonld subseqnently be
Managed as iXwm of other abeceveu, and the patient etistaiued by tonica
ftod nutritious diet.
CHAPTER IX,
PULMONARY DISEASES.— a?H/inM<rf.
■e Iiyperajmia are redder, shglitly heavier, inid lesa
i. Au unusual amount of arieriul blood escapes on ■
riosiiredistomlod, thonlvijolurepitlieliuin is swollen, ™
PILMONARY HYPERA;MIA.
Pi'LHONAKY hypcrffimm sigiiifieu an excess of blood in the pnlmonary
ressitlft. It may bt- gi>nc->riil or local, active or pas^iive. It possesses no
distinrtive piuiiical figns unless associated with puhuonary oedenm or
bronchial henuirrhage.
Anatomical ask PATHOLtMiUAL CHAKArTERisTUs. — Lungs which
are the seat of acfit-a hypenvmia are redder, i^liglitly heavier, and lesa
crepitant than normal.
section. The cjipillarios i
and tho bronchiul niuoouet membrane may be injected. (Kdcma may ac-
company a local active hypermniia. Active hyiicrffimia may speedily dis-
appear or it may terminate in iuflaninmtiuii.
\i\ jHisitire hyper.v'niia or congft-tion, llie lungs are of a dark red or
purple color, the dependent parts shttwiiig marked post-mortem staining
of a darker hue; the organs are heavier und less crepitant than normab
and the tlow of blood on scL-tion is copious and dark, but mixed with air.
The aipillaries are engorged, distended, and tortuous; the atr s:ics con-
tain scrum with blood corpuscles, leucocytes, and epithelial cello more
or less granular. The connective tissue is usually slightly (edematous
and shows small extravasations. In severe and continued congestion
these changes are exaggerated, there is greater thickening of the alveo-
lar walls, engorgement of the vessels, wdema. collapse of some of the
air sacs, and, decrease in the amount of air in the lung, which is of daik
red color dotted with lighter points oX extruvasutiou, partially decolor-
ised. The fluid from the cut surface is more watery. This condition
is termed splenization. Prolongwl obstruction to the pulmonary cir-
culation duo to mitral ditteafle results in hrmen induraiioa. Here,
iu addition to the capillary engorgement and alveolar changes, there is
extensive pigmentation of the lung along the lymphatics and vessels
and about the connective-tissue cells, from de^wsit of brown granules of
hfematiu derived from the degenerate red corpuscles and carried thither
by the leucocytes. There is also marked connective-tissue hy[)orplasia.
Tbe luug is consequently dark brown in i^olor with yellowish and red-
dish (Mttrhes due to extravasations in various stages of decoloration. It
is larger, heavier, firmer, lei<s u^deniatous, and drier than asplenoid lung.
i'VLHONAHY HYPERMMIA.
m
Iiy}}ostatic. eongention signifies jKiiwive liyp^rasmia of dependent pnrts,
usually btlateml and due to curtliiic weiikne8s in those long confined to
bod hy exhausting (Jiseaaes,
Etiology.— Jr/iif bypersmiamuy bedne to increased cardiac aotioa
from violent exercise, medicinal etimuliUion, mental excitement, and cer-
ttiin neurottes. or to local irritution from iutuilmiou of pungent gasei,
foreign budiei, and hot or cold air; or lo iliminution of inter-ulreolar
pressure in the rar«6cd atmosphere of high altitudes or during inepira-
torj' expansion of the chest nith olwtriu'ted air pnssageB, as in croup,
uedi-ma glottidiH, and tumors of the liirynx. Lastly, interference with
the circulation in one part of the lung may cause compousfttory or col-
hitcral hypera'mia of the other parts.
Pamre pulmonary hypera?mia is due either to ineflicienl propulsion
of the blood through the lung from weakness or inefficiency of the right
heart or to obslructiou iu the pulmonary artery or to interference with
the outflow of bloud from the lung owing to valvular disease or weak-
ness of the left heart or pressure on the pulnionarj- veins.
Symptomatology. — We can best recognize pulmonary congestion
by considoring its history and symptoms, iu connection with the physi-
cal signs. For example, if a patient is attacked with sudden dyspncea
after extreme physical exertion or cxiiosurc to the influence of a ntrcfied
atmosphere, as in high altitudes, pulmonary congestion should be sus-
pected ; and if the dyspncea is attended witli a profuse watery and blood-
stained expecloratiou and the signs of wdema, we may be positive of oar
diagnosis.
In Huch case* percussion reveals slight dnlncsa over the lower por-
tions of the chest.
Auscultjilion rcTeals a feeble respiratory mnrmur» crepitant rillea,
and usually an abundance of large and small mucous r&les.
Acrrntmition of ihf- Mcond hoiiikI of the. heart, at the pi)ln)on.iry onflrp, has
been coitMidoieil by somt> antlioi-s diaRoostic of pulmonary irontrextiuii ; but t)il8
Bicn cannot he i'«lieel on. an it tuav be oDl,r relative, duo to fi'ebleae&s of the
aorlic nonni! ; nioreover. lhi» accentuation is a common si^ in citrdiac disease.
In the conuestioD of tlie bm^ ^^)>icb immediately pr^cedi^fi pneumonia,
phi:fii«-:il examination reveals vt-rj- slight duhiess, with feeblem-ss uf the respira-
tory murmur aod. possibly here and there, a crepitant or ntilKrepilant rfile. Thb
condition, however, is nut usually include<l under the head of pulmonary con-
pfsttun.
Pboonosis. — Active pulmonary hypertemia maycause death within a
fewhonrs from oedema or homorrhsgc, or it may terminate in pneumonia.
It is ordinarily amenable to early and prompt treatment. Mild cases
are usually of short duration and recover spontaneously. Passive hj-
periemia is more serious, but the prognosis depends largely upon the
gravity of the canse. Chronic cases due to heart disease are liable to
•udden fatal attacks of oedema.
154 prtrntNAnr mssASSs.
Tbeatmext.— Wlien tUe congestion oomes on suddenly, fnll doses
of ergot should be givtin. Bleeding will be found useful in aiaes of ex-
treme plethora. Dry or wet cupping over the chest is sometimes bene-
ficial, A blister will ot'cahionally prevent the supervention vS inflnmnm-
tiou. If the heart is weak, it rihould l>u stimulated; und if pulmonary
oedema coexist, alcoholir stinmlauta should bo given freely und ft hydru-
gogne cathartio may be administered.
BROWN 1NDUR.VTI0N.
The 9t/tnptmn» of brown induration are those of the causative initial
disease, with cou^h and Im'moptysis,
The principal sitjH is dulness, limited mostly to the second intercos-
tal space near the sternum. Tliero are also exapgorated vocal resonsnoe,
brom;ho-vesicular or broncliial breathing, bronchophony, and occasionally
pet^toriloquy.
This iifTection may bo dlfTprentiated from other pulmouiiry iliseasea
by the position of the dulness and the presence of the symptoms and
signs of mitral diseitse.
Tkeatmevt will aim to relieve the cai-diao affection. Aramoninm
carbonate and chloride, moderate doses of digitalis and tinctnru of nux
vomica^ are especially indicated, and couu tor-irritation may be boneBcial.
PULMONARY HEMORRHAGE.
Pulmonary hemorrhage includes hemorrhage from the bronchi
(bronchorrhngiM) and from the parenchyma of the lung (pneuinonor-
rbagia). The chief symptom is hemoptysis. This term, used loosely,
in a broad sense denotes spitting of blood, whether in large quantity aa
from the rupture of an iineurism into the air {Kisuages, or in small
amount, merely streaking the sputum ol chronic bronchitis, or us found
in the msty or prnnc-juico expectomtion of pneumonia. Pro|>er]y, it M
aigni^cs the mising of more or less pure blood from Teasels bleeding V
into the larynx, trachea, bronchi, or alveolar structure.
Anatomical axu Patiioujuicai, Chakacteristics. — The appear-
ance of the lung after pulmonary hemorrhage depends upon the extent
of the hemorrhage, its cause, and the time at which the orgun is in- ■
apectad. If post-mortem examination is mjido soon after broiichini hem-
orrhage, the lung in general may be ana>mic, marked by isolated bright
red spots at points whore blood has gi-avitated or has been drawn into
anperficial alveoli. On section, coagnla may also be found blocking the
bronchi. If these collections in tho uir sacs and tubes are numerous or
large, the lung to that extent will be heavier, less crepitant, and less apt
|io collapse. Its cut surface will show red, firm patches or nodules re-
I
les r^- ■
VVLMONARY HE3JOHHIIAUE
136
seniblmg iularots, from which sero-eanioiis flnid escapes. The bron-
cliial mnoons membrnne niiiyaiipfiir uliiinsi uorninl, or i-ochyiuoiic, rcl,
swuUt'ii mill sofU'iioi. li the exuniinaUou be mmle long iifter death,
there may be liitle or do remaining evidonee of un abnominl cundition;
or the coiigulu in the air snia may l«* imrtiftUy decolorized. The heni-
orrhage may in sonio oases give rise tu lohuliir piieuiuoniu.
If heniorrlmge has come from an abscess or tubercular cavity, un
ermled tcswI or ruptured unonrisin may be found in the wall of the
cavity or in one of the trabcculae trftvei*8ing its space. Brown indura-
tion :tt the hing also will often bo found, with the evidence of hemor-
rhage due to mitral disease of long standing.
In other caseH, atherumuluus, fatty, or amyloid degeucration of the
Tpssels may mark the seat of purenehymatoua Iicmorrhage. Rarely sub-
pleural litematoma and htemotborax are present.
Etiology. — All those conditions which weaken the walls of the pnl-
lonary blood-vessels predisj>ose to ha-moptysis. They inolnde tubercn-
losis, abscess, anil gangrene, which diminish the local support of the ves-
sels; also changes in the vascular walls, such as atheromatous, fatty, or
amyloid degeneration, and atrophic changes incident U* liieniopliilia, pnr^
para, scorbutus, and the infectious diseases; also heart disease and other
conditions which produce clironic over-disteution of the pnlmonary
Lvessela. The usual exciting causes are musL-ular exertion, coughing,
r^lond speaking, or concussion from a blow or fall. Other crises occur from
penetrating wounds, but in quite a largo percentage of cases, no exciting
^oauso can be discovered.
SYMPTOMATotoov.— The chief symptom is expectoration, usually
of arterial blood, more or less frothy; perhaps immediately preceded bj
a sensation as of warm fluid trickling beneath the sternnm. This maj
follow severe congh or strain and without premonition, or may be pre-
ceded by coldness of the extremities, congestion of the face, headache,
dizziness, thoracic oppression, or palpitation.
Uarmoptysis may be followed by nansea and vomiting, and is apt to
[Occasion considerable mental shock. Large and small bronchial rales
Are present in must cases during active hemorrhage, and may remain for
several hours. Feeble respiration is sometimes noticeable and dulness
may be present, thongh frequently no signs whatever can be detected by
the most careful examination,
DiAONOsiB. — Ilfemoptysis may be mistaken for faiematemesis, epi-
staxis, or hemorrhage from the gums or the pharynx. The distinctive
Matures are as follows :
H.EMOPnrgis. IIveUATEHEais.
Biitory.
tTsually history of pulmooary or Usually gastric or hepatic disease.
heart disease, especially phthisis.
13G PCLMOSABT 1>ISEAS£S,
HjMOPTTSIS. a«MAIK«KSB.
A preceding thoracic oppreaaioa or Al«<**iiigs«seof pain orfalB*«
premonitory sensation of uicfchng^ ftuid "xnesa.
beneath the sternum.
Blood expeUed primarilT by cough. Biood expelled primarily by vomits
Vomiting secondaiy if present. ing: ^ *«nn_
Subsequent cough »nd bronchml Otest agv ^^^dv^
WUes.
Character o^ Mood.
UsuaUy bright red and trOthj from tTsuaUly dark ciocted or Kmntam -
admixture of air. may be mixed with food. '
Alkaline reaction. Acid reactioii.
In epistaris iMpection of the mms and poet-nans with rdl«cted light
reveals the course of the blood and perhaps its origin, ffemwrkoffe from
the (jHtm or the pharifHx can generaUj be readilv recogniwd bv carefal
inspection.
Prognosis.— Pulmonmry hemorrhage, though rarelj immediately
fatal, is in most cases indicative of phthisis. A single hemorrhage may
amount to a pint or more^ and continue from a few minutes to seTeral
hours. As a rule it is followed by others. In most instances it is fol-
lowed by the occasional eipeetoration of a small amount of clotted
blood for twoor three days. Freqnent recurrence, or severe hemorrhage
if not fatal, results in anaemia or may cause lobular pneumonia. When
occurring in phthisis, hwmoptysis seems occasionally to check its course
temporarily; commonly the patient expresses a feeling of increased
well being. Rarely, it is followed by a more rapid progress of the dis-
ease. It is a fatal symptom if due to ruptured aneurism, and serious if
complicating pulmonary abscesses, gangrene, malignant growths, or
when accompanying the infectious diseases or grave dyscrasia and occa-
sionally when resulting from heart disease.
Death may occur from depleted circulation, asphyxia, or from grad-
nal exhaustion dne to ansemia or to secondary pneumonia.
Treatment.— The patient should be kept perfectly quiet until ail
bleeding ceases.
The most efficient remedies for checking the hemorrhage are full
doses of ergot, gallic acid, or lead acetate and opium.
The hemorrhage may sometimes be checked by the inhalation of a
spray from a weak solution of liquor fern subsolphatis — "Ix-.aqnaad ' L
In estimating the value of any remedy for this purpose it must not
be forgotten that the bleeding will asnally cease in a short time wheth-
er remedies are used or not, Loomis relies more npon aconite and
opium than npon styptics. If ice is applied to the obest. it should be
Vreat care, as it seems to favor the supervention of broncho-
(er hemorrhage (Loomis* Practical Medicine, p. <i5).
PULMONARY AJ*OPLEXT.
137
POLMONART APOPLEXY.
Sjfnonyms. — Diffuse puUnotmr}' Ucmorrhugt!, pneumonorrlmgia^
bemorrhugic infnrctus.
Piilinuii:irT apoplexy is ;i rare iilTe<?tian. cansiMiiig of extrava»itioi) of
blood into tlie lung tisitue. It iiHually ooi'iirA in tlie lower lobes.
Siucc apoplexy etvinologiwilly refers to loss of tMiiBritnisne^B inci-
dent to rapture of n cerehml iirtery, llus term is not iiptly :ipplie<l l(» in-
tcrstitiul i>ulmonary hemorrhuge; nsajro. howevt-r. lias authorized it.
Anatomical ami rATiiOLu(;uAL Ci!a»ai.teristics. — I'ulmunai'y
apoplexy consists of uu csejpe of blood into the pttronchyma of the lung
from a ruptured vessel, uttenilcii by more or le«s luoeratton and iutiltm-
tion of the iisstics, itL-coi-dlng io the size of the daiuuged vessel, the cause
of the injury, uud the condition of the lung.
Tho Inng ig rrrljitlvely heiivier iirul firener thiui norma], and c<intain8
no nir in the iifTectcd portion. Not infrcriuently several extmvasHtions
exist from the bursting of vessels in different parts of the organ.
The resulting clots or hemonhagic infarcts, as distinguished from
embolic infarcts, arc of pymmidal form, the bases of the pyramids ap-
pearing superficially beneath the pleura us dark red or almost black
jKitclie^, the sides ourre^pDudiug to the iuter-lobular boundaries ; occa-
sionally tho pk'unv is also torn, and blood esnipeB into the pleural sac.
The cut surfiice is firm but moist and of uniformly dark color in the
early stages, but later the clots gnuiually become decolorized. Hemor-
rhagic infarcts somewhat resemble true embolic infarcts, but arc usually
larger and more sharply deflned. Apoplectic extravasation may canse
death immediately or from subsequent snjipuration or gangrene. It may
end in resolution, complete or aecom{HinimI by ciratrii^iiU contraction, or
may undergo cuAcation, udcitication and encapsulation.
Etiouiov. — Hemorrhagit; tnfarctus in the lung is usually the result
of pulniotuiry hypenemia .-irtlng njion vessels already the seat of degen-
erative changes. Such changes frequently give rise to multiple iineu-
risms which give way on sudden or prolonged intra- vascular prt^ssurc.
A severe blow or a wound of external origin may cause diffuse hemor-
rhagic iuGlcratiou or it may resnit from erosion of a vessel by ulceration,
SysiPTOMATOLOOY. — This affection is usnally, though not invariably,
attended with dyspntea and btemoplysis, the expectorated blood con-
taining small dark clots.
The principal siguA are: more or lees dulnesa, feeble or bronchial
respiration, and mucous ntles.
When the coagula are few in number, and small or deep-seated, per-
cussion yields no signs; but if they are numerous, or He superficially^
dutneaa will be more or less marked.
•38
PCUtOXARY DISBAUBS.
be
1
CpoD auscolbition^ diqcous, subcrepitant, and possibly well-niurkec
crepiutic riles will be detected in and about the extniTasations, until
ooa^lation of blood has uken place. Aftenrunl, respinitioQ will be
feeble or suppressed over tbe extraTumtions; or bronchial breatbin|
ftud exaggerated tocuI resonance may be obtained, if a large dot lies ii
apposition with n bronchial tube.
DlACN'Orii^ — I'hc diugnoiig of pulmonary a|>opIexj must be bajsed
Dpon the history and the character of the sputa^ in connection with.H
tbe eigns fonnd npon percussion and anscoltation. It is not likely tof
be mistaken for any other diseaee except pneumotiia, from vluch it can
easily be distingni&hcd by the history and bjr the expectoration.
T&£ATUE>*T.— The treatment should be mainly directed to the cause
of tbe hemorrhage. Kcmuvoi of the blood-clot Is probably hastened by
the administnitiuu of potassium iodide, or liquor potas^as and other
alkalies. Counter-irritation iii useful in some caees a few days after the
accident. Quiet must be nmint&iiietl for two or three week? to jireveul
a recurrence of the attack. If pneumonia ur pleuriiiy 8ui>erYene, thoyj
should be treated essentiallr the same as when ther occur alone.
PULMOXARY TUROUBOSIS AXD EMBOLISM.
PrufoxARV THROMBOSIS coosists of the gradual obstruction or »
blood'Tessel in the lung by a coagulum formed in «i7m. It occurs ia
the pulmonary artery or some of ita branches, as a reenlt of local non-
inflammatory vascular degeneration or of intlanimation in the surround-
ing long tissue.
PrutoNAKY EMBOLISM cousists of a suddcu obstruction of a ressel
by a foreign body, usnallv a fragment of a cardiac volvaUr vegetation
or of a thntmbus in some of the systemic veins. Emboliam muy occur
in the imlmouury artery by lodgment of a thrombotic fmgir.eut from
the veius of the abdomen or lower extremities or it may occur in th«
bronchial arteries by an obstruent brought from the mitral or aortia
Talves.
AxAToHicAL AXD PATHOLOGICAL Clt A RACTZRlSTics. — Pulmonary
tmMic infarcts are usually multiple and occur near tbe surface of tbe
lung, especially in the poaterior part of the lower lobe. In form and
gross appeantnee they resemble itrmtrrrkntjir infarcts, but they depend
Ufton obstruction of a blooil -vessel, instead of rupture. At the apex of
this infarct, usually at the bi^l^cation of an artery, an emlMlns is gen-
crallr to be fonnd about which a secondary thrombus has formed. The
conical form of the infarct correeponds to the distribution of the branches
of the occludeil vessel on the distal side of the obstruction. These being
no longer supplietl with bj-wd ^y the main vcmoI, become engorged, ac-
cording to Cohnheim, by regurgiution of bliMjd from the veins, but ac-
cording to Litten this is due to a small amount of arterial Mood still
I
I
PVLMONARY roLLAP9S.
i;jo
supplied to the port by arterioles, wliicb, however, are not sufficient in
size arid number to lifford udetpmle collaterul circulatiou. The chuuges
iu the part, conscfjuent upon engorgement and atasU, urc: migmtioD of
leufocytej), deterioration of the tunica intima, diapodosie of red corpus-
cles and engorgement or collapse of the air cells with thinning of their
val]». About the iniarct is a zone of active bypera^min. Kiiibolic in-
iarctuti may terminate in rewlutiuu or eicatrizutlon, but if infected in
ibscesa or gangrene. Harely caseation and calcification with encap»ula-
ion occur.
Etiology, — Thrombosis may be due to local vascular degeneration or
iiiflanimatiuii extending from tlic adjacent lung tissue, oepecially in con-
nection with ft't'blu hujirt power.
EmftoHum may be due to loosened fraginenta from the cardiac ralrea
or from systemic veiions thrombi or to fat-grannleii dniu-n into the open
veins at tlie site of a fnicture or crusliing injury to the long bones.
Symitwmatolooy. — The principal symptoms are sudden, severe, and
sometimes paroxysmal dyfipnoea, turbulent heart action, and puliation
of the juguliirs, from yieUling of the tricuspid valve. Exnggt-rateil res-
onance is sunietimes ileteeteO, owing to cutting off of the blood supplj
fruni some uf the jmlmoiuiry lobules, and conspquent distention of the
air i^ells. In the same locality, the respiratorv murmur will be feeble
or suppressed.
DiAONcisis. — Neither the symptoms nor the signs of these conditions
are sufficiently well understood to enable us to make a positive diagno-
sis in evi.*ry instance. Most reliance must be placed on the syniploins
and hist<iry.
Pkognosis. — The prognosis is unfavorable in proportion to the
amount of lung damaged hy the emboli or thrombus, nn<l is always
very grave if the emboli be infected. SmuU infarcts may undergo rvso*
lutiou. Death occurs from collapse, apua'a, or from secondary pnen-
monin, sepsis, or pbtliiHts.
Treatment. — The treatment must be exj^ectant
rULMO.VARY COLLAPSE.
5ynont/m«.— Apucumatosis and atelectasis. The latter term, though
referring to the same anatomical couilition as the former, is mure prop-
vrly applied to air cells which remain in the festal condition after birth,
not becoming distended with air.
Pulmonary collapse is a condition of the lungs in which nir cells
which have formerly been inflated have collapsed, and returned to a
qnaei-fcctjd slate.
AxATOMUAi. AND PATnoLOCiCAL Charactehistics. — Both the ao-
ijuired and the cuiigenital forms may involve the whole or part of one
lung or a part nf eiich: the collapsed air cells being en masse or in iso-
lated lobnles or groups of lobules scattered through the organ. In
140
PVUSONARY D/SEA.SE.S.
order of freqncncVtthu pirU iiffectud nre: tbe lower margin of the lower
lobea of both Inugs, the tongue-lIkc pruloiigatiou of tbe loft upper lobe,
and tbe posterior portions of the lower and iip|>er lobes of hnth lungs
neiir tbe spine. Tht' ci^llupBed parts correapond externally to Kmall irreg-
ular ftre^ns depresaod below tbe general surface of a reddish-bine, violet or
gniyish-blueoobjr. The crosA-«ection is dark red, smooth, tough, airlegg,
and the part rejidily sinks in water. Kueently collapsed uirsaog may l>e in-
flated, l>ut if this condition long persists, distention becomes imposKihle
and the parts subsequently undergo fatty or fibroid change or become
thf) teat of tuberculosis. The surrounding lung tissue is not infre-
quently em]>hysenmtons or oedematons; the bronchi which are still per-
vious are frequently dilated. Permanent and ettensive collapse from
prolonged compression results in a dense, solid, fleshy condition of the
lung, termed Ciirnificaiion.
Ktiology.— The affection is most freqnent in early childhood. It is
always preceded by inflammation of the bronchial mucous membrane,
the secretions front which collect in some of the smaller bronchial tubes^
where, acting us ball valves, they obstruct the entrance of air during
inspiration, hut ])ermit its esc:ipe in expiration. Ultimately the air
cells to which the obstructed bronchus is distributed become in this
manner completely emptied of air and collapsed.
Congenital atelectasis occurs in weak and sickly infants or may be
due to prc-muture delivery, and it may result from accidents in birth,
auch 1)8 llie inspiration of amniotic and other fluids.
In children, more or less permanent collapse is apt to follow an at-
tack of brnnnhilis, whooping-cough, measles, typhoid fever, severe diar-
rha?a, or any other exhausting disease. Disease of the brain or spinal
ooixi interfering witli tlie pneumogsistric nerve may c:iuse it. Colla]>se
of the lung may be due (o the pressure of mediastinal or intra-pulmo-
nary tumors, or to effusion into the pleural sac.
SvMcroMATor.oaY, — The essential symptoms are: great prostration;
pallor or duskiness of the skin, which hangs in loose folds on the ema-
ciated limbs; rapid, feeble pulse and coldness of the extremities: u feeble,
insuftfcient cough; great dyepncea, without the lividity which usually
attends this symptom, and rapid respiration, rising in young children
from sixty to eighty per minute, with an altered rhythm iu the respira-
tory acts. In this alteration of rhythm the pause follows inspiration
and precedes expiration, instead of occurring between exjtiration and
ii.spiration. as in health.
The chief ai/fm are : retraction of the intercostal spaces and lower
rib« during inspiration, dulncss over the collapsed lung when the apneu-
matosis la considerable, and feeble or absent vesicular murmur, usually
with harsh or bronchial respiration over the affected parts.
Jnsjieetion reveals the rapidity of respiration and its changed rhythm
and retraction of the intercostal spaces and lower ribs during iuspira-
PVLMONAHY COLLAPSE.
141
tiou. The Utter is ft very important sigu, but it also occurs in othor
discAses. .
Iti children the signi of percusaion are uot so rcliublc us in ndulta,
but when the dise»M^ id well initrkcd, more or less duliiifiui will be found
over the aftected portions, usually firiit iiL the biiiie oi thu lunge, then at
their anterior borders, and fiuully along tiie epinul column. If a whole
lobe is involved, diilnesa like that of pnoumoniu will be presfnt. Not
infrequently the collapsed cells are so scitttered through the luiigd, uiid
the adjacent cells aro so distended, that the affection may be quite ox-
tensive without giving any sigus ou pt^rcussion.
By auscultation, harsh or bronchial rcapimtion may be heard over
the colbipsed cells instea<I of tlie vesicular murmur.
Usually portions of the lung immediately surrounding the afTected
lobules remain pervious to air. so that tbu vesit-nlar murmur i« not en-
tirely lost; the sounds from the air vesicles are then mingled with thoso
from the bronchi, causing broncho-vesicular respiration. Ordinarily,
numerous bronchial rales are present, which may completely mask tho
vesicular murmur.
Diagnosis. — Pulmonary collapse U most likely to be mistaken for
pneumonia ur pleuritic clTusious.
The diagnosis in many cases must depend mainly on the symptoms,
«s the signs are by no moans distinctive. Whenever dnlness occurs, its
rapid appearance, within twenty-four or thirty>siT hours succeeding tho
<igi)S of bronchitis, is an clement of great value in diagnosis.
In pulmonary collapse there are few if any crepitant niles, which are
considered pathugnomuuio at pnenmunia. In the latter disease there is
Uiit the retraction of the cheat noticed incullapse^and duluess is UBually
greater and tho bronchial breathing more marked than in tho diseasB
uuder consideration. The fever symptoms are more marked in pnea-
mouia.
The features that distinguish pleuriay from pulmonary collapse are
the fl&tneaa instead of dulnesa on percussion, change in the level of flat-
ness and absence of a'ocal fremitus, and feebleuess or absence of respira-
tory sounds over pleuntl etTusious.
PRorfNoeis.— Mild atelectasis in the new-bom, not dopondont apoa
congenital defect, may bo corrected if restorative measures bo early ap-
plied and long continued. If of long rlnrntion.orwheu in adults due to
extreme compression, the affection is liable to be permanent and to cauM
more or less emphysema and fiually to giro rise to lobular pneumonift
or phthisis.
Atelectasis following broncliitis and whooping-cough is especially
fatal. According to Loomis (Practice of Medicine, p. 158), twen^-
five per cent of the loul mortality in young infants results from atelec-
tasis following bronchitis.
TuEATMENT.— lluviug fairly established the respiratory fuDCtions at
lit
PULMONAUX JjJiiJi'difJi^.
birth by the onliuur}* nictliuUs of ihu ubatetriciuti, it must not bo I
gotleu iu the subsotfuciu tn'^itmiiit of this iruuditiuii tlmt Uebility is llie
chief fuclgr in its pioUuctiuii. Tri-nlmc-nl iiiiisl ihtirt-furis bu ;-u]ni(irliiig
from the first. We must also atturupt to remove the tjecretions from
the broiiehi, so us lo prevent iinpliciition of olher air c^Ils. Willi
iu view, a mindoprcafitiig omoti<i may Iw given when the debility i» ii(
Tery ^reat, but it is genenilly unsafe to repeat ii. In mild cases eipee
tonint dose» of ipucuc are useful. In severe eaiiieii umnionium uarboiiatc
or ammuiiiuni iodidi; willt ah;ohoHn i^timuhintii iiro indicated. Countor-
irritation of the surfiujc l)V nuMins of vigorous friction or sinapii^ms is
naefal in most cases. The diet 8hoHl<i be nonri«hing. hnt not too con-
centrated. Concentrated nourishment h apt to derange the digest!*
organs^ and do mor^ liiirm timn good.
PULMONARY (EDEJIA.
Pulmonary oedema consists of an interstiHal extmvasntion of serniiK
irith effuaiou into the vesicular portion of the Uings, which rcuders the
cells and bronchioles correspondingly inijtervious to air.
AXATOMlLAL .\Sn P,\THOl,0(Hr.VL CUARACTEKl:*TICS. — PulmOIUiry
cedema may occur either ante mortem or post mortem; a given ease can
only be settled by reference to the history, and llie syniploms and iign%
present before death. It affeets most fretjuently the dependent parttsof
the lungs, but it may involve the whole or any i>art of one or both. Iu
•well-umrked tcdemu, the pleura is moist, and its cjivity may oontoi
serum. Tlie luug docs not collapse on opening the chest, and is abno
mallr light colored, unless the a'dema is due to hypcra^mia. It is heavie
llian normal, aud pits on prca'sure. The scrum oozing from the cut sur
face is frothy in proportion to its tidmixture with air; very slightly soi
the alveoli and bronchioles ore idmost completely fille<l with serum. I
has a reddish tinge if the affection, is due to h>']}era'nnu, is always albu-
minous, and usually contains alveolar epithelium, but unless due to hy-
pera-miit it holds but few iutra-vuscular cellular elements.
Stidlouy. — Pulmonary a>dema is probably duo in everj' case to on
of three causes, viz. : abnormal permeiibility of the vascular walls from
changes incident to certain diseases : increase of intra-vasculiir pressure
from active or passive hyper»mia, or change in the character of the
blood; two or all of these factors may co-operate in its causation.
It is not infrequently assuclated with general dropsy dependent upon
cardiac or renal disease. It may occur from heart failure in tlie course
of acnte general disease such as typhoid fever, or in purpura, scorbutus.
»Dfl3miit, and otiicr olironic affections.
It may occur in one lung or a part of a lung from the presence in
the other parte of collapse or oouBolidation ; and hence it often compli-
cates pneumonia, phthisis, or pressure from tumors or pleuritic effusion.
I
PULMONJiRY (EDEMA.
143
Symptomatoloot, — The chiof symptoms are dyspuusa, increased
rapidity of rt'spimtion, und oough with frothy expoctorution.
Tht! prinoipnl .siyns are Tery moist subcrepitant riUes, wiih more or
lc«8 (lulncss oTtr the bust of the lungs.
Inspection, )iiilputiou. uiid mensuration yield uo ohanicteristic signs.
ICetipimtiuu is iucreu«cd in friKjueiK-v.
liy porcUf«tfiuti, dulue£6 is obtained on both sides over the most d»<
]>eudent ponious of the lun^^s.
On auseultittiuii, tliere is a ft-eble respirutory murmur, whicli nuiy bo
elightly broDclio-veBiculiir. with iibundunt ni»i;jt and cnLc1<1ing subcrepi-
tant nilt?a. These Bonii'timva resembl*? tlie <:repilaiit niles of pneumonia,
but lliey are Tiiore moist, not so numerous, and are nsiuilly heard in ex-
piration as well as in inspiration. The vocal resonance may be iti-
creased.
DiAGKOsis. — Pulmonary ecdema is liable to be mistaken for the
first and third stagesof pneumonia, forhydrothorax, and capillary brou-
chitis. The distinctive signs between these diseases are as follows:
PULMONART CEDEUA. P-VEUVONIA, FIBST AKU TBIRD STaOKB.
Slight dulcet upon both sides. DtdiiOKs nioi'e or Icm marked, um-
ally ronflaed to one ttiile.
AtutcuitatioH.
Mucous and subcrepttaot r&les on Crepitant and sulKrepitant r&leeoa
both sides. one side.
PPLKOSABY (EDEMA. HtDROTHORaX.
Vocal fremitus may or may not be V''4x:al fremitus absent,
iucreascd.
Pcrffumnim.
Moderate dulncss. the upper level of Flatoeiw, the upper lino of which
vrblchdocM not varj- ■with clianges in x'aries wiUi the changes in Uie]>atient's
the patieotV position. iw^ition.
AlUCultatwH.
Subcrepitant rAles. Atweuce of the renpiratory murroor
and r&Ies.
Pulmonary oedema is distinguished from capilhrtf bronchitU by the
history, the presence of considerable dulness on percussion, and by ab-
sence of the aigus and symjitoms of general bronchitis.
Prognosis. — The prognosis is always grave in puhnouary tedeuia ac-
companying general dropsy. <Edenm in frequently the cause of death
in pneumonia. Extreme dyspnwa vriib bubbliug nllet" and rapidly de-
Telopiug cyanosis coming on in such affections indicates a fatal termina-
tion.
Tkeatmekt. — The treatment of this condition will depend upon the
144
PVLiiOIiAHl' DISEASES.
^^a»e With which it is afisociated. If it re*nlu from Bright's diseaw,
aoridcs and cathartica vill be iiwessury to stiiimlate tho other emnn<y
wnee. Diuretics will »Uo be useful in some laaea, bat the crippled
aueva cannot respond readily to our efforts to increase their functiooal
activity.
If the condition is dependent u|«n diBeiiso of the heart, digitalis will
fte apecmlly useful. If it results from debility, induced by low forms of
<Ji8eii9e, general stimuhitiou is very essential, and diuretics wul sudorifics
*re indicated.
If it results from pulmonary cougBstion, active counter-irritation by
Sinapisms or dry cups ahuuld be nuuie, and diuretics, sudorifics, and
<»tnartic8 should be Bimultaneously employed, care being taken not to
•exhaust the patient.
Uigitalig, scdpurius, potassium acetate, and ammonium acetate are
■the best diuretics, Jaboraudi :uid the hot-air or vapor bath are the
^ost suitable means to cause sweating.
aaliiie cathartics, and elateriumoreuonymns may be employed when
it is desired to act on the bowels.
When patienta are greatly depressed from protracted disease, care
0l]ould be taken to prevent jmlmonary oxlema, by frequently changing
tli&ir position from the l)ack to the sides, and vice veraa.
PULMONARY GANaRE*?E.
Pulmonary gangrene is a putrefactive necrosis of lung tissue, result-
ig from pneumonia, sepcictemiii, or local injuries.
AxATOMiCAL \su PATHOLOGICAL CnAR.aTEHisTics. — Gangrene
isually occurs at the lower part of the lung, and. according to Flint, on
^tbt* posterior aspect of tho upper portion of the lower lobe. It ia
Tisuully contiued to a few lobules, bat sometimes is diffused throughout
it large part or even the whole of a lobe.
A part of the lung which is entirely deprived of its blood supply
inidergoes coaguLition necrosis. Being exposed to the action of inuumer-
tble Imcteria, the devitalized tissues speedily exhibit the ehanicteristics
of moist gangrene. They bei:ome a tlark brown, dirty mass, wliich lifpie-
fies, and appears in the expectoration as a greenish-black, extremely fetid
flnid, containing organic germs, shreds of tissue, pns corpuscles', oil
globules, pigment granules, and various products of chemical decompo-
sition. Circumscribed gangrene is surrounded by a line of hypenemio
demarcation not present in the diffuse form. The discharge of the
ichorous slongh leaves an irregular cavity, intersected by vessels more
or less occluded by thrombi. Tlie walls, at first ragijed, may granulate,
and by contraction finally obliterate the sjmce, or a chronic abscess
mav result. The process, at first limited, may become diffuse; in this
form perforation of the pleura not infrequently occurs. From the
l*VLMOyAHY iiAyUHENK.
145
local llirombi in the pulmoQar; and brouuhiul veeiselif, metasUilic septio
jmboli muy uHtjtblisli secondary ulucetwus, in dUtunt organs.
ETioLO(iv. — G;iiigrtiH« iiijiy develop in the (bourse of bronchitie, pnen-
monui, phtlusis, cancer, or otlitr imlmonury digeasM, and nmy follow
severe penetntting wonitdti or the eiitmnce of foreign bodits iuto the
larger bronchi. It may eoinpliciite pyieraia, septics&niiu, or certain of
the prolonged debilitating fevers.
SYUPTOMATOLooy. — The principal aymptoniH are great prostration^
pallor, ema<:ijttion, nipid pulse, nipid and op]tre^se<l reapinition, htcmop-
tyeis.anJ foiigb, with abundant greenii^h.browniith, or blackish purulent
ipntnm of a sickening gimgronous odor, and containing fr.igments of the
decomposing lung. The odor is not pcroeired in the breath const^Dtly,
but mainly after cunghiiig.
The most prominent »iijHii are: dulucss on percussion, witli large
Knd gniall mucouii nikis; brouchial breathing or atidence of tliu respira-
tory murmur; and, wlien the slough has been thrown ofl', gurgles and
retfiiiratoi*}' aonnds indicative of a cavity. The disease at flrtd presents
the signs of eonsotidation, which are soon followetl by breaking down of
the liiDg tissue, and the production of vomic«.
DiAGXosis. — M.ost of the symptoms and physical signs are not distinc-
tive, as the same may be found in phthisis, bronchitis, or dilatation of
the bronchial tubes. The diagnosis must therefore rest Ujwu the char-
acter and the odor of the expectoration, which may be considered
pathognomonic
Small, circumscribed patches of gangrene, which occasionally occur
in hronehifU or around tubercular deposits, cause fetid breath und fetid
expectoration. The odor in these cases is only teniponiry, whereas in
di^nso gangrene the fetor is persistent, though most marked after each
act of cough and ex|>ectoration.
In bronchial dilat^iiion or bmnchisctasis the sputum is abnndant and
fetid, but not brownish in color, and the breath has not thai peculiar,
sickening odor of gangrene, which, once impressed on the olfactory
sense, is not eaisily forgotten.
Pbooxosis.— This dependa largely upon the cause of the guugreno,
and upon the extent of lung involved. In the diffuse form, death .a
inevitable, usually within a few days. In tho circumscribed form, re-
covery may occur, but in either cjise there is great danger from pviemla
And sepsis, rieath may result from acute hemorrhage or cxhauittinn.
Treatment.— Quinine, tincture of iron, alcoholics, jmd nonrishiug
diet are the chief remedies in this affection. Inhalations of thymol,
carbolic acid, creasote, eucalyptol. or tuipentino may be useful in modi-
fying the ofTuusive odor and in limiting the amount of discharge.
Anodynes shnnld be used to rioothe pain. Cases of cure are reported
from external incision and drainage, conjoined with internal medica-
tion.
lO
1^6 PULMONARY DIS^AS^h.
PULMONARY CANCER.
Pulmonary cancer is fortunately a rare disease. It is usually of the
medullary variety, though sclrrhuSj epithelioma^ and other varieties also
occur.
Anatohical and Pathological Characteristics. — Cancer may-
occur in miliary bodies scattered throughout the entire lung, or in
nodules ranging from two to ten or twelve pounds in weight; or the
lung tissue may be almost supplanted by the malignant deposit.
Whether primary or secondary^ single or multiple, the ultimate result
of pulmonary cancer is destruction of the lung immediately involved,,
by pressure, atrophy, or by infiltration with the cancer cells and the pro-
ducts of their degeneration. Extension occurs chiefiy along the lym-
phatic spaces. AVhile growth proceeds at the periphery of the cancer, dis-
organization takes pliice at its centre, where a cavity is usually formed
after a time. About the cancerous nodules not infrequently the lung
becomes congested, inflamed, (edematous, collapsed, or emphysematous.
There is always enlargement of the bronchial glands, and usually pleu-
ritis, with extensive thickening and adhesions, and effusion of bloody
serum into the pleural sac.
Etiology. — Pulmonary cancer rarely develops before the twentieth
year, and more frequently affects men than women. Heredity can usu-
ally be traced. It may spring primarily from the epithelial or connective
tissue of the lung, according to its type.
More frequently it is secondary to cancer in other parts, which pen-
etrates the lungs by direct growth or by embolic cells through the cir-
culation.
Symptomatology. — The most marked symptoms are pain and ema-
ciation, with some dyspnoea and cough, and often bloody expectoration
which resembles currant jelly.
Tiie .signs vary with the conditions. If only the bronchial mucous
membrane is affected by the cancerous deposit, we obtain simply the
signs of bronchitis. If the air vesicles are filled, we obtain the signs of
pulmonary consolidiition, as in pneumonia. When softening and ulceni-
tion have occurred, cavernous signs are sometimes obtained. If part of
the air vesicles are filled, and others remain open, we obtain broncho-
vesicular respiration and other signs similar to those of phtliiais.
The occurrence of the nodular variety of cancer in the lung gives
rise to signs which are often distinctive. We generally notice the fol-
lowing:
Inspection reveals more or less loss of motion and retraction or
bnlging of the tlioracic walls on the affected side; the former when the
lung has colhipBed, the latter wlien the growth is peculiarly large or
when considerable pleuritic effusion is present.
FCMfOXAIir CAXCEIt.
IV,
On |iil|iatioii, vocal fremitiu will Iw feeble or fiiippreiised, according
to tlio proximity of the tutuor to the chet^t wnlla.
Porcusftion, most frefjtieiitly near the middle or the upi>er jwrt of
tbu ehejit, will Rhow dulness or flatness over the tumor, according to its
jic;irncss to the chest walls. In many instjinces, over one or more jduces
luaonance remttius normal, surronnde^l hy nreiis of flnlTiese, owing to the
prti8en<:« of a small portion of healthy lung surrounded by a c:ineerou8
mass.
On auaciiltation, the respiratory aonnda may be feeble or entirely 9np-
preaseti over the tumor. Occasioniilty the cancer rests upou n large
bronchial tube, in such a position that the sounds from the latter are
tnnsniitted to the surface, gtviug rise to broucbiul breathing and bron-
chophony.
if the plour.-i [a involved, tliere will be an exudation of serum into
Hs cavity, yielding the signs of chronic or of snbnonte pleurisy. Upon
exploratory aspiration, the fluid is often found more or lei's »ingninoIent.
DlAUXOSi^. — When the disease is primary, it is very difliriilt to de-
tect. When gccoudury to canter in other portions of the l)ody, the
occurrence and persistence of bronchial or other pulmonary signs shonid
lead us to suspect its true nature.
I'ulmonary cancer is most likely to be mistaken for chronic or sub-
ncnte pleurisy with effusion. It bears some resembbmee to phthisis, and
iilso to aortic aneurism.
If the cancer is attended with effusions into the ]deural sac, an accu-
rate diagnosis cannot be made by the ordinary methods, but the chamo-
ter of the fluid obtained by aspiration will usually enable as to make a
correct dingnotiis.
The differential points betveeu the uodulur variety of pulmonary
.ODDcer and chronic pieuriny will be seen in the following table:
PULUONABY CANCER. CtUtO.NIC Pl^UBtSV.
•Sjffnpfom*.
Kpatlyconslaiitimiii; ami often cur- Uttl^", if any. j-ain : the cjcp'^ctoro.
nint-jcliy expecloraliou. ' lion, if any, only puruleiii.
JVrCMWIOH.
Diilne*M does not begnu at the b*.*o Flatness beginning al llie ba»* of
of the Inns: : iistmlly one or more ino- U»e lun^. uuiforni to lis iii>|>er hmit.
lotrf) '*pot8 of ii'wiinnce within the
area of tliilncsA or flatness
Autcultatian.
V*uaWy some respiratory siffns, due Absence or the respirator}' murmur,
to inolftUJ portions of normal lung, or and usually of the bconcliiu) sounds ;
to only partial oontwdidation of the the latter when heard are UifTuspd and
pulmonary parenchyma. Jintaitt.
Aapiratinn.
SonetinMS asanj^tif nolent fluid. The Serous or puniteot fluid is obtained,
fluid, when serous, coa^lates mucti
mora slowly than in pleurisy.
!:»
PULMOSJiJtr msEASKS.
Oancer of the lung ia not likely to be mutuken tor phihist'g, though
such »n error might be niaik-. The caficcrous growth does not often
begin iu the apex of the lung, and it may become very exlcu«tve without
causing bronchial riiles. The reverse is tme in phthisic
The history of norti^ nmuri»m is different, as iutnt-thoracic cancer ie
nearly always secondary to external manifestations. The symptoms duo
to pressure, viz., jwiin, dyspnu*a, dysphagiti, and venous congestion atul
pulsation, are \cm persistent iu aneurism than in cancer. ^
AnenrisniH nsually have u distinct expansile pnleation, and whffl
they cause a murninr, it in likely to be double, that is, eystolic and dia-
Btolic. Cancers have no pulsation excepting that communicattHl from
the aorta, and this is feeble and simply lifting. If a cancerous growth
by pre«sure on the artery, causes a murmnr, it is always systolic, no
second sound being produced.
Prognosis. — The prognosis is always hopeless. Death usually
BultB within a year.
Treatment. — Auod)'nes to relievo pain are the only remedies thaT
can be recommended. None of the remedies which have, from time to
time, been recommended for the cure of cancer hare borne the ti^t of
experience.
PtLMONARY TUMORS.
Tumors or morbid growths in the Inngs may result from hydatid
syphilis, enlargement of glands, absce&ses, and maliguant disease.
HYDATID CYSTS OF THE LD.NOS.
Hydatid cysts iu the lungs constitute a rare uffeclioh, which preseal
symptoms Hnd f<igns similar to those of phthisis. The cyst n)oi<t U
queiitly occnpies the lower lobe of the right lung, and is generally sei
ondary to hydatids of (he liver.
Anatomical asp Patholooicvl Ciiar.icteristics. — The wall
a hydatid cyst is composed of an outer aud'an inner layer, and the cvst
contains a clear fluid uou-coagn table by heat or acid. From the inncf
membrane develop young echinocacci with chanicteristic hooktots; tbe^
cysts may in turn develop within themselves others of similar form.
The growth after attaining a variable size may by fatty degeneratit
of its contents undergo evolution and largely disappear, or it may
main permanently as thewwt of calcification. Suppuration ma}* ocei
within the cyst, and its sub8e(|uent course may l)e tlwt of an absceseT
Agiiin, by gradual increase in size, it may produce great disturbance bj
its pressure, by exciting inflammation, or by rupture into the surroni
inglung or pleural cavity.
KTioLi.Kjy. — Tlie ova of the ttenia echinococcus, which commonly i]
habits the intestinal tract of dogs and other animals, upon entering tl
BTTADW CTSTS OP THE LVHUiS.
149
hnmiin etomach are freed from their cupaules by the digestive fluida.
Thence the pjmiailes huiTow to the Tisceru, chiefly the liver^ and bocomo
hydatid cyst«. Tiio dii^eaeo ia rare in this country, and is seldom found
excepting among jwopk- who mingle freely with the lower niiiinals.
Symptomatologv.— Xlie symptoms are like those of plithiaia, viz.,
cma<.'tatiuu, night-swetitti, cough, dyHjiiiu^a, nnd cxpt'ctonttion of bloody
and puralent s]»ut». Filially, hydiitid c\»iA, nr portions of them, and
the booklets of tlie echinocooci may be thrown off through the brouohi.
Symptoms of pyrexia are due to the ftecondar}' inllAmmution^ not to
any specific notion.
The principn) sifjm, if the tumor bo large, ore: bulging and loss of
motion of the side, nodulnr prominences in the intercofital spnces: and,
when the cysts approach the surftioc of the lung, duhioss or llatueiis ou
percussion, with su]tprt'ssed respirutiou or tubular breathing. A positive
diagnosis can selduni be made until tbe booklets of the echinoco<-'cua
are di^'uvered in the sputum. This dues not occur until hite in the
disease, when, after death of the e;(/u£0OH, it begins to be ejected from
the body.
According to Bird, the diagnosis may be made with a fair degree of
certainty ejirly in the disciuic if the eyst is of any considombh' size and
impinges against the chest wall, lu such cases the following signs have
been noticed :
Inspection reveals det-nbilus always on the sound side. The respim-
tory movements of the affet-tcd side are dt-Qcient, and tliere may he
slight bulging in one or more phices along the hitercostul spaces, over
the cysts.
Vocal fremitus may be absent, and fluntnation can sonteiinios be de-
tected over the cyst by palpation.
On percussion, flatness is found over a limited area corresponding to
the cyst. In order to be of value in diagnosis, this area of flatness should
not be less, than three or four inches in diameter. It should have a
ronnded outline, and it must be clearly sepiirated by a line of demnrca*
tioD from the surrounding resominee. It does not change with the posi-
tiou of the patient.
Ill auscultation there is absence of the respiratory murmur over the
area of flatness, and normal respiration around it, immediiitcly l>eyoud
the line of demarcation. The compressed lung close about the cyst may
cause a more or leM tubular sound.
PtAGNOSiti.^The affection is liable to be mistaken for phthisis or
circumscriU-d pleurisy. Attention to the differential oharacters noted
in the following table will aid iu making the diagnosis:
Btdatid cvsts ov tbk Lu:«a6. PnTaisia.
/iMjieWion.
Promioeace of UieiDtei-costul spaces. No proniineoc** of tlie ioteroostat
spacM.
150 PULMONARY ^DISEASES,
Hydatid cysts of the lungs. PHxmsis.
Palpation.
Absence of fremitus, and perhaps Exaggerated vocal fremitus ; no
fluctuation over the cyst. fluctuation over the consolidated lung,
PercuMvon. '
Flatness over the cyst sharply de- Diilness over consolidated lung,
fliied by alineof demarcation from the gradually fading off into normal res-
resonance of the surrounding healthy onance.
structure.
JlfiCTOSCOpiC.
No tubercle bacilli in simple cases. Tubercle bacilli commonly present
in the sputum.
AtLScultation.
Absenceof respiratory murmur over Broncho-vesicular respiration, or
cyst t^flat area). cavernous signs over dull area.
The distinctive features between hydatid cysts of the lungs and
circumscribed pleurisy are as follows:
Hydatid cysts of the lunqs. Cibcuiiscbibed pleurisy.
History.
Usually located in the infra-clavicu- Usually located at the base of the
lar or axillary regions. chest.
Symptom* and Signa.
Gradual accession of the local and Usually ushered in with acute febril?
constitutional symptoms. symptoms.
Inspection.
Nodular prominence of intercostal Uniform prominence of intercostal
spaces. spaces.
Percussion and Auscultation.
Signs usually in the upper part of the Signs generally in the lower part of
chest. the chest.
Treatment.— As tlie disease can seldom be distinguislied from
phthisis, the treatment must generally be the same as for the latter.
In those cases where tlie disease can be positively diagnosticated, aspira-
tion of the cyst and injection with iodine (Form. 11) is the most rational
treatment.
DISTOMA PULMONALE.
The people in some parts of China, Corea, and Japan, by the use of
surface or ditch water in the preparation of uncooked food, and for
drinking purposes, are liable to a peculiar form of pulmonary ilise*\Be
due to entrance into tlie lung of the distoma pulmonale, which infests
these waters. It is an animal parasite somewhat resembling an ordinary
leech in miniature, being eight or ten millimetres long, with oval and
ventral suckers by which it effects locomotion.
SYPIilUTIC OIHEAHE OP THE I.VJVixS.
151
By burrowing in the walls o^ the bronchi it canses atculiir broncbi-
«ctatic navit!P«, surrouniletl by irregnlar zones of congostiou inid iiitlum-
tion and containing debris, mucus, and the parasttBS with their ova.
S\"MPTOMATOMM{Y. — The sijmpiou)/i and niijnx are those of chronio
bronchitis of increasing severity associated with frequent, and often
severe hemorrhages.
The presence of the characteristic organism in the expectoration ^
the history of the ease^ and the geographical locality of its occnrrence
establish Ihe. dinynoHis,
Some patients recover with or without treatment, bnt the afTeoiion
is of long durntion and no specific medication avails. Prophylaxis is
the most important part of treatment (Annual of Universal Medical iSci-
ences, 1888).
SYPHILITIC DISEASE OF THB LUNGS.
It is ft well-recognized fact that syphilis canses a morbid condition
of the lungs, the Bigns of which in no way differ from those of ordinary
phthisis. Cases are occasionally ol>scrved in which a specific form of
bronchitis or gtimmata occurs as u result of the venereal taint.
The signs of syphilitic brunehitis are the siuue as tho^e of the non-
«peciGc uffecliou. A distinction between the two can only Xye made by
attention to the histon,' and the attendant symptoms.
DlAONOjiiK. — The differential diagnosis between ayphilitio disease of
the pulmonary parenchyma and phthisis is extremely difficult, and
often inipossilde. But when uueomplic:ited, pulmonary syphilis usually
differs from phthisii, us shown in tlie following tabic:
STPnnJTlO DtSBASB OF THE LUNOS.
POTOISIS.
Hintorg atid Symptoms.
The hislory ttt sypbili«; ihioktiiirig
oftli*> peno^teun) anil jtoricliuiidriuin
<i\'fr the inner «>ni| nf tJit> ilaviolf^-s am)
one or morp iif tliw nn-tilagefl of tlii*
upjK>r i-ibft, with t(iih-sti.*i-nii) leiidernewi
on in-essui-e over the upper |>ttrt «f ibc
•lernuni. Csiinlly ppJIIk*!- fever norde-
«idetl >.>nia(.-iuiioii, am) no haMnnpty^is.
I'lt^ysical Signs.
Xo history of sypliilis; no thidieniuff
uT the |>eriustetini ur pericliunilrjum
owrtii»> t'Livick-s ur curtilages uf the
uppei" pib». [Mid no !ttih-Kt*>i'nal tciider-
nes-i. Hpctio fpwr ami ii)ar)rL'(l pma-
ciution always present, with usually
liirmoptyftis.
Dninew) over Uie noilulcH, iisiiully
oonlltKMl t<» on*; Uwt;. uiiil Tuunil »t its
inw or «l Ihv lower part of the npiwr
lobe. T)m; tUilne>» ■•■iiiiuiiiri^' cii-ctiiu-
■M-ritied for 11 long; time. Viscid sub-
civpitant rAles, or s^vc-ntl miK-uus
«l)c){a, dilTusMl over a oonKidcmble por-
tion of tJie ItinfT. i>re l>«)ipved to he one
of the enrliPHt indimlionn of th*- srph-
ihttc itft*^ iioii : f:ilpr tlie uiiKi'iiltiitory
xigott arc tlie sartiu tu thwie of phtliisis-
DiilnoM usu&lly at the apex, and
^Tidiiiilly I'XtvDding' over the «ur>
roiiDtliDt; lung.
132
PVL3I0NARY DliSSASHS.
Pnoososis.— The prognosis is favorable iuuncompliaited cases when
diecuvered eiirly.
Treatment. — Anti-STphilitic constitutioual remedies as iodine, potus^
BiDm iadide,and tbti compounds of mercury are iudiciated. If thette were
oftener tried in casea of so-called phthinia, probably more vould be
cured. We should nlao employ tonic and supporting measures, similar
to those recommended in pulmouury phthisis.
ENLARGED BROKCHIAL GLANDS.
Aa an independent affection, this is of rare occurrence. It deserves
attention here from its close resemblance in some particulars to phthisis.
Ak.\tomical and P.\ti!ological t'HAKAcrEiusTns.— The chief
bronchial glands lie at the bifurcation of the trachea and about the two
main bronchi, where they are uumerous and in relation in front with
the aorta, pulmonary artery, and |H.'ricardiuui; behind with the aorta^
oesophagus, vena azygoa, and sympathetic: plexus. Those about the
bronchi are also adjacent to the large venous and arterial brnuchee and
pneumogastric and recurrent laryngeal nerves.
Knlargcmeut of these glands occurs from engorgement and increase
of iuterstilLul connective tissue with thiukeniug uf the capsule. When
acutt), Kuppuration may occur.
EriouaoY. — Some enlargement of the bronchial glands usually ao-
oompanies inflammation of the Inng or bronchitis; it is marked in
phthisis, syphilis, and malignant disease of these orgiins. It also occurs
to some extent in typhoid fever, measles, whooping-cough, and other in-
fectious diseases.
Symi'TOMATolocy. — The prominent symptoms are: a dry, ringing,,
and paroxysmal cough like that of jiertussis hut without the whoop;
with dyspnoea, and more or less pain and tenderness on pressure near
the fourth or the fifth vertebra, associated with emaciation, hectic flueh^
and night-sweats.
The symptoms vary greatly according to the size and position of th©
enlargement. Compression of the bronchi and lungs gives rise to cougb,
expectoration, and dyapn(pa.
I'resBure upon the recurrent laryngeal nerve prwluces' dyspnoea, occa-
sionally of a spasmodic ty|>e, and may also cause hoarseness or aphonia.
Crowding of the tanior upon the cpsophagns produces dysj>hagia;
pain and tenderness result from implication of the sjTiijmthetin pletus.
Compression of the pneumogastric accounts for the palpitation, ntpid
pulse, and the nauseik and vomiting that sometimes occur.
On inspection, we find aa si(j»i* frequently, distention of the cervical
veins and sometimes cyanosis, rarely deficiency or absence of respinitorj
movements of one side due to ocelusion of the main bronchus.
By palpation and percussion, tenderness muy usuoUy bo detected over
P£HTUSSIS, OS WHOOPINQCOUUU.
\h:\
the bronchial glands in the interacapnhir region neur the fourth and
fifth dorsal rertebne. Circumscribed dnlnesa over the enlarged gUnda
is sometimes found. Compression of a bronchus maV cause collapse of
the lung, with consequent uniform dulness.
By uuBcultation, we usually heur numerous n'lles and feeble or
harsh respiration, or in other words tlie signs of consumption. Some-
times arterial innrmiir^ may be detected. Agiiin, pressure on a bronchus
may cause Iftcalized riiles and feeble respiration; or it mayjireYcnt respi-
ratory sonnds in the portion of lung fiU]>plied by that bronchus. In
these cases n deep breath will fref|nently bring out the respinitory sound,
where it could not be heard in ordinary respirntion.
DlAcyosis.— Enlargement of tht- bronchial glands cunnut usually
be distinguished frum phthisis, but in some instances a reasonably cer-
tain difTereutiutiun can be made by reuienibering that the disease under
consideration usually occurs at an earlier ago than phthisis, and that
the pain, lendeniesB,and dnlness which it induces are first found in the
region of the bronchial glands, ininte-ad of over the apex of one hing.
Piio(;sosis. — The prognosis must be based upon the evidences uf the
structures inrolved, the size of the enlargement, and its rate of growth.
A sitiiplu inllammutory enlargement may be arrested, but if tiTUiinaiing
in Bup]>uration it is frequently fatal. >Syp}ii!itie adenitis rajiidly yiehls
to appropriate remedies. Malignant disease in thia locality is always
fatal.
Tuberculosis of these glands is likewise nnfavorable.
Tbeatuent.— Treatment is nsuatly of little avail in this disease, but
the remedies which are most beneficial in scrofulous enlargement of the
fiuperlicial glands should Ifc tried. Iodine, potitssiam iodide, calcium
chloride and cod-liver oil may be used, with quinine to relieve fever, or
iron when fever is not present.
The diet should be plain but nutritious, and all the surroundings of
the patient should be made as healthful as possible.
PERTUSSIS, OR WHOOPING-COUGH.
Pertussis is an infectious, contagious disease, often epidemic, and char-
acterized by paroxysmal, spasmodic cough terminating in a prolonged
inspiratory crowing or whooping pouml. It is most common in children
under ten years of age; it is rare before the third month: it seldom ofTects
idulta but is occasionally observed even in advanced life. One attack
usually gives immunity from later ones.
AyATOMiCAL AsnPATHOLOoiCALCiiARACTEKiSTics. — The ouly mor-
bid condition, found in fatal caae^ of pertussis, which is due to the dis*
Mae specifically, is a more or less mai'ked catarrhal inflammntion of th»
upper air passftges, luryni, trachea, and large bronchi. Other patholu;:-
icul conditions present are secondary and due largely to the severity uf
154 FVLMONAUy DISSaSES.
the cough. Pulmonary resicular emphysema is commonly present, and
sometimes bronchiectasis, chiefly in the upper lobes. Pneumonia and
atelectasis are not infrequent complications. There may be congestion
of the meninges and apoplectic extraTasation into the brain, associated
with effusion of serum into the cerebral cavities. Prolapsus ani and
hernia are occasionally observed as results of the cough, and more
rarely, rupture of the memhrana tympani.
Etiology. — It is highly contagious and is said to affect even the
lower animals. Infection is usually conveyed directly from one person
to another, though a third person may be the medium of communication.
Recent evidence favors the germ theory of its production, but as yet no
one micro-organism has been discovered as the sole cause.
A stage of incubation of from two to fourteen days precedes the ap-
pearance of catarrhal symptoms.
Symptomatology. — The disease is conveniently divided into a catar-
rhal, a paroxysmal, and a declining stage. Sneezing, coryza, epiphora,
and some cough characterize the first period, which commonly lasts from
one to two weeks, and iu no way differs from an ordinary cold.
The more severe the affection, the shorter the first stage. In the
second period, the cough becomes a series of short expiratory efforts
ending in a prolonged inspiration with a stridulous whooping sound
caused by spasmodic contraction of the glottis.
Generally several of these series occur in succession, terminating with
the expectoration of a small amount of viscid secretion, and with some
of a &othy nature, and often vomiting of a large amount of thick,
glairy mucus. These paroxysms last from half a minute to a minute or
longer, and recur during the height of the attack, every two or three
hours, or sometimes three or four times an hour. The longer the inter-
vals, the more severe the paroxysms. They are more frequent at night.
Conjunctival hemorrhage, oedema of the eyelids, and epistaxis are
frequently caused by the venous congestion which occurs during the
cough. In some cases there is marked cyanosis, followed by great ex-
haustion. Three or four weeks is the average duration of the second
stage. In mild cases the characteristic cough may be entirely absent.
In some cases it may persist as a habit for many months even after con-
valescence. The symptoms of the third stage are those of a declining
<»tarrhal inflammation of the air pasBuges, which usually lasts about two
weeks.
DiAGN'Osis. — The diagnosis rests upon the history, the peculiar char-
acter of the cough, and tlie expectontion or vomiting of large quantities
of viscid mucus. Affections of the bronchial mucous membrane, or of
the pulmonary parencliyma, which are frequently develojied during the
course of pertussis, yield the sjinie signs as when they occur independ-
ently.
pKOGXOsiri. — Whooping-cough is a serious disease among infants. The
PSHTU8SIS, OR WHOOPINd-aOUQU. 155
prognosis improTos with increasing age, and larger children seldom suc-
cumb to the affection, excepting when it is complicated by other disease.
The indications are good if the patient is fairly well between the par-
oxysms, but evidence of illness is significant of some complication. In-
tercurrent attacks of measles or other diseases are unfavorable. Bron-
chitis and broncho-pneumonia, especially the latter, frequently cause a
fatal termination. Cerebral congestion, apoplexy and convulsions, or
more rarely, hemorrhage from a mucous surface may be the cause of
death.
The patient may die from emaciation and exhaustion due to fre-
quent vomiting. The affection is frequently preceded or followed by
measles.
Treatment. — Many "specifics" have been recommended for this
disease, but none have proved effectual.
Morphine and chloral may be given in doses suited to the age of the
patient, especially to adults (Form. 2). For children I like better potas-
sium and ammonium bromide or hydrobromic acid with syrup of luctn-
carium, with or without syrup of hydriodic acid.
Sulphate of quinine in large doses, given in solution so as to make
the strongest possible impression on the sense of tiiste, has been highly
recommended, and, according to reports in the current medical litera-
ture, it will cure the majority of cases in a few days; but my own expe-
rience with it has been unsatisfactory.
My experience with the preparations of anemone pratensis, thymus
vulgaris and Oenothera biennis has been very limited, but never satisfac-
tory. Antipyrine in doses of gr. ij. every three to five hours for a child
twelve years of age, to be discontinued as soon as any cyanosis ap-
pears, is highly recommended by many; and bromoform in doses of
Til sB.-i. for a child of the same age, has been extolled by others.
^
TTxDER pulaiouary phthisiB may be grouped several affections, differ^
ing somewhat in their nnntomicnl charncteristicfi, but closely resembling
each other in their physical signs. From tliis Ititter fnct, it is especially
appropriate, in the matter of diagnosis, to t-ousider them together. The
term phthisis will then include all those wasting pulmonary afTectiuDS
which are ulteuded with e^tudiition or inlillrutiun iiHo the pulmonary
parenchyma, ranping consolidation, and are attended or followed by more
or less induration uud coutraciion and snbeeqiient breaking down of hmg
tissue, whether these diseases be the result of a simple inflammatory
affection, or the cause or the refiult of tuhertuhir infiltration. 'I he term
pulmonary phthisis will therefore include fibroid phtliiiiiB and the ordi-
nary sou t« and chronic forms of pulmonary tubert-uloais. Any special
symptoms or signs whicli are of value in differentiating between these
rarious conditions will be separuti'Iy considered.
Fibroid phthi^iis is aUo known as cirrhosis, induration, or fibroid de-
generation of the lung; sometimes as chronic catarrhal pneumonia, and
occasionally as bronchieotasia.
The ordinary forms of phthisie have varioos names, as, chronic
cronpous pneumonia, caseous pneumonia, cheesy or tuljerculons iutiltra^
tioD of the lung, chrouic tuberculosis, and pueumonic phthisis.
PULUONABV TtBEaCL U>6m.
Pulmonary tuberculosis may be more or less acute or chronic; run-
ning its course within u period of six mouths or a year, or beiag pro-
longed in eiceptiouul cases for many years. The term acute tubercular
j>hthi8is is properly applied to miliary tuljerculosis of the lung as a part
^H of tt generally disscmiuutod diseasu.
^P Anatomical AND Pathological Char-^cteriotics. — Upon j>ost-mor-
tem examination usually both lungs are found to be affcL'tcd. A lung
which is the seat of ordinary tuberculosis may appear superficially normal
or niuttltid, with grayish -yellow areas over which minute tulwrcles may be
aeon in the pleura. This membrane may also l>e covered with an inflam-
Ijuatory exudate. The organ it* heavier, more solid, and le«a crepitant
than normal. Section usually reveals at the npei one or more ragged
cavities, and yellow, cheesy niusaes, some of which may be semi-
PULMONARY PBTUISI8,
157
fluid. About these are miliary foci of caseation, a lino in diameter^
sharply defined to the naked eye, ronndeil, firm, transluceut, and gruy
or yellowiah in color. Thronghont the rest of the affected lobe or the
«ntire organ may be Bcattered miljftry tubercles, and larger ure.is ihc ^izo
of a pea, more yellow iu color. There is aceompuxiyihg brouchitie, and
from the severed tubes, some of which are dilate<l, pus may bo pressed.
The non-tuberciilar parts of thtf lung may be the seat of oraphysoma or con-
gestion and opdema, and the bronchial glands are infiltrated and enlarged.
In acute tuberculosis, tubercle bacilli commonly fiud tudgment
on the mucous membrane of the bronchioles or alvuoli, having entered
the bronchi with the inspired air, or occadionally by rupture into the
—h
ne.S8.— ToBcaouL ii,uuiitcvll; A. pi>itl>rlii-Ml««Ua: crouodlriiiplLoKtoelto: <t,flbfou
n-iiciitum.
pAssages of a tubercular gland. They may, however, reach the lung
through the circulation by one or more emboli from a distant tuber-
cular involvement of a vein or the thoracic duct Whether ihcy pri-
marily gain footing on the epithelium of the air passages or on tho
eudotheliuni withiu the vessels, under favoring conditions they effect
the formation of a tubercle.
The tuherrle has no constant form, bnt consists of one or more mnlti-
uuclear giant cdU, surrouuded by au aggregation of smaller epiiheliuid
cells, about which is a xone of round lymphoid cells the size of leucocytes
and smaller than epithelioid celln. Between these, and wntinunim wirh
the irrpgtilar processes of the giaut cells, is a fibrous reticulum more
or leis promiQenU
Tubercle bacilli are present in and about these elements.
Epithelioid and giant cells, though not [>eculiar to the tubercle, are
more frequently found iu it than elsewhere.
The many oval nuclei of the giaut cells are arranged at its circnm>
fercnuc or at opposite poles. The epithelioid cells may have one or
two nuclei; the lymphoid celU, which are smaller than the epithelioid,
have eafdi a siugle relatively large nucleus. A proiniueut feature «>f ihe
I5>
PULMONARY VlfiEAtSEH.
tubercle is its non-vnscularity, with u tendency to undergo early coag-ti-
lation necrosis, with coalescence of its cells into a homogeneous, firm,
gray nias^, which Inter becomes softer, clieesr, nml yellow.
This ciweaiion invariubly hegins nt the centre of tlie nodule, itnd is
probiibly tho result uf the IuqVl ot nourishment nnil the specific action of
the bucilli. This tubercle foriniition is the siime when occurring in the
lungs as elsewhere; its 8ubgiefjut.'iit courso is, however, very difftieiit and
vttricB in theso organs ftcoording to the mode of infection, the resistjince
of the tissues, the number of bitcilli and possibly their vinilenoe. Frnm
tho primary focus, the niigrating leucocytes and round celbearryihe
tubercle bacilli into tho surrounding intercellular and perivascular
lyuiph spaces and into neighboring alrcoU. Xew tubercle develops wiier-
ever the germs gain footing, and, either as a process of iiiHamnii.tory
exudation ur uf cell prolifenitiun starting from their walls, the adjacent
air cells be(:onie filled with Qbrin and celluhtr elements beiiriiig tlie nox-
ious princij>le. The walls of the alveoli and neaociiite<l bronchi become
infiltrated with round cells and thickened. The capillary plexus is de-
stroyed as the process extends and the tuberclea ooalcsce, forming larger
fooL While extension proceeds at the uircnmfcrcnce, the centre under-
goes caseation and softening, and eventually nmybc partially disirhargcd
through the bruncliij leaving an irregular, rapidly sloughing t-avily behind.
By iu<piration into other alveoli this discharge becomes the means of fur-
ther lobular extension. In some instances, in addition to these evidences
of acute infliimmation, breaking down of the lung, and wide dissenii-
Dfttion of caseous foci, and more or less extensive fibroid thickening or
cirrhosis of the [K-ri bronchial and interlobular tissues will be observed.
Such are cases either of ehronic intlaniinatiou of the lung ujHin which
' tuljerculosis has supervened, or of primary pulmonary tuberculosis in
which the partially successful efforts of nature to limit the disease have
resulted in connective-tissue hyperplasia.
Etiolooy. — The predisposing causes of the disease are those inflii-
enoes whicli depreciate the genenil heiilth of the individual or which, by
diminishing locid tissue resistance, afford fitting soil for growth of the
bacilli. Though the essential cause, the tubercle bacillus, is probably
rarely trausuiitteil from mother to child, it is reasonable to snppoee that
the weakness of constitution which tul>ercuhjsis engenders in the parent
may be inherit^-d by the olTspring. In so far, the latter is a more suita-
ble tield for infection. As reported by James T. Whittaker, of Cincin-
nati, ubservatious by Caokor {Veuhchg Mediziual'Zeitunyj Berlin, Jan.,
18lv^) and F. V. Birch-Hirschfeld {IfeHinrhp mffiirhiixrhr WorheHxchnf'ty
I*ipzig, March, 189"^) seem to prove that the banilli may Iw transmitted
directly from the mother to the fcptns. Children of those who are
debtl)tat<Hl by other diseases, by vicious habita, or by age receive a
simihtr heritage. The predispo-sition tn tuberculosis may also beacquired
by those who are habitually subjected to improper hygienic intlnences.
PUlitOJfAJiY VUTUISIH.
15ft
Poor or inmifHoient food, scanty clothing, want of clesnlineos, impure
or damp and chilly air, and lack of annshine, rariouBly combined, may
redace the most robust nonBtitntion to a ronditiim aa fHvnrnble to
phthiBie tuf. is the inherited, so-t'iilU'd armfulDUg diiitlieaii?. Prolonged
lactation, frequent rhihl-bearing, ntrohuliiini, and clironie malaria, by
enfeebling tho constitntion, also prepare l\w way for InUerciihtr infec-
tion. Rronehitis, pnounionin, and other pii)monary iiffeftinns frequently
prejtart' the soil locally for the growth of the 8|KJcitlc germ.
It is now generally conceded that the ultimate cauBe of tuberculosis
is the tubercle bacillus, as fir*t determineil by K'x'h in 18-S*..*. This is a
slender rod varying in length from one-quarter to one*huIf the diauicter
of a rod blood corpuMile; it ia tstr.oglit or curred, occurring singly, in
chains, or in grou)>s,and is incapable of voluntary motion. When prop-
erly stained, it has a peculiar bi*aide<l appearance, and if highly niagiiiQed.
Btnull bright spots may be seen within the rod. having the tippeantnce of
Biiores. The bacilli are I'clativcly enduring, but grow outside the body
only under the most cart-ful regnlution of tempfnitnre, nutrient media,
and other conditions. Tubercle UicilH enter the lung chiefly through
the uir pjiesages, conveyed by particles of dried phthisictil E{jutuui or
dueL
£ntranco may take place through the circulation from a primary
focus elsewhere. Such a focus may in rare instances be estiiblished by
the ingestion of luberculoui^ meat or of milk from a diitoiiscd linimal,
Chickc-ns that are allowed to eat the pputum from tul>ercuIous pmients
often contract the disease and may become a gource of infectioD. There
can be no doubt that in a small percentage of cases the disease is con-
tracted by direct contagion, as in case of those who have nursed con-
sumptives long and closely. However, norH'ithstanding the vart multi-
tudes who yearly die of consumption, very few well-ant henticated ca5es
of direct contagion^ or infection from ingestion of tuberculoussitbgtanccs,
can be adduced. The investigations of Henry P. Loomia, of Xow York
(Hesesirches of the Lr>onii& Laboratory, Xo. 1, p. 75), show that forty
per cent of the bodies of persons dying suddenly iu general good heidth,
apparently iM?rfectly free from tuberculosis, have tho bacilli in the
bronchial glands. Therefore, while it may be admitted that KochV
bacillus is the ultimate cause of the disease, it appears impot«nt except-
ing in the presence of a favorable soil as furnished by thoee of depraved
constitution.
Stjiptomatoixjov. — The chief symptoms of ordinary pulmoti.'iry
tuberculosis are only too well known, even by the laity. Few there are
who have not noticed among their immediate friends the bright and
suffused eye, backing cough, progressive emaciation, hemoptysis or pur-
ulent sputum, the hectic flush, and the night-sweats of tbi» dread dise;ise.
The affection often comes on insidiously, with ii slight hacking cough.
which does not attract attention till the |wtient tiikes a severe cold, or is
leo
PULMONARY DISEASES.
tAken down with some acnie disease from which he doee not coiivulwce
at the proper time; he is theu discovered to have s3-mptoins of con-
sumption. Sometimes, howevt-r, there may have been no hacking cough
in the begiaiiing; wo uro often told that the disease started with a severe
cold, whoopitig-congh, meaales, influonxa, typhoid fever, intermittent
fever, pariuriiion, or chronic affection of the throat or bronchial Tubes.
la quite a large percentage of cases the patient bus been apparently in ■
perfect health nntil ha*nioptysig has occurred; from this he may have
perfectly recovered, but noi infrequently the gyniptoma of a grave dis-
ease huve steadily progressed. Often there is a history of prolonged
overwork and exhaustion culminating in fever, supposed to he roalari-
ouB or typhoid, during whii-h the evidences of pulmonary disease ar«
diic'uvered. In most instiiiices lotis of vcight occurs early in the affeo-
tiou, depending generally upon loss of appetite or imperfect digestion.
Daily fever of two or three degrees is common, and a nearly uniform
symptom is rapidity of the pulse; even while other symi)tom« may not
be pronounced, the pulse frequently runs from one hundred to one hnn-
dred and thirty per minute. The cough is at first hacking, with little
or no expectoration; subsequently the sputum may become mucous and
later mnco- purulent. Hwmoptysia occurs in a considerable number of
cuses, but not in all; in many, early in theatUiek; in others, not until the
close of the disease. A simplo streaking uf the sputum with blood
should not be considered as evidence of tuberculosis. In mauj coses
these symptoms gradually increase for six or eight weeks, and then
slowly Bubdidc until the disease is arrested> and it may not again become
active; but in the majority who are less fortunate^ as the disease pro*
presses there are only periods of comparative health between tlie attacks
of great depression, and each of these latter is likely to leave the patient
weaker than when it begnn, bo that he grows worse, although at times,
not only the patient, but his friends are encouraged to believe that he is
improving.
Disorders of the digestive tract are prominent accompaniments of
the pulmonary trouble. Aimrexia, cominouly an early itymptom, may
be aE80ciat«4! with nausea and vomiting; the latter may Ik ilue to tlie
severity of thu cough. Gastric pains, which are often present, may be
reriex or may be dependent upon au inflamed condition of the mueons
membrane of the stomach. Diarrhcea is frequently very troublesome in
advanced cases, and is not uncommon at any period of the disease*
Kapid emaciation, proportioned to the acuteness of the atTectiou, is a
natural conse<)Ufnt of continued fever and anorexia, and attendant mal<
nutntiou nmy l>e aggravated by litemoptysis or a chronic colliquative
diarrhu-a. In many instances tulurcular patients are }io]>eful to the
«nd, though this is less common than is generally supposed. In tbe
later stages of the ilisease, cerebral aniemia or possibly tubercular changes
in the brain itself, or the sympathetic effects of imperfect digestion
nffcct the mental condition, causing irritability, fretfulness, 'cerebral
PVLMO^ARY PHTamiii,
101
fAtigue upou nieotnl exertiun, and finally, iu sonte eiiai-a, Iiullticiimtions
or fixed delirium; tliouj^h commonly the mind remuiun clear to the l:ist.
The *i'^(w differ in Trtrioua stajjea <if the uffectjun, the most im|inp.
taut being; diminished movement and sinking in of the cbeet walls in
the infraKjIftvicnlar region, with dulnesa on parcusaion; and nt an early
stage, feeble re(<j)iratiou. ur HubiTepitant n'lleit rontined to one apex.
foUuwed by broncho- vesicular respiration, exaggerated vocal resonance,
juetiilliL" rules, and the signs of cavities.
riitliiBis is generally described x\i having tfiree 3tagi?e, but these run
impen'fijitihly into eacli other, iu that the eigne of two or of nil of them
are likely to be combined at one time in the sanif individuMl. Tha
fitage^, therefore, f*jinnot be sharply delineated, and I think an attempt
to describe the signs of each separately wotild only Isad to confusion.
The BtJi^os of phthisis consist of: tiret, the incipifnt stage: seeund»
the stage of more complete deposition, occasioning coniiiolidntion iiinl re-
tracliun; and third, the stjigo of softening with breaking down of lung
tisiiue and the formation of oaTities. The pulmonary lesions occur with
alKint efjual fre(|ueney on the right and on the lefl sidi- uf tlie chei«t,jind
almoat always they are to be fuund at the a|H>x uf the lung.
Inspection nntl mensuration yield no sign^ in the early stage of this
disease, except incre:iKe4l nipidity of the respimtory m»tvementp. After
a few weeks, in the second stnge, in addition to the rapid respirations,
we observe more or less lo«s of motion, with sinking in of the rhe^t
wall over the affected org:in, especially diiring deep inspinition. lu
the la^t stage of the disease, there is marked emaciation, with promi-
nence of the clavicles due to the sinking in uf the tissues above and
I>elow them; loss of motion becomes more distinct, and there 10 depreis-
sion of the chest wa)ls, usually in the infra-clavicular region.
BxoefitUmal.—Xn iixcAi\i\\on\i\ cu-ws, cavities may oxist in the apices of tb«
lungs wiltiout uny L-'.>iutilerublu (]«[>reHsion of \.\w chest walls or diuiiuutiuo ia
their niuvciui-nt«,
Early, palpation furnishes no signs. As soon as any considerablo
amount of cousolidatiuu has taken place, the vocal fremitus is apt to ha
increased, but this sign 'ms vurtable, and therefore unreliable. S^imetimea
gurgling fremitus is detected over superficial cavities.
Ernrptionnl. — Shrinking' of Th« aifecteii lunj^ may di-ag the heart a nhort dlo*
TAOce from il.t nomial positiun, ait inillcat«d by the site of its tip«x beuL The
f^mnutipn of a lar|;e cavity ixvii^iunolly causes biils'iag of the portion of Iba
cheat which was formerly dcpresw-d.
On iH-Tcnesion in the tir^t fi/itge of this diseiue. there is alight dulness
if the superficial portions of the hing be affected; but if only Uie deeper
fttructures are involved, this sign may be absent.
Dulnes:'. when slight, U best obtained with the patient's mouth opeUf
and the djfferetice in the resonance of the two sides can be most easily
recognized at the end uf a full inspiration.
11
162
PULMONAHY DIHEASES.
The late H. A. Johnson, of Cliicu)^, told me that he &otneUin«a ohiAioed ex-
cellent results, in obscom rtisi's, by listeitin^ wiili tlie oitiiimry hinaunil :ttrtti(^
aco|>e, the cbe^t [>iec<< of wbii-b wus h«lil by ibe patient nbmil twu inuhoa id front
of his opea mouth while pcrcus&ioa was being made on U\e client.
Id this connection, it must be constuntly borue in mind that mod-
erate dolness i& frequently a nornutl sign over the right apox» nnd that
QX\wv diseases than phthisis, as, for example, bronchitis and cireuiu-
scrihed ]>neumDnia. not infrequently cause temporary duluess iu thu
infra- CI lav ipular regiun.
I)ulnes8 orer the left apes, even though slight, is always abnormal,
and, when persistent, is nearly always a sign of phthisis. Marki'd dul-
ness, if persistent, has the same eigniflcant^o when found over the right
apex. This sign is sometimes found behind when it cannot be deteotetJ
iu front. It is frequently present in the en pra-cl avion lar or clavioular
region when it cuuuot be obtained below the clavicle.
Exct'ptiviifii. — In Ibt: llrst Htu^e vt [ibthisis Ibe ti-KHinncc in sotuatimv^
TesioulQ-lynipunitK-, on wtxiunt uf secondary cirruniM,-nbi->l t-inphysunia.
Cunftoltdatiou ot the ileepor jKirtionH of the lutig iiiiiy ciiuse no ihiInvK> upon
ordinary percussion i( healthy hing tissue intervene beiwi^n it unJ tlie sitrfiwc.
In fon.'ibli* percii&£ion a snmll amount of consolidntion at llm aiu'fu-e of the hin;;
may be tiverlooked in consequence of the intense iwtonanco from the deeper
It iihould be remembered, in estimating the amount of phthisical con-
Bolidation. tlmt the degree of Juliiei^s and its area maybe due to the
temponiry luinsoliilatiou of circumscribed pncuaiouiii. The extent uf
phthisical coneulidatiou in such cAses can only be aacertjiined after the
inflammatory product has been abs<jrbo4l.
Iu the uvi-ond iitufje ot phthisis, dulness becomes very marked, and
gnidunlly extends over a wider area, owing to progressive pulmouary
consolidatioii; up to this time, dulnesE is almost universally t:un6ned
to one side. \i the same lime, tubular — or, according to Flint, tym-
panitic— resriiiance may be caused by the bronchial tubes or the
trachea, especially when percussion is maile nc:ir the borders of the tipper
part of the stonium.
Exceptional.— Iu this, as in llie first stage, veBiculo-tympantUc resonutu^e
may be obtained in mre instances.
In the third Ktayt; dulness is obtained over the affected lung, unless
cavities of considornblo size exist nejir the surface. In this case, reso-
nance over a limited portion, surrounded by dnlnese and corresponding
to the cjivity. may be tympanitic, amphoric, or cnicked-pot iu char-
acter. Sometimes early iu the morning, duhicfis or flatness may hi oh-
'Hfted over a cavity, owing lu its being filled with secretions, which will
^place, after free expectoration, to the signs of a vomici. In this
{e, or in the latter part of the second stage, dulness nearly always
PULMONAIiY PHTHISIS
103
apl»edir)! at the apex of the opposite lung, where it can bo detected bv
oauipariug the resonance ovor the diseaaod etruottire with tlmt below th»
ecoud or third rih.
Amoug tiib early Bigns of thu diseaae to be detected by utitictiUation
are feeble or cog-wheel respinitlon, with ftubcrepitanl Mies, limited
to n Bmull portion of the iipfx of ouf lung. Oi .;u-ioniilIy tlie iriucous
click or a few crepitant or sibilant r.lles,or eriiinpiiiig ur friction sounds,
may be heard in the same locality. Broncho* vesicular respimtion is
obtained a little later. The henrt-sotind^ are heard with nbuormtil iu-
tensily over the affected lung: if the cotit-olidntion be upon the right
lide, the first sound of the heart wilt be nioEt distinct; if upon the left,
^tfae second sound is more intense than the first.
In the first stage, the exaggerated bronchia] whisper is a sign of
considerable value, and exaggerate*! vocal resonance can usually be ob-
tained.
At a hitcr period^ in the second stage, bronchoTesicnlar reiipiration
becomes distinct, the respiratory sounds are harsh and tubular m qual-
ity, and the expiratory murmur is prolonged and high-pitched. There
are also large and small, moist, cmekling, ur metallic rdles, which are
often sticky in characler, and not affected by coiij.'hing. Friction truuiids
are often present, due to circumst-ribed jdeiiritis, caused by the tubercu-
lar deposit in the pleura. In a few atses, subrrepitani or sibilant, and
occasionally sonorous, rdles may still be heard in the second stage, lim-
ited to a small s|)flce over the affected tissue. Krtles are generally most
abundant in the morning, before free expectoration has taken phice.
Vocal rewnaucf, with the whispered or the loud voice, ib now tjidgifcr-
ated or bronchophonie. In uonie cases, wheTi tlie consolidated lung im-
mediately surrounds a large bronchial tube, pcctorihtquy may be ob-
tained. |)uring the latter part of this stage, the eigne of incipient
phthisis usually appear at the apcv of the opposite lung.
In the third stage, when cavities have formed in the lungs, if they
are empty and are connected with a bronchial lube, aivernous or
broncho-cavcruous resi>iration will be detected. True cavenmus rpspi-
ration, of a soft blowing or pufhng chanictt-r. and of low jiitch, is one of
the very rare sign^ of jihthisis. Broncho-cavernous respiration, hnving
much of the bronchial element, still with a 'hollow quality strongly
snggesiire of a oaviiy. is heard in nearly every case, .\mphoric respira-
tion is found in exceptional instances only. Associated with these signs
we usually hear numerous rAles and gurgles with bronchophony, pec*
toriloqiiy. or nivernoiis voice, and occasionally niclnlHr linklinj; and
amphoric voice. The nigns of the second stage also aregenenilly present.
If cavities are filled with fluid, none of the ordinary signs of the
third stiffe may be obljiined. Small cavities located in the deeper por-
tions of the lungs are not easily detected.
lu adraiiced phthisis, we vnay rerisonably conclude that a cavity ex-
^■^ PULMONARY DI8SA8B8.
'M* whenever the respiratory and vocal sounds over a small space, and
iimitef] tO'it, are peculiarly intense and bronchial in character, and asso-
^riated with metallic rales.
l»iA(Jsosi8. — Pulmonary tuberculosis is to be distinguished from
Mronic laryngitis, chronic bronchitis, pleurisy, chronic pneumonia, syph*
Uu of the lung, cancer of the lung, and other intrapthoracic tumors. Its
differential diagnosis from these affections will be found under their
respective titles. The diagnosis will depend upon the history, ^mp-
toms, and physical signs just mentioned, and upon the discoTery of
tubercle bacilli in the sputum. The presence of these bacilli in any
numlKii- is always indicative of tuberculosis, and in mtjst cases their
ubunduuce is in proportion to the severity of the disease (Clinical Diag-
TI0H18, Jaksch) ; their absence from the sputum is not in every case posi-
tive evidence that the disease does not exist.
Elastic 0bre8 in the sputum, though not peculiar to tuberculosis, are indicia
tlve of pulmonary ulceration.
To Stain Tubercle Bacilli is Sputum. — Many modifications of
the Koch-Ehrlich method for staining tubercle bacilli have been sug-
gested.
Ziehl's solution, which remains good for many months, is now com-
monly employed instead of the aniline preparations. It consists of dis-
tilled water one hundred parts, alcohol ten, carbolic acid five, fuchsin
one part. The procedure which I have found most convenient is as
follows:
(1) Examine the sputum on a plate of glass against a black back-
ground.
(^) Pick out a very small quantity of nummulated purulent sputum.
A platinum needle fixed in a glass rod is most suitable for this purpose; it
should be sterilised in ttie flame of an alcohol lamp or Buosen burner before
usin^.
(3) Spread the selected sputum, in a thin layer, evenly between two
glass slides, by drawing them successively one upon the other.
(4) Dry in the air or high above the flame of an alcohol Iwnp or
Bunsen burner.
(5) Fix tlie albumin by passing the slide several times through the
flame with the film iii)wurd.
{i\) Pour about twenty minims of Ziehl's solution upon the slide
thus propiired, nnd lieut over the flume till it steams.
(t) Iji't it stimtl for thirty seconds, or longer; then wash in clean
watiT.
(S) Di'colurize to a fuint pink color with a two or three per cent
sohiti"»n of uulplmrii- or any of the mineral acids.
This cun lu' done best by dipping the slide for a few seconds in *ba
ACVTS illLlAHY TUBBHCVLOSIS.
IBff
w*id sttluliou, wushing directlv in water, aud liuldiug it up to the light
for iusjMictiou, re|K.*ating the operation until the faint pink color is ob-
lainetl.
(f*) Count«rstaiu with a two or three per cent wat«ry aolation of
xnethvleno blue, wtiich is merely iKiured upou the slide and left from
thirty to sUty sooondfl with or without heating. Methylene hlne, if a
gooil article, is readily Holiihle in water. Two or three grains of chloral
may be added to the ounce of methylene solution to prevent decompu-
aition.
(10) "Wash in clean water.
(11) Dry, and mount with cover-glaM in glycerine or permanently in
balsam, and examine; or dry and examine directly without a cover-
glass, with a one-twelfth oil immersion lens. This lens with a No. 4
eyepiece (Zeiss) magni6es about a thousjind diameters and shows the
Uicilli as represented in 'Fig. 59, which was drawn for me by Uene-
age Gibbee, of the University of Michigan.
The bacilli may be seen distinctly with lower powers, but their detec-
tion ia much more easily and sjHfedily accomplished by this lens.
Thus prepared, the small beaded twicilli appear red. while all other
micro* organ isms, cells, albumin, nnd fibres are fitained bine. The only
other micro-organism yet discovere*! which closely resembles the tuber-
cle bacillus in form, size, and manner of staining is the bacillus of lep-
rosy, which difr<.*r8 from the tubercle bacillus in taking the watery
nuilin sljiius ir(|uully as well as other buutcria (Linsley's trunslaLiuu
of Fraenkers Bacteriologj', page 231).
Discovery of the bacilli may sometimes be faeititatetl by ihuroughly
stirring, and boiling iu a large test-tube, about 3 i. of the apulum with
3 vi. of a solution of caustic soda, :i parts to 1,000, until it forms a
thin muss. This should Im uUuwfd to settle twenty-four hours, when
the sediment, which carries down the bacilli, should be examined.
AOCTB MILIABY TUDEHCCLOSIS.
Miliary taberonlosis of the longs is a part of a general disease;
though all the riscera, and especially the peritoneum, pli-ura, and men-
inges, may be involved, the lungs are the chief seat of deposit.
AXAT03IICAL AND PATHOLOGICAL CnAKACTEBISTICS.--SmalI UOduleS
the aize of a pin-head are observed seattert>d over the pleura and dissem-
inated throughout the aiTected lungs, whirh arc usually congested and
obdemutous. To the unaided eye these tubercles appear sharply defined.
Microscopically the outer zone of lymphoid cells ia seen to merge gr^-
ually iiiUj the surrounding lung. The air cells contain to some degree
the elementa of exudation.
KnoixinY. — The immediate foeus of general infection may be in any
PVLMOySRX DISEASES
VTguu, \ouea, joiul^, or in the oriniirj tract, but usaally it is in the
JaDgs or IvinpliAtic glmoda.
Ulctiration iuto a lymphatic tmuk Is foUowed by entnuico of bacilli
iuto Che circulation and more or le^ extensive infection of other purUi.
SvuiTOiiATonxiV. — The general s}-n)ptonis are very like those of
typhoid fuver, tlough the temperature is frequently highest in the
morning, ranging between 103" and lofl" F., and occasionally going np
to 107" F. Prostration is very early ami marked. Involvement nf tlio
meninges gives intfinric iieadache, vomiting, opisthotonos, delirimn, and
ocular disturbance. The pnlmonury symptoms are not choracteristici
but cough is usually present and esi>eclorutioti, if present, is frothy in-
stead of muco-puruleut. Xo tubt-rcle buc-iUi are present iu the sputum,
unless H localized tu)H.>rculotjis uf the luug has existed before occurrence
of the miliary form ol the difieow.
Acute miliary tuberculosis is attended by no physical signa anleea
the mucous membrane lining the air passages is involved, and then
there are no signs except those o^ bronchitis. The diagnosis in such
coses niUBt rest ufton the history and symptoms, and the exclusion of
other ])ulmoniiry iiffections.
DiAOXOsis.— Discrimination between the various forms of phthisis
is often attended with more or less nnceriA^uty. The principal features
of value in distinguishing between them muy be seen iu the following
table:
FlBKOID AND OTHEB VAHl- CHBOKIC TfBEIlCVLObitt ACCTE MIUART TCI
ETIEK OF SDIPLE ISFLAM- OR THE OBMXARY LOSIS.
MATORV PHTHISIS. FOHM nF PHTHISIS.
The constitutional nynip-
toros come on slowly, and
are less »rvere ihun would
natumlly be expected from
thecnndition otttie lunj^.tts
iodicateJ by |>liyiiic)il sij^iu^.
HMoty,
The coDstilutional The disease is ushered in
gymptonis come on more with cliilU and fever njih-
rapidly, and are pntver out complete rctui-udons,
than would be ex|M;ctt*d und Uinre is rapid acve«<
from till) ]jhy*ical signs. sioDOfgravecoastitulfonol
Rymptonw. wlnpti cannot
bo .icfouritcfl for by the
broocLilis, si^ns of which
are Uie ouly ones to be ob-
tuiaed.
The fever Is Intermit- Thofevermoreoonlin* Fever remittent, tem-
tcnt. wfUi an afternoon or uous, with nearly con- pertiture oJteu hiKrhest in
evening (jlcvatioQ in tero- slant elevation of tem> tlieniurning, varymgfi'om
pvrature of from one to perature. but less 103' to 105' orevea wr F.
two de^refv. markf^l exacerbutiooa.
I>lurrha-a not common. Diarrhoea usual.
FIHHOlh PHTHISIH.
107
PiBRUlD AND UTHEfC VAKl- ClIHOSK imERcL'LOSIsi AcCTtJ MILlAUY TtUKRCU-
mcsiirsiMPi-K isFLAy- ok the orwnart lobis.
MATilRV PHTHISia. KUKM OP PHTHISIS.
Bn|iiil respiration, and
signs of ciHiitoliilaliuu upua
[>{iI(>utloti, iHjrcufaMon. nnd
tending over a large jmrl
of till.' lung.
No tubercle bacilli in
sputum.
Signs.
Rapid res pi ration,
pliyfiical iigvs ul cuiitfjl-
idittion l(;»s marked uod
Itiiiilcd to a Amnllerarpii
than in Ibe preceding
variety.
Tiil>ercleli>acilli inftpu.
titin.
Rapid respimtion. wilh
usiiftllytlte jtigus ui l>ron-
clillJs, Olid ordiaorily nt>
iiign5 of L-oiiftulidatiuQ, Init
orcasionolly Blight dul-
nesa.
Usually no tubercle bOf
cUli in sputum.
PinRUID PHTHISIS.
5y;(on;/wij*.— Fibroid degeneration of the lungs; fibrosis; chronic
pneninoniM; interstitial )met)moniii; cirrhosis, or scirrhua of the lungs;
induration ut Iho lungs.
Filirnid phthisis ia a cbrouic iiifluniumiury :itlectiuii characterized
by com pa ni lively slow progress, thougli in the majority of cases it fiuoUj
teriitinates in lubcrculudia. As compu-red with the ordinary form of
cunsuixipiion, the b-yniptoms art* shght iu proportion to thi* uuiuuuC of
lung tissue involved.
Anatomical and I*.vth«ix)OICal Charactrkistics. — The chief ana-
tomical changes consist of hyperplasia of the interalTeohir, interlobular,
and peribronchial struoturcs, which encroach npou the uir passages and
blood-vessels, correspondingly diminishing their capacity; this encroacb-
moul is &ubse<|UtiUily iitcrcu«ed by the contraction of the newly formed
Blements. There is little or no exudation into the air cells. The dis-
[^«aBe may involve a imrt or the whole of one lung, or both Inngs may be
affected, though commonly it is confined to one side of the chest
throughout the greater portion of its course.
]usi»ection of the alTcOted organ reveals In most fatsos more or less
exteuiiivf adhesions uf the overlying pleura, and often extensive thick*
«ning of the latter wenibrauu, especiully when the disease has resulted
from pleurisy.
Occasionally fluid ia found in circumscribed pockets of the purtiully
obliterated pleural cavity. The thickened pleura may present very
naoh the appearance and density of tibro-cartilage. When the process
is general, an entire lung may be found shrunken to one-tenth uf its
normal size. The color varies from a dark red to a blaish-gruy, marbled
with black and streaked with lighter lines.
When localized, the shrunken, cirrhosed area contrasts strongly
rith the adjacent normal or emphysematous lung tissue. This part is
abnormally heavy, and sinks readily in water, and when pressed yields
bnt little fluid from its cut surface. In advanccil cascs^ the tissue is
108
PULMONARY DIHJSASES.
BO firm that upon section the kuifo ^ratca as in cutting curliluge. The
cut surface is of a dark griiy or blackish color, interw<iteii hy vt*nowtgh-
whito biiiiils, mid mottled with lighter circles marking the positioa of
ohliterutcd veg84.'l>« and tubes.
Ar thp procuss advsinees, and c-oiUr:iction of the new liattuo occurs,
many of th*' air cells become destroyed, idthoiigh here and there islets of
normal or emphysematous vesicles may still remain. Dnring the pro-
cess, many of the hroiidiial arteries, toother wilh numerous brnuehes of
the pulraunar}' urtery are obliterated: and us a result of the pr»R>os8 of
contraction, liere and there dilatation occurs in the bronchial tubes; and
bronchiectatio cavities are found, lined by dark rod, thickened nincoua
membrane, and cfintaining purulent fluid, or cheesy dehris. These cavi-
tica may also bo the «eat of ulcenition or ganprone and vai-y from half
au incli to tvo inches in diameter. The bronchial glands are frenueutiv
enlarged, and ultimately these and the cirrhotic lung tissue, in many
cases, become the seiit of tuberculosis.
When the afTectiori is confined to one lung, the opposite organ niHT
be functionally enlarged or may become emphysematous, and not infi^
quently at the autopsy tliis luug will be found the seat of bronehilis or
acute croupous piieunioniu»-hieli lia.s bettu the immediate cause of death.
In markeiJ cases the heart is disjilaced toward the allected organ bv
traction of the contnicting tiasuen, an<l its right cavitiets are usually
dihitcd, wliilo their walls iire hyj)ertrophied as the result of obstruction
to the pas&'ige of venous blood through the lung.
K'noumv.— The disease occurs must commonly in males betweon
fifteen and forty years of age, and is generally the rct'ult of local causes
having little or no dependence upon diathesis. Catarrhal pneumonitk
and pleurisy are among the most frequent (causes of the disease, but it
mv.y result from ehrouic broncliitis or acute croupous pneumonia; cir-
cumscribed indumtion is also a common result of arrested iiiilmonurv
tuherculosifi.
SyMiTOMATOLOOY. — Tbo progress of fihroid phthisis is not so rapid
B8 that of the common form of consumption; but its symptoms and
signs are usunlly much the same excepting that the symptoms do not
a]i{>ear commensurate with the pulmonary lesions, as indicated by tho
physical signs.
As a rule, the disease is chronic from its inception, although its d(
Tolnpment may date from an attack of pleurisy, pneamonia, or broa-|
cbitis. The origin is often oltscure, and the history is similar to that of
chronic bronchitis, ftith frequent cxacerbjitions. Dyspnoea, though oftea
iilMent or moderate, increases with the advance of the disease, and ie
subject to exacerbations, during which the ditticulty of breathing may
be experiencod for seveml days. Daring the hitter portion of the dis-
ease dyspnoctt is constant upon any exertion, and eventually becomes very
groat, even though the patient is quiet. Cough u a common symptom^
F!BR<Ht) PHTItlHltL
though it varies mnoh iu differeut cases, and different periods of the
Bame case. It is increased bj recurrent iittaeks of hroochitie, and is
genemlly worsft during tho winter monthft. When hronchieptaBis exists,
the cough is likely to be jwroxysmul, esiiecially severe in the morning,
uid accompanied b}- a profuse, fetid exjfectoratioii, after which relief
may bo experienced for seveml hours, Vuniiting often follows lhe«»
piiroxysnis of coughing. The sputa nmy be scanty, and viscid, but when
dilatation of the bronchial tubes has taken place, it in generally copiouB,.
sometimes amounting to two or three piuts in the twenty-four hours.
It may coneist of mucus ur mucu*pus, and is usually uf a yellowish or
greenish-yellow color.
Ila^nioptysis is not nncomraon. even in the absence of tnbercnlosis.
During tlie grenter portion of the divotme the Hi>petite usually renuiina
pwtd. and conspqueiitfv the strength may he fair »ntl emaciation gradual
unless tuberculosis superfencji. Jn well-mnrked cases the signs arc tol-
erably distinctive.
Inspection sIjowi^ flattening of the chest wall over the affected part,
uid dopressiun of the shoulder may bo observed.
Ou palpation, vocal fremitus is exaggerated. The heart is dislocated
more or le«8 toward the affected side, as shown by the positiou of the
Bpttx-beat.
Percussion gives dulnees over the affected side and exaggerated res-
onance on the sound iiide, whi<'h sometimes extends, in consequence of
the distention of the himiihy lung, from two to four inches beyond the
mudbiu line toward the affected side.
Auscultiition gives bronchiiil breathing and bronchophony, with or
without bronchial n'lles. .Subcrepituut niles iirc, however, couimonly
present- The vesicular murmur is feeble or absent.
The dingnosis^ prognosis, an<! treatment of flbrnid phthisis will be
considered with pulmonary tuberculosis, though we may here stale that,
during the earlier part of the disease, the treatment indicated is essen-
tially the same as that for chronic bronchitis.
pKOitXOSlS IX THE VAKlorS FORMR OP PrLMOSARY PUTHI8I8. —
Acute miliar>- tuberculosis freipiently runs its course within three to six
weeks, and seldom extends over three months. Chronic tuberculosis-
may terminate fatally within five or six months, but it of ton lasts for
two or three years, lilt' avenige duration being about eighteen months.
The records of autopnies show lliat about twenty-five per cent of the
patients dying m ho8)utaIs ns a rc^lt of accidents and acute disictse.
liave ciciitriccs in the apices of the lungs resulting from old iuAamnia-
tions, probably of tubercular origin; and experience has shown llutqnile
a large percentage of pnticnia suffering from well>marked though not
extensive tuberculosis recover. While I am not able to fortify my im-
pression by statisticjj. I believe tlmt. all told, about thirty-three per cent
170
PULiiONAHY DJJSJCASSS.
recoTer undtT ortlinnry cuitililioiiti, tuii] I think tlml putieiitg sent cnrly
to high iillituiles unil n dry ntiiiaspliert! have their chances of recovery
lucreiiux] fully fifty ]M.'r trent. Whera the digeiiee is so extensive nt the
apex of one Imig tltjit the signs may hti n^copnized below the sccoiid rib,
perfect refxtvery, so that no ■gigns wlmtevor van be detected, sddom
oocnrs, hot the disease not infrequently becomes arrested, the cough »nd
:ill other symptoms dissippuaring, tlie evidence given by » scar in tlio
Inng Iveiiig all that can he detectetl on careful physicnl examinotion.
When tlio disease has extended as low as the fonrlli rib, therL- uro »
few cases in whom it may be arrested, provided they hnrc the best
hygienic surroundings; but after the whole of the upper lobe of one
lung and possibly u small part of the lowur lobe, togctlier with the apex
(if the opposite lung, have becomo involved, it is very raru timt much
imitrovenieut tnkea place, though even when these conditions exi«it
;ind lifter cavities of considerable size have been formed, we otxiision*
ally find the disease arrested, so that the patient may live for many
yenrs.
L'suAlly fibroid phthisis continues four or five ye^rs, sometimes
louger, but finally it eveatuates in tuberculosis, termiutiting iu much
the same \*'ay as the ordinary form of this disease. ■ Usually death rcstilts
from asthenia, occasionally from heart failure, iind in a small percent^iga
of cases from hemorrhage. Out of over six hundred private cases of
which I have records, but five are known to have died from hemorrhage.
Generally tho approach of death ia indicated by rapid extension of tlie
disease and speedy failure of the vital powers.
After decided swelling of the feet occurs, patients seldom live more
than five or six weeks; they naually succumb in from three to eight
weeks, when the strength has so far failed tliat they are unable to leave
tho bed, though sometimes life is more prolonged. Two or three diiya
before the fatal issue, many consumptives become so feeble that the
sputum is raised with great difficulty; cough becomes less and less fro-
quciit, and may finally ceaso a few hours before death.
Trkatmbst op the VxRiors Forms of Put.monary Prthisi**. —
Having considered some of the special forms which jmlmonury phthisis
assumes, we may discuss moru f\illy the general treatment.
As a nuitter of prophylaxis, healthy persons should not occupy the
siuie apartment with consumptives, and great care should be exercised
to prevent the drying of tuliorcutar sputum, and to thoroughly disinfect
or ilestroy it. The treatment of acute tuberculosis ran stddom if ever
be more than palliative, though it is proper to use the same remedies
that are recommended -for more protracted forms of the disease,
For chronic tuberoulosis the most important remedies are alcohol,
malt preparations, cod-liver oil, nalcium chloride, quinine, iron, iodine,
fifiiniacol, and oil of cloves, with proper climate.
rilEAIMKNT OF PVLXONAHY PHTHIHIH.
m
Alcohol should be use*! in hirge quantities iib muuli i\» ciin be borne
viihont affecting the hciul, provi(lin{^ it does not derange digestion or
cause elevfition of temperature.
Cod-liTer oil should ha given to those patients vho can take it wttb>
out disturbing their digestion, in doses of a teospoonfnl to a tablesiH^ion-
in] three times u day» always commencing with small doses. AVlicuever
cod-liver oil cannot be borne, it may be substitntod by cream or prejMmi-
tione of malt. The latter are nsually prefenible to oil during ivitnn
weather.
Calciam chloride is a remedy of undoubted value in many coses. I
have found it more aerviceablc than the calcium or sodinm liypopho?-
pbites. The dose is from ten to twenty or oveu thirty grai)is llireo
times a day. It may be dissolved in a smiitl (juautity of valur, and com-
bined with the cml-liver oil. By shaking the bottle before the medirino
IS poured out, the two can be sniliciently mixed. It may be added to an
emulsion of cod-liver oil prepared as directed (Form. 3).
Quinine is the best remedy for relieving hwtic fever. It will nsn-
ally prove efficient when given in the some muimer as for intermittent
fever. It acts most promptly when given in one or two large doses a
coupiC of hours before the fever is expected. It should be i>oiitinued in
this m:inner until the temperature falls or einchoiii^m appears; even
though it fails torlieck the fever the patient is generally benefited by it.
Iron is a vahmble remedy in this disease, but it must not be given
when there is much fever, for it aggravates this symptom.
Belladonna is the beat remedy for checking the night-swenl«. Si.t
minims of the tincture of belludonna. ur the oiie-huudrwl-and-twcntieth
of A grain of atropine, at bi<d-tinie, is riuffieient in umny casfcs. but the
dose may bo increased to twice this amount, aud repeated two or three
iimee daily if necessary. For the siime purpose, aromatic sulphuric acid,
iflx. to x.T. properly diluted; minute doses of aconite; of agaricin, gr, \\
of line oxide, gr. iij. ; of ergotin, gr. ij.; or of black oxide of manguncso,
gr. ij.; may bs given three times daily with success in eome cuses, but
nny or all may fail. 1 have known obstinate night-sweats checked
occiuionally by nibbing into the (»kin ii powder of four per cent of
salicylic acid triturated with magnesium salicylate; by placing a largo
pan of cold water under the bed at night, by sleeping iu light blankets,
or by drinking a preparation made by steeping for two or three hours
two heaping tables pooufuls of sago iu one imd onc-holf pints of water,
reduced by evaporation to about one-half pint.
Touic doses of mercur)' bichloride gr. ]^ to j^^, or gold and sodium
chloride gr. ^^^ to ,V will 1^ found beneficial in some cases, especially
those of a chronic catarrhal or fibroid character. The same may be 6uid
of arsenious acid, but this must not l*o given when there is much fever.
When there is a suspicion of syphilitic origin of the diseaao, potas-
Biam iodide shonld be tried.
PULMONARY DIHEASES.
As a rc:»iilt of numerous ex|>eriuieiitH on Guiiiea*[tigB and monkey's,
E. U Shurly* "f Detroit, ami Heiieage U ilibt-s, of Auii Arlwr. Mioh. , have
denioiiitruteil tliut :iniiiiais may be reuik-red iiuiiiunc to tiilten-ular vinia
by hypuilermu- injections <jf ii<|iier>iiii lioluliong of vlicmically pure iudine^
prepared by J. E. Clark, of Detroit, or of gold and uodiuin chloride;
and tliey liave ivfoinmeiKlcd. for tlie cure of consumption, liyi^Klvrmic
injectioiui of these remedies with inhalations of chlorine gan. The in-
jections should be made with an absoUitely clean syringe> which should
Always he wiiinbed with pure abmhol liefore and after using. The treat-
ment should be coninK'tire<I with email doses, which may be gradually
increased until some constitutional effects are observed or until (be
largeet dose recommended is rcache<I. It is usually best, excepting iu
advanced cases, to begin with the iodine (thongh it is apt to cause con-
Giderable smarting), and it slionUl be continued ten to fourteen days.
nnd thou may bu given alternately with the gold and sodium chloride
solution, and later, after four or five weeks, the gold solution may be
used alone if everything is going well. In some patients tlie gold and
Bodium chloride answers best, but 1 think most beiiefit will be derived
from the iodine. The dose of iodine is from one-twentieth to 0De*6ixtli
of a grain, and of the gold and sodium chloride from one-tweuty-fourth
to one-eighth of a gmiii.
When symptoms of iodism api>ear or there is loss of ap)>otite. di8>
tar1>ance of the bowels, or L>omp1aint of unusual fatigue, gold prepara-
tion may bo snlMitituted for a day or two, when the iodine may Ik' given
ugain iu diminished doses, which may snbsequently ho gradually in-
creased. Sometimes, white i>ntients are receiving the gold and sodium
chloride in large doses, pains are experienced in tlie bowels, and in some
iiutuucej there arc uncomfortable sensations in the head; occasloiiallyr
also, profuse sweating has been noticed. If any of these symptoms de-
velop, the dojte slionld l>e at onre diminiBbed, or the rt'n}edy sulistituted
by the itnline. The most favorablu place for llic iujec-tion is bencjith tlie
loos<^> skin in rbe gluteal region. As it is dittimilt to get at this point
on account of the clothing, the injections arc given to women just
below the inferior angle of thescapuhi or between this and the spinal
column. Injections are advised daily for about two weeks, every second
day for the two following weeks, and subsequently once in three^ four,
five. six. or seven days, gradually diminishing the frequency according
to the result. When these remedies are acting well, the appetite aud
strength gradually improve, the weight increases, and the cough and ex-
pectoration gradually diminish. The chlorine inhalations may be given
either by means of some of the common or specially devised inhalers, or
iu a room filled with chlorine gas. The latter is applicable to hospitals
where small rooms can Iw arranged, or even to small bedrooms, where
it is readily carried out in the following manner: £rst,a steam-atomizer
ifl made to throw iuto the atmosphere of the room a solution of sodium
THEATMENT OF J*VL^OJ!fARY PUTUI^lS. 173
chloride, about tiftcen grainft to the nance; this is continued until tlie
atmosphere is so permeatt*d hy the spray that a person on the opi>o6it«
side of the room nan taste the salt. One or two tea«{K>onfals of chlo-
rinated lime are then placed upon a saucer and wet with a mixture of
hydrochloric acid one part and wat*>r two parts, whirh cnusea the rapid
liberation of chlorine gas. This ig then held directly under the fipray of
salt solution, and tlie gas is carried by it into the atmosphere nf (he room,
where the patient s\U for ten or fifteen minutes — as long as he oan woll
tolerate the inhalation.
I have employed this treatment in over a hnndre<l cases of phthisis
during the last few months, and found it very beneficial in the first sljige,
helpful in some cases during the second stage but of only little vsdiie in
the third stage, though occasionally even then some appear heneHted by it.
Among other remedies iu phthisis, creaaote has been very highly
recommende^l, in doses of one to five Tninimtii. or even as much Jis half a
drachm, several times a day. It has ap|>eared to roe moet benefiuial in
moderate or small doses (Form. 7). Morsen's croftsote is seemingly leas
irrituting4han other preparations. Guaiaeol, one of the chief constitn-
ents of creasote, has been r|uitc extensively tried in the trentment of
pulmonary tuberculosis. Althcngh I have had but little experience
with it. general report, and eapwially the apparently gowi resulta oli-
tained from its use in surgicd tnhiTruhjsis by Xicholas Senn and W.
'J'. Itelfielil, of t'hicdgo, induce me to recommend its thorough trial in
pulmonar>' phthisis. It may be administered in essentially the same
doaes aud manner as creasote, but I prefer the carbonate of gnaiacol,
which has but little taste or odor, causc^i little irritation, and is appar-
ently qnita as oflUcient when given in corresponding doses.
Oil of cloves given five times a day, in doses of two to twelve min-
ims, or oil of cassia, in doses of oue to live minims, in conjunction with
other remedies, has Ixwn of great benefit iu some coses. The medicine
thonid be drop{>ed in c«{>sules Just before it \i taken and administered
with each meat and in the middle uf the foreuuuu and afteruDon, the
patient taking, wlien possible, a glass of milk with t^ach d(«e— uerer
takiug it on an empty stomach lest it cause irritation. The duse should
be small at first and increased, one-half to ono minim each day until
the maximum dose is attained unless it disturbs the digestive organs.
The therap4*iitic value of tubercnliu ia still uncertaiu, but the
majority of those who have tried it believe that it is more potent for
harm than for good.
Sedative troches (Forms. 35, 36, 30, 33, and 35) and sedative in-
halations of benzoin, opium, or chloroform are nsoful in allaying the
cough (Forms. 53 to OO). Stimnlant inhalations are frequently ser-
viceable in the early stages of the disease. They are moat conveniently
administered with the Globe nebulizer shown in Fig. 30. For this
purpose, iodine, carbolic acid, creasote, or oil of white pine arc most
174
PVLMoyART IfmSASSa.
fiequentiv umhI (Forms. G'i^ 68, 60, and 72 to 74). Congh mixtures ar«
nrcpfcgarj, €«p«cmll r late in the <Iiiu*afie, but they should bo gireu ii.<i spar-
ingly as possible. Sc«Iative trocben and uihalatione are prefembly when
tLcT vitl answer the pur[H)i^. The neuralgic painii which ofteu trouble
phthisical patients are best prevented by regular and vigorouit frictions
of the surface with u course towel; when severe, they art! usuiillr
promptly relieved by hot applications to the surface. These applii.-a-
tions should bens hot as can be borne, and should be frequently repeated
until p'lin aubsideit.
ConntorirritfltioD is useful, especially in cases of an inflammatory
dinraeter, as those growing on t of pneumonia, bronchicisy or pleuritis,
b-fore tubercles have been depositc*!.
I sometimes employ for this purpose an ointment composed of tartar
ma. v.— Olou Kebi'Uzkii. ^Sdlr. np«t>u>nl wUh vn MiriimnurvoT t«B Of Ari««li pounda
only. It nioy also be um^ by xht IkauJ ball.
emetic, crotou oil, cautharides, stramonium, and camphor (Form. ](>).
It is an effectual aud almost ptiiuless oounterirritaut. Burguudy pitch
plasters crotou uil, iodine, or blihters may he used for the siuie ])Urpuse.
The digestive functions must receive careful attention. Nutritious
and easily digestible diet of varied elmmeter should be ordered.
Climitlie Treat me nL—^lfmy consumptives will be greatly benefited
by suitable climatic iullueuees. tu the Grst stage of [ditLisis, I believo
that the patient's chances of recovery are improved from fifty to seventy-
five per cent by residence in a suitable climate; in the second stage, from
fifteen to thirty per cent; in the third etage, a small percentage will be
permaneutly beuetited; aud iu a large proportion of others life may be
oonsidenibly ))rolonged.
There is no climate to which consumptives may bo scut indiscrim-
inately, but suitable places should be seleet|.-d for each putienL Some
2REATMSNT OF PULMONARY PHTHISIS. 175
patients foel better in cold weather, but the majority are better in sum;
raer. It will be found that those who feel best in winter are likely to be
benefited by a comparatively cool climate, the others in a warm climate.
Ab a rule, a warm, dry climate and high altitude are most salutary. It
is always desirable, when there are no contra-indicutious, that the ; atient
iu the early stages of the disease should be sent to an altitude of from
six to seven thousand feet; but this is not suitable for those who ^^'e
nervous to a marked degree, or who have a high temperature, pro-
nounced cardiac diseitse, emphysema, or laryngeal complications. Ha;mop-
tyeis is not, as is often supposed, a contra -indication to a sojourn in a
high altitude; on the contrary, bleeding is often promptly checked by
this change, and those who seldom or never have hemorrhages in a high
altitude frequently experience them quickly upon a return to a lower
level. In the second stage of the disease, a high altitude is often bene-
ficial, but we cannot feel so certain of its results; therefore it is best to
send the patients to an altitude of not more than two or three thou*
sand feet, and, if they do well, subsequently advise a higher altitude.
In the earlier stages, warmth is not so important, providing an abun-
dance of sunshine and dry atmosphere can be obtained, though it is
usually best to recommend for such patients a soiitliern latitude in winter.
In this counlty in summer the high altitude of Colorado, AVyoming,
Montana, and Utah affords a typical climate for these cases, whereas iu
winter they generally do better in New Mexico, western Texas, or
Arizona.
Those for whom an altitude of two or three thousand feet is prefers
ble often do well in summer in some portions of Dakota, Nebraska, and
Minnesota; in the Adirondacks, or the mountains of Virginia, North
Carolina, or Tennessee. In winter, more suitable climates are found in
warmer latitudes; many cases will do well in eastern Tennessee or west-
em North Carolina or in Georgia at from fifteen to eighteen hundred
feet above the sea. The typical climate for these cases in the winter
months is found in Arizona or southern California, in the latter among
the foot-hills as far as possible removed from the ocean. Southern New
Mexico and the western portion of Texas are favored by a similar cli-
mate. In many parts of Mexico, patients in tlie first and second stages
of consumption do remarkably well during the winter months.
In the Old World, the mountainous regions of southern Germany,
of Switzerland, Austria, Spain, France, Algiers, and Egypt, according to
their temperature, offer advantageous resorts for summer or winter.
In the advanced stage of the disease, patients, if sent anywhere,
should be recommended to a warm climate and usually to a compara-
tively low altitude, of not more than one or two thousand feet above tlie
sea. For these, a typical climate is found in Arizona or southern Cali-
fornia, and many of them do well in Florida, South Carolina, Georgia^
and Texas.
176 FULMONARY mSBA&ES.
In the Old World, these patients aleo find a snitable climate in southern
Spain or France and in Algiers or Egypt, but usually persona who have
passed to this stage of the disease are much better off at home, where
they are surrounded by friends and the comforts that cannot be ob-
tained elsewhere. No patients should be advised to go from home ex-
cept those whose financial condition will enable them to secure easily
the comforts as well as the necessaries of life, and usually to surround
themselves with agreeable companions and friends.
CHAPTER XI.
THE HKAHT.
AN ATOM V AND PHYSIOLOGY.
A EKowLEDRE of tbo anfttomy nnd physiologjr of Ike heart ia so esscn-
tiiU to a correct diagnosis, that ve shuU givi; ihem brief coiigide ration
before proceeding to the means for detecting cardiac diseases.
The heart is a hollow, muscuhir org-an of i;uni<'al form, which as the
centre of circulation distributes blood throughout the entire botly.
IxK'jited near the centnil portion of the chest, it is held in plane above
by the large blood-vessels springing from its base, and below by the at-
tachment to the diaphnigm of the tibru-serons sac which envelops it. In
front it is aheUcred by the sternum; posteriorly by the thick chest
valk, and spinal column; and laterally it is cushioned by the Inngs.
U« long axis is oblique to the jierpendiuular axis of the tOiesl: its bai«B
is directed upward, outward^ and backward toward the right shoulder;
its apex downward and fonrard.
Tlie pericardium, the libro-serons sac which envelops this organ, is
voni]to8ed of an external, fibrous layer and an iuternul, serous layer. The
external layer incloses the arteries for about two inches from the base of
the heart, and i^ continuous with their external covering; below, it is
attached to the dia|thr!igm. The internal, serous layer completely en-
velops the heart, and covers the blood-vessels springing from its baaa
fur about two inches. It is then reflected upon the inner surface of tho
tihroas layer, and passing downward covers the iipjwr surfnre of the
diaphragm, Iwnoath the heart, thus forming a closed kic siniihir to the
pIcnrM. The two serous aurfacos of the pericardium, ronstiintly in ap-
position during heullli, are moistene<l hyseruui.and glide npon each
other without friction during the action of the heart. The pericardium
extends from the level of the second to that of the seventli left coiital
cartibge. It is farther from the chest walls superiorly than inferiorly.
The heart, with its pericardium, ia in relation: anteriorly, with the
anterior borders of the lungs and a small portion of the thoraric walls,
Irom which it is separated by a small amount of areolar tissue; lateraUy,
with the Inngs covered by the pleurte; posteriorly, upon each side, with
the lungs and pleurfe. In the middle line posteriorly, it lies near the
spinal column, from which it is separated by cellular tissue and the
morta and oesophagus.
la
ns
THE HEART.
The heart is iiboat the size of its owner's fist, its weight rangiug
women from uight to ten (•iiiices, iu iiieu from ten to twelve. T
anterior surface is eouvci,; the posteriur surface fluttciiwl; ilie right bo:
der is long, thin, uiiil ehitrp; the left burder is aliurt, tliick, and roun<leiI.
Runuiii^ kingituiiin'.iily ubuut thu heart is a well-defiiu'd fissure, found
upon the anterior surface within hulf or tlireo-qniirters uf iin itidi of the^
left burder, and on tlie foslerior surface a similar dislancc from the
right border. This (insure lodges the ooronary arteries, which supply
the hturt with blood; and it indicutes the position of the sepLum, wUieh
divides the right side of the heart from the left. Ncnr the base of the
heart is li tranRverse fissure, interrupted in front by the origin of the
pnlniouury artery. This fissure indicates the pogition of the septnia
between the cavities at the base of the hmrt and those at the »pt!X.
By these septa, the heart is divided into four cavities : two above at the
base, known as the right and left aurirles; two below at the apex, known
as the right and left itntnchs. Ench of these cavities is capable of con-
taining about two fluid ount'ea. The walls of the cavities npon the right
side are thinner tlmn those upon the left, and the walls of the auricles
are much thinner than those of the vcntridos.
Tho right auricle receives the blood from the venous system, through
the ascending and descending veuie cuva;, and transmits it tlirougli tho
nuric-ulo-ventriculnr opening, into the right ventricle, which, contracting,
forces the bloml onward through the pulinonnry artery into the lungs.
The loft auricle,, receiving the blood from the lungs through the pul-
monarj' veins, transmits it to the left ventricle, whence it is distributed,
bv the aorta and its branches, throughout the body.
The internal surface of the heart is lined by a glistening membron
known fts tlie euiioranUum, folds of Mhich at the various orifices con-
stitute tile valves. At the orifice between the right auricle and the right
Tontricle, we find three of these folds, which nre named tho tricnEi>id
valves. At the orifice of the pnlmonnry artery are three simihtr folds,
knouu as the pulmonary semi-luuar valves. At the aortic orifice are a
similar number, called theaortic semi-lunar valves. At the orifice between
the left auricle and ventricle are two folds, known as the niitml valves.
The greater portion of the heart lies heneiith the lower part of the
sternum, but the right auricle, atid h small part of tho right ventricle,
e:iteud from one-half to three-fourths of an inch to the right of the
sternum; the ventricles extend about two inches to the left (Fig. 1).
The auricles are on u line with the third ribs, the right auricle ex-
tending considerably beyond the stenmni into the third interspace upon
the right side, tho left being located beneath thi' third left costal carti-
lage and intercostal 8|»ace upon the left. The left ventricle lies mninly
behind the right; tni;t jMirt of it which is superficial is found entirely
to the left of tho sternum. Most of the right ventricle lies behind the
lower part of the sternum; but u small part of it, at the base, extends to-
ASfATOMY AND PUYSlOLOaV OF THE HSART.
the right (»f llie stenuim^ and its \\\wx in ruunil to tlto Ipft of tins bone
h) the triangular spuce between tho stfriinm and the margin of the left
lung. The base of tho hfart extends to the upper inargin of the third
rib, corresponding beliind to the sixth and seventli dorsul vertebrrc; its
upex lies at the flftli costal interspace from an inch uud it half to two
inches below the nippU*. about half uti inch to the right of the tnntnniil-
Ltry line, and two or two ;tnd a liidf iiiclieii to the left of the sternnm.
The position of the npex changes slightly with the respirator}' mov^-
ments, the position of the patient, or with the distention of the slomuch.
It is KuA t)mt lltc npex miiy move n» iDiioli asan inch and a hitir from left to
riKl>t. or rice tvrsn. wli^ii the pnlifiii lii-s on the rijjiil or tli« loft sitlo; a few
ClweAliavR b«en reporttnl in whii^li pi-olnn^ini decubitus on one side «eeni8 to
liave caused periuuneDl tUalucatioii of ttje lienK.
From the base to the apex of the lieart, in u vertical line, the di»>
t»nce is nliont tive inohL'n. Mearfuriiig from the mesoi^ternal line U) the
loft over the thinl rib, the heart extends from two and oiieOtfllf to three
inches, uver the fuurlli rib three and cue-half to four inches, and iu
tlte fifth interspace front thivc to three and une-luilf inches.
Pimlinn tif the rcz/rc*.— The relation of the valves to the surface of
Uie che«t may be ascertained by jiaiiifing needles through the cliest walla
of the ciidav<«r before the thorax is npeneil. In this niunner it hns be^u
kfifcrtiinetl thai the pulmonary valves lie beneath the junction of the
tliird costiil cartilage of the left side with the eternuni. The niitnil
Ynlves lie close to (ho left border of tho steiiium in the third intercostal
space. The tricui'pid tulve^ lie in front of the mitiiil. near the middle
of tho sternum, un a line with the fourth ribs. The aortic %'alvee li«
beneath the steninni, jusl below the level of the third ribs, and a litllo
iu the loft of the median line (Fiir. 1). As indicated in Ireiiting of the
chest regions, a very gmall circle, wiih its centre at the left edg« uf the
steruuui iu the third intercostal simcc, will include the greater part of
mil of these valvce.
Till? dtsrreponcy notiresiMe in the iIoBcriptioiis, by djfTi^ivnt niithors, of Ih*
po^ttinii of the v»lve<i is pruimbly chic, iu tlie main, lo their Itomj; locatetj ofler
tlif thoi-iuc hiis been opeaeil, when the collapse of the lunges has more or kat
.phuxl the hwirt.
C
The aorfn springs from the base of the left ventricle, and passes
upward, forward, ami to the right, to the second intercostal space, where
it is more superficial than in any other part of its conrse. In this situ-
ation, it is within tho pericardial sac; thence it passes backward, upward,
and to the left, and finally jiasse* downward, bending completely upon
itself, so a« to rest along the left side of the fifth and »ixtli dorsal ver-
tebne. Tho highest portion of the arch is on a Uuo with the first custo-
■tomnl itrtienlatioD,
PUYHIOLO&ICAL ACTION OF THE HEART.
181
The Tentriculur diastole follows ittuucdintely uftcr their systole.
The eluatic tissue of the urtcrios oontracts, forcing u portion of the blood
bftckwurd towiirU the henrt, which it is })i'cveiitcd fruiu entering by the
•bruiit ch>suri.' of the »omi-lunar valvo8 thut guurU the uortic aud pul-
monary orifices.
With i/iasloh of the rentrxchif the he!irta«auin«8 its fonner shape and
position, the aurioulo-rentricular valves open, and blood flows passively
into the ventricles. This occupies about one-fourth of the period of a
complete airdiac pulsation.
Closure of the »i>nii-lun»r Tulves, which is cftused by the contraction
4t( the arteries, produce-s the second sound of the heart.
The diai^tule of the ventricles is followeil by a period of rest, which
<H!cnpie8 about one-fourth of the time for a complete pulsation.
During this period, the blood continnes to flow from the auricles
mto the ventricles, so that, at the instunt just prccodiug another pulso-
.K^**
.^s
■< z
Tio. SI,— PBvnoi.ooicj,L actk^x or ras hurt (altMwl sllichtly from tlalnliKi').
In ll)r> tlla^Tvm. the Uuwr drela reprsKoU tbe phj-Hiokjgtcal acUaD of th« bMut, apart rron
4iir mitnlfffst filrm.
Tlic i)UUTt.-in!lerepr«fleiitBtbeexUrrualiiiaiil(eHUiiJdiuiot Uie biurt'* atftlan: tlw rl»K iMtwom
"^ circle* iUiuitnttt>a the Bouads utd perlouls ^r itll«n<«: outBii)<^i>t the uut«r rlrde reftrewiibi tbo
miiiliii al Ota apcuc afaioat Uis cbeat walL Udm radlaUiv traat Uit) eeotrs reprawol tbe puks
to Cba mck, wrtoc and ankli-.
iion, all of the cavities of the heart are full, but not distended. With
the contraction of the auricles, the ventricle* are di«tendefl by an addi-
tional amount of blood, but probably the auricles are not completely
emptied. The distention of the ventricles, caused by tbe systole of the
auricles, excites their contraction, and the blood is forced onward into
ttie arteries. If the cycle of time taken up by a cunliae pulsation were
divided into five equal parts, about one-fifth would be occupied hy the
kjfltole of the anncles, two-fifths by the systole of the ventriclos, and
two-fifrhff by the dijistole of the ventrirles and the period of repose.
The physio logical action of the heart in graphically represented b; a
motiification of Oairdner's diagram (Fig. 31).
183 TH£ MBART.
As Bocn by tbo iliiigram, iho sjstole of the nnrtchK gives rise to do
exterual iimnlffstutioiiB, but with the beginniDg of the ttniricular *ya-
toir KG jiiiiiiveiiite the first sound of tho heart uuil, at the same time,
we may feet the beat of tlic apex agaiust llic chest wall, uiitj tht* carotid
pulse.
The lon;,^, first sound, a^ indicated in the diu^tnim. is followed by a
shurt period of silence, known as the first eileniT, during which the
radial pulse may usually bo felt.
tmiiiediaiely fuUuwiug tho first silence tho ventricular diastole
begins, :ind with it occurs the second souud of the hearty which, as in-
dicUed in the iliugram, is lihurler thau tho first, uud is fuUowed by the
second or long silence, extending through the period of rest and the
time occupied by the auricular systola
lu some cases only one souud of the heart can be heard, either at the
iipox or at the base. In such instances, in onler to determine which is
the fiiijt and which tho second, it is absolutely uecessani' to associate the
auond with the imerial pnlsntion. This can only be done, in the major-
ity ol cuiiff, by feeling fur the carotid pulse, which occurs with tho first
sound of the heart. If the heart were beating slowly, it might be easy
to recognize the position of the radiid jiulse between lh« first and second
sounds; luit as the length of the first silence, during which this may be
felt, does not usually exceed tho tenth of a second, it is difficult to be
certain wlicther it accompanies the latter part of the first or the first
part of the second sound. Knowledge of the iustunt whcu the carotid
pulsation or the apex beat takes place is iudispcnsablo in ascertaining
whether an abnormal sound precedes or accompanies the systole of the
ventricles.
The regular contraction, dilatation, and rest of tho heart consti-
tute what is kuowu as its rhythm. In licalth, eiich pulsation is
similar in every respect to those which precede and follow it. In
disease of the heart, alterations in the riiVtUm arc among the most
constaut sigua; and iu all tlic allcctiuus giving ri^ to abnormal sounds
produced at the valvular orifices, tho signs occur with either contraotion
or dilatation of the organ. It therefore becomes necessary in the physical
diagnosis of cardiac disease to ascertain the rhythm of the heart. When
the pulsations are of normal fre<{Uency this is an easy matter, if we
recollect that the first souud is dull, heavy, ntid prolonged, while the
second sound is comparatively short and clacking, and that the period
of restf or long silence, follows the second and precedes tlu> first, and
also the first sound is coincident witli the carotid pulse and the impulse
of the apex beat. If the heart is beating more than a hundred times
per minute, it is always difficnlt, nnd frequently imposgible, by ausculta-
tion alone, to distinguish between the two sonnds.
If we divide the eotiru |wnod of the cardiac pidKations into two portA, one of
iDotioD and the other of rcbt, it al once becomes evident tltat the more rapid tho
PHYSICAL KXAittyATWjy OF THE HEART.
183
puJsations the ehorter miul be Uie perioti of rvpofie, and coosequeottv Iheshorter
will be Uie silence between the iwo nmuiiiIs of the heart. This is well illustrated
by a series of circles of iacrefuJng size (Fig*. S2).
In th^ flrst or smallest circle, wliich indicates the most rapid pulsatioD of the
heart, the intervals between the Qrat and second, and the second and first,
no. St— Rbtteh or TSB HBUtT (Loons).
fiouods are eqool ; whereas in tiie largest circle, Jn which the interval between
the Qrst oad second sounds is represented by the saino distance upon the circum-
fersace as in the siuull circle, tlie time between the second and the (Irst sound is
greatly iDcreused, aa indicated by the greater disiunce on Uie circumference.
la Ihesmull circle the tiinu between llic first anil the second souud in equal to that
between the second and the llj-st, while iii tlie large circle the ttnie between Uia
firat and the second iiouiid. which correspondit to the period of motioo, is only
alwut ono-foni-th as great as that which includes the period of rest between the
second and the (int.
PHYSICAL EXAMINATIO:! OF THE HEAKT.
The methcMls employed in examination of the heart are thoee already
dewribed, except Eticcnssion.
Upon inspection of a patient snttering from cardiac advanced dis-
ease» we often observe a ]>eou)iar sodden expression, with ptifilness of
the lower eyelids. In many instances there is marked pulsation of the
veins and arteries at the base of the neck. Slight pulsation of the
jngnlar vein is not a sign of cardiac disease, for it may be caused normally
by the auricular contraction. Distinct systolic jngnlar pulsation in this
position is always associated with more or less dilatation of the right
aide of tlic heart, which iiiuy result from protracted eniphy»t!mii, mitral
disease, or ubbtrucliou of the pulmonary artery by embolism or throm-
bosis. When very marked, eajieeially on tlic light side, it is always as-
sociateil with dihitJttiDn of tho right ventricle .-ttul regurgitation of blood
through the tricuspid valven, hy which the im]tul^ is transmitted di-
rectly to the jugular veins, as there aVe no valves guarding the opening;
of tho descending vena cava into the right anrick*. Pulsation in the
TeioB is always most distinct when the patient i^ Iviug down, and may
be rendered still more noticeable by pressing the blood upward in the
vein with the fingt'r, and idluwing the vessel to refill from below.
VisibU' pultfiitiaii in iliB superficial arteries is not uncommon in con-
ditions of health; but M'hen this is exc-essive and symmetrical in the
carotid, subclavian, and brachial arteries, it is alwaii-s due to hypertrophy
and dilatation of the left ventricle^ with regurgitation through the aortic
Talres. Marked pulsation confined to one subclavian or carotid artery
»
I
184 TMS HEART.
nsnallr inHinates dilatation of tlie vessel, aud the uommencement of an
aneurism.
By inspecting the chest, we obtain information regarding the/or*?*
of Uie cardiac region and the position and character of the apex beat.
Enhirijcimnt or bultjing of the jfrtf>c(rr(ltal ret/r'on may be normal, but
it is frir([ucntly duo to enlargement of the heart or effusion into the
pericuriiial &ac. lu this latter instance, the intercostal spaces are more
prominent than in the former.
The unuHiially dmtiiiirt pulxatlonn ottcn seen in children and eroaoiated per-
Bonn h&vtf been mistaken for bul^'iti;^'; but siicii errors may be avoided by careiul
iasp«ctiou aad palpation.
Rachitis may cause bulging of the preeoordial region, but in such in-
stances a corresponding depression is usually found on the posterior
aspect of the chest, immediately to the left of the spine, and the spine
is generally curved.
Prominence anteriorly caused by aneurism of the aorta is found only
above the fourth rib.
Depression iu Hit! priKcordial rpfjion, of a permanent chamoter, usa*
ally indicates previous perlcarditifj wilh aillieslon of the two surfaces of
the pericardium to each other, aud of the pericatrdium to the costal
pleura.
Care must be taken not to confound wiib this condilioa tlios« rliyihmical de-
pressions which niuy o<.->:iir inileiwnUent of ailh«siutis, us the result ol atmo-
spheric pr«9«ure. These tube pUu.*; utiL'n the hi-ui-t i^ L'lilut';^*^! and the left lung
contracted, provided the i»er8oti bus thin and clastic chc»l wiills.
Inspection reveals any alteration in the position, character, and force I
of the itfH-x Ixut. The apei is crowded upward and outward by hyper>
trojihy of the left lobe of the liver or by abdominal tumors. It may bd
carried directly upward to a point above the fifth rib by pericardial
effusions; it is raised by contraction of the left lung, as in fibroid
phtkitiiti. It is crowded downward and to the right, when the left lung
is enlarged by emphysema, or it may be drawn iu the same direction by
contraction of the right luiLg. It is crowded to the right by collections
of fluid or of air in tlio left pleural sac, or by large tumors occupying
that side of the chest ; to the left, by corresponding conditions upon the
right side. It is forced downw-ird by anearisms or by other medias-
tinal tumors and is drawn downward and inward by hypertrophy of the
right ventricle. It is carried downward and to tiie left by hypertrophy
of both ventricles, but in uiiconiplicated liypertroi)by the ape.x seldoiu
extends more than an inch to the left nf its nnrtnul position. It is also
caj-ried downward, and often far to the left, by enlargemi^iit nf the hearty
as the result of dilatation or of dilatation and hypertrophy fombined.
The significance of alterations in the position of the apex beat is showu
at a glance in the following table:
I
PHTSlfAL EXAMINATION OF TUE HEART.
185
J>i»pliiv(;mentii of the Ajfj?.
Apex crowded t<J tbv right or loft.
Apex MUfwtl.
Apex more or less upward oad out-
ward (to Uie left).
Apex depressed.
Apex more or less downnrard and to
tlw ri^jbt,
A|>ex more or less downward and to
the left.
Stgnificanre.
Fluid, air, nr tunmni inoppoiijleajde
of chest, or coDtruclion of tliu corre-
fi|ionding Iudi*.
Pericardial effusions. Cuntruclion
of left lung.
lIyij.?rtropliy of the ]«ft lobe of Uie
Ifver. Al>doniiQal tumorn and peri-
card in I t^tTllHtOtl.
Aneurism or other mediastinal tu-
mors.
Puliuuiiory emphysema. Contrac-
tion of till! right Inng: or hypertro|>liy
of the njfbt ventricle.
Ilypepli-ophy of the left or 1k>Ui
>'entricleA. Dilatation of the heart.
Hyftertropby witti dilatation.
The areii over which the cardiac inipnhe can be seeu is increased in
all those diseases which cause enlurgeoiL-nt ul tbo heart.
yc€blo pulsationd above the fourth rib arc usually duo to auricular
contraction, but they may be cnused by an aneurism of the aorta. The«e
two <;onditiuns (r.tn be distinguished front each other by noting the time
of their occurrence. Pulaatiou of the auriclen olwaya precedes the apex
beat, while that of an aneurism must necessarily follow or accompany it.
If the lieart is acting slowly, this distinction can be made easily by ordi-
nary inflpectioD, but this is not the case if it is beating rapidly. Under
Buch circurastauces the differentiation is fucllitatcd by attaching, by
means of wax, two bristles, each carrying a paper flag, to the two pulsat-
ing points, one ovor the apex and the other above tiie fourtli rib. By
watching their BiOTemeuts, it will be easy to determine which is first and
which second.
When there is dilatation of the ventricles, or when agglutination of
the two surfaces of the pericardium has taken place, the rhararffr of
the impulse is wavy or undulating; it may sometimes be seen over the
«ntire precordial region.
Alterations in the force of the impulse may bo recognized ordinarily
upon inspection, but can be better appreciated by palpation.
Before examining the heart by palpation, it is always desirable to
Mt»rtain the condition of the j/uUe, the tiigus furuiahed by which are
aoiuetimes sufiicient to establish the diagnosis.
If the radial pulse is of iinmtnal forc^ ujion the two sides, it is proli-
ably caused by an aneurism, though it may depend upon an abnormal
didtribntioD of the arteries. In the latter cMe pulsations iu the brachial
urteriei' iire alike on the two sides; whereas, iu case of aortic auenriini,
tbey Tary in force,
18C
TBE HEART.
U the pulse is siimll and weak when the arm is hanging in the oatn*
nil posilioUf und if it ([isfippcars upon raising ihe arm, geucral anteniiu
i»i prt'sciit, luid it may be itie only cunse for this sign. When the »nu is
iu the uiitunil ]>ositiou, if the pulse is smikll aud weak, and if it main-
t»in8 the Kaine chamctcristtcs when tlio arm u elevated, thero is likely
to ho disease at the milm] valves; if the ptilite \a altw very irregular, it is
probably caused by uiitral steuoiiit*.
If the pulse is small aud irregular, but distinct, and upon elevation
of the arm becomes still more distinct, two lesions are i>resent, one at
the mitral valves, and the other at the aortic.
If the pulse is full and distinct with the arm in its natural position,
and becomes much more distinct and assumes the characteristics known
JM hammer pulise when the arm is elevated, there is prof>ahIy regurgi-
tation through ihe aortic valves, witli more or less hypertrophy and
dilatation of the left ventricle.
Upon examining the chest by palpation, we obtain cridence concern-
iug the force, freijueney, and regulurity of the heart's action, aud we
may dctoct-abnormul pulsations or thrills.
By pressing firmly upon the sternum with one hand, while the other
is pressed upon the back, wu arc sometimes able to detect pnliMtiona
in a slightly dilated aorta which oould not be felt in tin ordiu&ry
XDonncr.
The position of the impulse la to be noted. Forcible pulsation above
the fourth rib may be dne to an aneurism; but if observed to the left of
the i^tennim, it is ordinarily caused by hypertrophy and dilatation of the
left auricle. The two conditions may be differentiated by observing-
whether the pulsation precedes or follows the apex beat.
When the left lung is retnicted frum the base of the heart, palsation
of the pulmonary artery may he frequently seen in the second inter-
costal space. It can be distinguished from pulsations of the auricle by
the time of its occurrence.
Abnormal pulsations along the course of the aorta are nearly always
anenrismal; but in Tcry rare instances they are caused by displacement
of the artery, as in rachitis. If the pnlsations are feeble, titey can bo
most distinctly felt during expiration.
Pulsation benesith the lower portion of the sternum, and in the epi-
gastric region, with disapptarauce of the apex beat, is a sign of enlarge-
ment of the right ventricle.
The/orf« of the heart mi»y be increased or diminished.
The force is increa/tfd in simjile hypertrophy, and in hyi)ertrophy
with dilatation, whenever the former more than compensjttes for the
latter. It is slightly increased in the iiirly stages of endocarditis, and
of pericarditiis: and it is increased by simple irritability of the heart, as
in hysterical palpitation.
OccasiouiiUy a donble shock is felt iu case o£ extensive bypcrirophj
and dihitiition, due to the rebound of the hei:rt after its systole.
The force is thvnuxxhed when the chest walls are very thick, iu con*
Be<)Ucnco of a large amount of adipose tissue; when the heart is abnor-
mally separated from the chest walls, as in pulmonary emphysenitt; and
when there is effusion into the pericardial sac. It is also diminished
when the hi-iirt is eufeebleil by atrophy, fatty degeueration and S4>fteh-
ing. or genend muscular debility resulting from protracted or low forms
of fever or other disease.
The )iQsition of the apex beAt can often be detected by pnljMition
when it is not perceptible upon inspection. It is altered by the diseases
mentioued in speaking uf inspection.
The/re^wtfHi-^ of the heart's action is increased iu such a great vari-
ety uf diseases that it is not a sign of much importance in the diagnosis
of cardiuc ulfectioiis.
JrmijuUirity of the heart's action is often a sign of diseiiso in this
organ.
When the pericardial surfaces are roughened by e.xndation,/riWro«
fremituM may bo obt4;ined. This is usually most distinct in the fourth
intercostal spuce, near the left margin of the sternum.
Kt'gurgitation tiirough tlie valvular orilices gives rise to a pecnlicr
vibration known us the pvrrttiif tremor or thrill, which may be felt by
the fingers. This is s<tmetimps detei^ted by simjjly touching the sur-
face, but in other iiistnnces tirm pressure must be maile.
£xceptiomtK — TLe muua Kviisali'm in <Kx.-iuiioually coiumunicatetl from tba
largvr arteries.
yeeh\e epignstric puhftfion is fref^nently found in perfectly healthy
individtials; but pulsation in this luoality, asm/eiated witli absonce of
Uieapex beat from its normal position, is generally the result of dilatation
of the right ventricle, with or without hyjiertrophy. This is u common
sign of dilatation of thu right side uf the heai't caused by pulmonary
emphysema. Epigastric pulsation nniy be due to the impulse uf the
abdominal aorta, es])ecially in emaciated people who have formerly been
of full habit. It ooi'urs also when a tumor rests upon the aorta in such
a manner as to be lifted with each pulsation; and it is one of the signs
of aneurism of tliis artery.
Excepiioncd. — Sometimes epigastric pulsation is due to tbe actiou of Uie
heart upon the left lobe of tJte hver.
Uepatie pulsation in a few i-are iastuuces is cuuiwd by venous i-v^urjj'itulion
from n dil.ited riRtit vontriole, through the tricuspi*! vaU-en and llic n^lit auricle,
into the iiscending vena cava. It wimptinicn exlf-iuls over the entire liyiKH'lion-
driJic region of the right hh1«, but in oTj>pr instances it is limiteil In » (tortiuti of
the hver. Sunilar puliiationK nn* obnerveil in very rare cases, as the result of an
ftueon»ni, tiie pulsalionn uf which are traasmitteU throui^i tlie liver.
Suoielmies u peculrur pulMitiou is communicated to tlie epigastric region by
188
THE HEART.
th* iTitole of the Iteart, the apex of which draws the diaphragm upward in coo-
trnction instead of urowdin^ )tdownwa.ni, in I'^mKOiiimm-e of uij:glutiniiti()ri uf Uie
two ffurfuces of the pericardium. This puliation is the rovei-sc* of thut ordinarily
observed, the expansion taking pUce with the dilatation instead of with th« con-
traction of the h«ari.
By peruuBsion, we learii the size of the heart, or delect collectiona of
lluid or air in tho poricanlinm. It Is gtiienilly considered vcrj" diHieult
to map out this orgun by jiercussion, but by attention to the following
rules we iiud it companitivcly easy. The patient should bo iu tlie re-
rumbent posture when the examination is made, and the force of the
blow ehouhl he proportionate to the dejitli of the part to be examined.
To lejini the extent of the cai'diac area wliich is not covered by lung, we
must percuss lightly; to learn the deeper outlinca of tlie organ, a harder
stroke must )» made.
For clinical purposes, it is not necessary to find the exact limits of
the heart in every direction, for our resolts will be equally good if w©
Mcertnin simply the upper, lower, and latenil lines of dulness, orer its
greaiter diameters.
Tojind the b»se of the heart, percussion should be performed on a I
lino parallel tu the steniuui and abuiil aii intdi to l}u> left, so as to nroid
the dulness occasioned by the aorta and ihe pulitiuiiiiry artery, which in
no way differs from that of the heart itself. On this line percussion I
should be matle from alwve downward, until we rwich the upper limit of
cardiuc duluess, ordinarily found at the third rib.
Ti/ hcafe the lateral tfonndarkn, percussion should be made in the
fourth intercostal spaces. Beginning in the right mammary region,
where there is perfect resonance, the examination siiould be earritHl
{Tadually toward the sternum, until the cardiuc dulness is reuched;
which will Hsimlly be about half an inch to the right of this bone.
Upi>n the left side, the examination shonld bo commenced left of the
line of the nipple, and oarried grudunlly toward the sternum, until ciir-
r'iac duhiess is obtained, usually about half an ioch to the right of the
loammillary line.
It is a difficult matter, by simple jtercussion, to find the huper border
1^ the heart, sinew it lies immediately ubuve the left lobe of the liver,
and tt distinction between the dull or Hat sounds produced by theee
two orjrnns is hardly practicnbia If we find the apex of the heart either
by palpation or by aneoultation, and then the upper surface of the liver,
ill the right mammary region, by forcible percussion, and draw a straight
line between these two points, it will correspond almost exactly with the
inferior border of the heart.
Cardiac DulnfotH. — Iu a small triangular space at the inner part of
the left mammiiry region, and at the lower part of the sternum, the
heart lies close to the chest wall, not being covered by the anterior border
of the Inng (Fig. 1). This area, which is about two and one-half ioohea
r
PHXtiWAL EXAMINATION OF THE HEART. 189
in width, and nearly the same in height, is known a« tbe arm of super-
jicial jardiuf dubivnif. It might npjtropriutely be called the area of
canlinr jhitiK'stf. Tbe apex of lliis trii»iij?le is ut the centre of the ster-
num, neai'ly ou a Hue with I In; /ourth rib; tbe hise cnrrc^puuilti to the
costal c^irtilage of the sixth rib.
This space is iilttred in extent by various iliaeascs of the heart and
the luugi^. lis area is usually incrciscd hy nil thotse iiffec-liuus wbicli
cause onbirgenient of the heart, us hypertrophy and dihttatiou, or simple
ypertrojithy.
Id «oiiie ca»i.>8 of hypertrophy, an r*mphyftcmatoiift condition of the hing inura
than couDterbalattces the enlargement at the heart, and thiu the ftpac«, in»teat|
K«I beinf; iocreaseil, ih Uiininifihed.
H This area Ih aleo increased by effusions of fluid into the pericardial
B>c.
■^ Nominlly, the area is increased by forced expiration, and diwinishsd
^by deep inspiration.
^p The area of superficial cardiac dnlness is diminUhtd by emphysema,
which crowds the anterior border of the left lung over the heart. an<] by
pneumothorax: it '\n ohiiteratvfl in the rare disease knoun a« pueumo-
pericardiumr in which air or gas collects in the pericardial sac, and thtt
normal dulness is supplanted by tympanitic resonatiee.
The arfft of dftf/i-sftifed rardinc ihihiexn corresponds to the borders ol
HjEhe heart. It extends normally from the third rib above to the resonance
1 of iho stomach below; and luterally from about tbroe^fourlbs of an
inch to the right of the sternum to within half an inch of the left nip-
ple. This ai'ca of dulness is iucrcased in those affections which causa
onlargemcnt of the heart, as hypertrophy and dilatation, and by peri-
cardial effusions.
When the diilness is first increased in the upper portion of the pr»..
exordial space above the third ribs, we may be almost certain that there
is pericardial effusion, for an increase in the vertical diameter of this
^feea is seldom found iu disease of the heart itself.
^^ The area of cardiac dulness is apparently increased by consolidatioa
if <lje left lung.
t7*lie outlines of the heart may be traced a little more easily by atwcoltntory
CJ ffhion llian by Uie on1inar>- method of percussinK. In prataising- ihiR method.
rrxiky ei»)'loy ritlier thf* solid stethoscope made for this parpose, or iho
' *'-»*»ry hin.iuraJ Rt<»lhoseope with the small cliest-piece. In either caso Ih»
B * — g>i«ce nhoiild lie phicfd over thf inoHt superflciid («irl at the heart, and [ler-
r *:» *x should be made from the i-eswjnant portion oI the lunjrs luwurU the con-
O-^^^i-tion of The heart, from above downward and laterally from wiUiout in-
— By iliin method, as feoon aa Uie outer limits of the pericardium are
1 * the change in the percuuioa note fa at once perceptible to the littteaer.
"^Uacultation over the heart, accurate information cannot nsually
'-f^^ed by the unaided ear; but by mediate ausenltatioUf especially
w
190
THE HEART.
it tlie small cbeet-pieco of the 8tethosoo|>e be used, most sitlisfuctorv
results cun be secured.
The puticnt should be in llu- refinnlx'Mt poiiitionduniigatleaHtapor-
ti(}ii uf ihf exaiinnutiuii, wliicli !<li<jnli] be ooiiiuieneed wIiiIl- the itidivitUntl
is breatliing iiiitunilly. Siibscfjiiontly, the putieut should bo directed to
take three or four deep iiispiratioiii*, which will unable ns more clearly
lo delect sounds that nrc produced by the liiugs. Theu be sliouhl hold
bis breiUh for a few secouds, which will euitble tis to eliminatv pulmo-
nary sounds, uud will reudtr the heurt-sigus uiure distinct.
The exftmiiiatioTi must uot stop with the pra;curJiaI snace, but
should be ciirried over the entire ehost. and tlie various points must b«
loeuHzed at which the heart sounds, both nornnd and abnormal, may
be he:ird nio»t dliitiuetly. It is uot the polut at which the sound may
be heard which is of dIuguuHtic importance, but t\xQ point at whirh iV i>
U>udt»t.
CAITSE OF THE HEART 80UXD8.
Considerable difference of opinion exists regarding the cause of the
heart sounds. All concede tlial the sccund sound is iitiuully produced bj
closure cf the scnti-liumr valves; and it is geneniUy admitted that several
elements enter into the production ui the first sound, though the ini-
portauee of each of these is variously estimated by different anthors.
The mjiin factors in the proiUiction of the first sound are: Hrst, the
cloaore of the mitral and the tricuspid vjilves: second, the contrHction
of the muscular tlbres of the bciirt; tliird, the impulse of the ajiex
against the chest walls. Besides these elenicTits, friction of the blood
ag]iiiist the inner surface of the heart, and of the heart against the sur^
rounding tissues, evidently plays some part in forming this sound. (
believe that the contntotion of the muscular fibers is a much more im-
portant factor in the production of tho first sound than is geuerully
supposed.
Tlip influence of tbo contraction of the muscular flbi-es may be sbo^vn by ihe
following- Kinipio experiment. Pla^e the t'nd of tli€ stclhoscoiH.' ovt-r the body
of a niusol<' tt-liirli «»n hf ronlract4?d or i-elaxed witliout nioviRc the inlegunicnts,
BK, for I'x.iinple, iitmn the ball of the thiuiib : t]i.-x and extend (lif; leniiiual
plialanx re^fiilarly almut seventy times a niinule uiul (nie will bear vvlmt tilniusl
sevtns to be the heart beatiag immediately ben^iitli the iitsli'uiiit.-iit. Skudu Ktutes
IIkiI Ihe tieart, sounds may be produced bv thi* ai-terii^s. and it opiwaif. u> lollow
witli tolenible certainty Ibat both ventricles, the pulmonai->' arteiy, and llie aoita
ai-e capable, eueb Mipamtely, of producing both tlie first and second sounds fietcep.
tible in llie region of Ihe heart.
In heiiUh. the /iVW sQuml of the heart is dull, soft, and prolonged, as
compared witlt the second, and is synchronous with the systole of the
heart. Ilie njiex lieat. and carotid pulse. Its point of maximam intensity
corro8p<inds to the a[>ex beat.
The aeiQttd aoutid of the heart, which is dependent upon closure of
MODIFICATIONS OF THE HEART HOUl^DH BY DISEASE. VM
tbc semi<Iunar valves, cnused by resilieuce of tfao arierieSf is shorter,
Bhar^jcr, uud more superfieiul tbnn the first, uiid poseeasea none oi tluit
muscular element obacrrud iu the Intttr. it coiiu-ides vith the dtiuitulc
of the heiirt and follows the arteriul puUc :tiid tipex beat. ltd jKiiit of
gra:itcst iiiteuiuty is cl the artii;u1;itioii of the left third costal curtttago
with tlie sternum. IniineiUaloly following the serond stmnil in ll;o
period of silence, which varies in duration with the i-npidity of the
heurt'a action.
T/i€ exiriii of /he area oxer which Iho c:irdiiic sounds n\ay be heard
will vary with the adaptjibility of tht* surrounding orgiiiis for trutisniit-
tiiig sounds. If the lungs :ire fsolidified, the rounds may be heard much
farthtir tlian in thi> normal etindition; but if tlie lungs are emphyscnta-
tous, tho soands aro not Iteard ns far a& in health.
Usually the sounds produced upon the right side are heard loudest
over the corresponding portion of the heart, and toward tlic right side
of the etcrnuui; whilo those produced upun tliL' left are hoard loudest
over the left side of the heart, and nearer the k-ft nipple.
As a nile, the lieart sonnds arc louder in c-hildren and in those with
thin chest w.alls tJuin in adaltn or in those with the parietes very mus-
cular or thickened by adijWBo tisane. Tho intensity v:;rit-s in different
individuals with the clianging force of the impulse and tlie conforma-
tion of the chest walls, and with peculiar idiosyncnisies, which we can-
not well undorstund.
Hence, we re<'ogni:^u the necessity of studying a large number of
healthy hearta, for no ouv individual can be Uiken as u standard.
MODIFICATIONS OP THE UEABT SOUN'DS »T DISEASE.
The heart sounds are modified by disease, in their intensity, pitch,
guaUty, mat, and rhythit. They may be preceded, ac<;ompanied, ur
followed by abnormal sounds known as murmurs; or murmurs may
entirely supplant tiieni.
The iuteusity of tin? heart sounds is i ucn'o.tpfl by hypertrophy of the
ventricles, nervous irrit^ibility, cardiac palpitation, consolidation of ad-
jacent luDg tissue, and, exceptionally^ by dilatation of the heart. The
intensity of these sonnds is dimiimhed by simple dilatation of the ven-
tricles, by fatty degeneration of the muscular fibres of the heart, ur by
deposition of fat between them or on the surface of the organ, by soft-
ening or debility of the muscular fibres as the result of protracted dis-
ease, for example, typhus or typhoid fever, and by pericardial effusions.
It is also diminished by pulmonary emphysema. The heart sounds ore
■oraotimes masked by bronchial niles.
The -ywrt^iVy of the heart sounds is considerably altered in a great
rariety of disrnsei^. The sounds, instead of iK-ing ck^tr and distinct, as
in typical healthy ciises, may be slightly mutlled. or they may be associ-
Ated with an indistinct and transient sound which closelv resemble!) 'l
ios
TUE HEART.
murmur. This impuritr of the heart sounde, unless Maociated with
other Eigne of cardiuc dJaeaae, U at mi diagnostic importance, becMiiBt- ifc
^Tery fre<inently ocfrnra as the result of pulmonary disease when the
:eart 18 in no way inrolred, and it is often noticed in healthy indi-
Tidualg.
The first sound of the heart is rendered duller and lower in pitch
than natural, by hypertrophy of the ventricles, with thiokening of tho
tricuspid and niitml valves. The second sound is modified in the aamo
Way by thickening of the semi-lunar valves without regurgitjition, and by
>S8 of elasticity in the arterial wall^.
The first Bourtd of the heart is sharper and higher pitched than nor-
lal in dilatation of the ventricles without alteration of the auriculo-
rentricular valves.
The second soun'l of the heart may be higher pitched than natural,
)r, in other words, acce».t:mted, at cither tho aortic or the pulmonary
>rifice.
At the aortic orifice, this sound is somewliat intensified by hyper-
rtrophy of the left ventricle, tlua to obstruction in the art«rj-. A ventri-
[elo thus hypertrophied propels the blood with increased force into the
Aorta, unduly distends this vessel, and thus causes sudden and more
forcible contraction of the artery, with a sharper sound from the scmi>
I;jnar valves. Wpll-markpd accentuation of the second sound in this
•position results from scUiug back, on tho valves, of an incresised volume
of blood, and it is always caused by dilatation of tho aorta.
Accentuation of the second sound at tht pulmonary orifice occurs ia
ft great variety of ditieases. It is tlic most pe.'sisteut of nil the signs of
Cardiac disease, but it is also found in nearly every «isc of pulmonary
congestion from whatever cauae. Whenever the/e is obstruction or re-
gurgitatiua ut tlie mitral orifice, there must be increased tension of tlie
blood in the left auricle and in the pulmonary veins, which will be
transmitted through the short pulmonary circuit Uick to the pulmO'
nary artery. This will cause a sudden and sharper elo.Jiire of tho valve*
fhicU guard the outlet of the right ventricle. Obstruct-on in the pul-
monary circuit fnmi disease of the lungs, by inducing hypertrophy and
dilatation of the right ventricle, causes extreme distentiot. of the pul-
monary arterv with each pulsation, and consequent accent a dt ion of the
I second sound in the pulnionarj* area.
The heart sounds become metallic or tinkling in quality in irritable
conditions of the organ and when the stomach is distended with gaa.
E.Tcejftional—T\v heart sounds are very inetajlic in chai-acter in the rare
disease known as pneumo-pericanUum. They are ■oraetimes metalhc in left-
Bided pneumoOiorax. Th« Home chnractt-r i» somotimes noticed with llie ^cond
"oiintl, at the aortic oriOce, when there i* atheroma of thi« vessel limited to its
initial portion.
The seat of the heart sounds is a limited space in which they can be
MODIFJVATION OF TUB HEART SOCSDS BY PISBASS. 19a
Iwttrd moat distinctly. It may be altered by several diseuees. The
sonndfi obtuiuable over the apex are heard above their normal position*
whenever the nUlominal org»us are so enlarged as to eneroui'li upuu the
thoracic cavity, m in disteulion of the stomach, or calurgeniont of the
hver. or ascites, or large ovarian tumors. They are also heard ttbova
their normiil position when efTu«ioti is pre^ut iu the periciinliiil site.
These sounds are heard belon- their tisuiil sent when the upi.'X u
depressed by mediastinal tumors, or by hypertrophy with dilatation of
the auricles. They are displaced laterally by pleuritic effusions, pnen-
mothonis, and by deformities of the chest. They are displaced to tlia
]eft whenever the heart is enlarged, wliuthor by hypertrophy or by dila-
tation, or when it is dmwn from its position by contracting adheKiona.
The rhythm of the heiirt soundii i^ ulteretl by many dise;i»e«.
Fre^juently the heart arts regularly for some time, iind then drops
one or more beats to go on »g:iin with its regular pulgations. This is
known as an iNiermiftent rhtjihm.
If the intermittent rhythm includes tho i>criod of one i)ulsTilion only,
it is of no s{>ecial importance, us such phenomena mx;ur under a variety
of circnmstiinceH, independent of curdiuc dlseuite; it is a cnrions fact
that intermission in tlie heart's action often occurs in some people just
preceding a thunder-titorm. But if this intermission occupies the time
of two or three pulsations, and if the heart's action is irregular — that is,
beating rapidly, then slowly, fintilly interniittlug, nnd thou sUirting up
irith nipid pnlsjitions, us if to make up for lost time — it is a sign of car^
diac diseat-e.
The first aonnd iif the lieart is jtrolouijeti by hypertrophy of tho ven-
tricles, and by agglatinatiou of the surfaces of the pericardium. It is
4horientd in dihitation of the ventricles, and both sounds are shorleued
by fatty degeneration and softening of the heart walls.
The pertwl of refmttc is souiettmea pmUimjpU by obstruction to tho
onward How of the blood into the left ventricle, owing to stenosis of the
Diitnd orifice.
KEDiPLirATioN OP soiTXDS, another alteration of tho rhythm, con-
insts of a repetition of ono or both of the heart sounds during u t>ingla
pulsatiuu, so that three or fonr sounds may be heard witli each contrac-
tion of the heart. Ordinarily, the right and left sides of the heart con-
tract at exactly the same time, and consequently the soutkIk which aro
protlnrcd in the two cannot be disting^uished; but oca-isionally there is &
«light interval ht^tween the closure of the valves at the auriculo-vontrio-
nlar or at the arterial orifices of the two sides, so that the sontids do not
occur simultaneously, and thuH the first sountl ntuy be doublerl. tho
second sound remaining natunil; or the second sound may be doubled,
the first ri'inainitig single: or both may be doubled.
This phenomenon occurs in disoiises of the hoart, bnt may often Iw
discovered in health, if searched for with the differcDtial stethoscope
'3
194 THE HEART.
(Fig. 15). When occurring in disease, reduplication is usually
caused by stenosis of the mitral orifice or incompetence of its ralves.
This gives rise to increased tension in the pulmoimry circuit and to
abrupt closure of the pulmonary semilunar valves, which thus slightly
anticipates the closure of the aortic valves, and causes reduplication of
the second sound.
Reduplication of the first sound is due to tardy closure of the mitral
valves. Some care will be necessary to avoid mistaking reduplication
for endocardial murmurs which precede or follow the normal sounds.
Intermission is a characteristic of reduplication (Loomis' Physical
Diagnosis). In some cases reduplication is infiuenced by the acts of
respiration. In forced or laborious respiration, the first sound may bj
reduplicated at the end of inspiration and at the beginning of expira-
tion; the second sound may be reduplicated at the end of expiration and
at the beginning of inspiration.
CHAPTER XTL
THE UKART. —Continued.
AB.NOHMAL SUL'NDS— CARDIAC MURUUILS.
ThI! abnormiil fiouuds lieurd over the prEeconlial region are ilenom-
innled murtuurH. homeliiiiuii these ure jtroUuucd ufKiii the surface of
the heart, hetwei'ii the two layera of llie iierirjirdium, but iiiont of thorn
originate witliiii iho heart. Thu hitter arc known aa ciidocardiiil iitid
the former as exocardial murmurs.
The exocakiuai. or ptKiCAKDiAi. FHirxios sofxns or mukmurs
are pi'oduceil by the rubbiug togelhcr of the rouglieuod surfaces of the
pericardium, iu the same mattQcr that frictiou sounds are produced
Tithin the ptoura. These murmurs vury greatly iu their iiileiisity and
qnality. Souietinies they are very indistinct, at others loud. In cjuality,
they may be grazing, gi*atiug, rubbing, croakiug, or crackling, like
pleuritic friction houihU
The (jualily of an exocardial luurmnr yielils no information regard-
ing the peculiar condition of the surface which produces it, though, iu
the dry stage of pericarditis, tlie grazing sound is the one most likely to
be beanl.
Theee murninrti may be either single or double; that is, they nuty
occur with the systole or with the diastole of the heart, or with both-
They sometimes accompany the valvular sounds; ut other times they
arc mdependeut of them. They arc always superficial in character asid
they seem to be produced immediately beneath lliu chest walls. The area
orer which they can be heard ib restricted to tlie pra;cordial space. They
are genendly heard loudeist ut the junctioti of the fourth left costal car-
tilage wiih the sternum. They generally last for only a few hours, sel-
dom longer than one or two days, and then disappear in consequence of
the exudation of serum into the pericardium. As the serous effuHiou
becomes tibsorbed in the later stage of pericarditis, the friction murmur
may reajipear.
Pericardial friction sounds are distinguiehed from endocardini mur-
murs - first, by their Buperficlal character: second, by l>oing limited to the
precordial space, i.e., never being transmitted to the left of the apex, or
above the base of the heart; third, by their being independent of valvular
sounds; and fourth, by the variation in their intensity with changes iu
the position of the patient. Whcu the patient is iu the erect or in the
196
THE HEART.
recuuibent posture, the heart does not approach so near to the surfuce
of the cbeit us when he is leuniiigweU fornunl.&nd therefore (hcsouuda
are uot hs distinct. In geiiend, tlio intensity is greater during expira-
tion thun during inspiration.
Periuiirdial friction soiindB are diBtinguiehed from pleuritic friction
sounds by their confinement to the prsecordia, by their synchronism
with the cardifl'! movemeuta instead of the respiration, tind by cuutiuu-
auce during lempurury suspensiuu of the respiratory act.
Ejccf:ittio»nl.—\z shoiili.1 be reiuemberLMi Unit, in some t-iuws uf plourisv, nib-
bitig uf the filiiviM l-iyoruf ttic ]>cHc-Ar(liiim ai^ainst an inflaiiiecl pleura pvM ri»«
to a fnctjon sound having the »<aine rbytlini as the heart, ntid cutiUnuing while
respiration is suspended. Huch a. sig-n is called a eardio-jjictiritic fricHtm mur-
ffiur. It is easily tuistakea Tor Uie pericanliul miirinur, hut its cuiisv should
always bn suspected tvlieu otiier si^'ns of pleurisy exist, especially if the pieunsy
be associated with pueunioniu. Thi» (lound dilTent (rum the penL-iinljut iniirinur
in tlie UDifurmity in iriti^nbity uf the siivces^ive soumls, in its htiataliun to the
border vt the lioui't, and. hi Kuiue wkM;s w tlie eml of iiispiratiun, ftiid in yen-
ertUly btttng aJTectMl to a greater or tem degree by the movements of iiuspiriLtiua,
EximcARDiAL 3JL'KUL'ii.s vary in tlieir intensity, pitcii, and quality;
but tliese elements are of very little imjiortance from a diagnostic point
of view, as the intensity and the pitch of the sounds yield ns no infor-
mation whatever, and the quality is never characteristic, except in the
presystolic murntur duo to stenosis of the mitnil oritlco.
These Bounds are produced by changes in the physical condition of
the heiirt, in whicli vase they are known us organic nmrniurs; or by
changes in tlie condition of thu blood, when they are termed inorganic,
ana-niiu, or liEemic murmurs.
Organic murmurs arc usnnlly permanent, though not infrequently
they cease for a considerable length of time, and in some cases they
may entirely disappear. The inorganic murmurs are tntnsitury— present
for a few huuK or days and then disappearing permanently, or to recur
after a short interval. Sometimes they come and go while the exami-
nation is being made.
A murmur in t)te prteconlinl ^pnce indicates nothing except a di»*
tnrbance of the normal relations of the begirt to the blood, and may bo
due to a change in thu physical condition of the heart itself or in the
normal composition of the blood, or it may result from irregular oon-
tractions of the cardiac uiuscle.
The important things to nolo regarding a murmur are: 6r8t, the
seat; second, the rhythm: and third, the quality. The direction in
wbich the sound is roost clearly transmitted is also an essential fentnre
in diagnoitis.
in noting the rhythm, we observe the relation of the murmur to the
systole and the diastole of the ventricles, and we ascertain whether it
precedes, accom])anies, or follows thti first or second sound of the heart.
I
CARDIAC MUMS/aUS.
197
In a few instances, the peculiar quality of tho Bonnd itsolf is im-
portant. Some murmnre are grating, othera blowing or rushing lo
quality, and obhors arc harsh, or soft, or muaical. A mnrmiir may have
many of these eharacteriatics at different times without any appreciable
change in th« conditions which produce it
Whenever we hear an abnormal sound in the pr»conliiil ^mce, we
ahonld ascertain, by careful examination, its point of maximum intensity,
whether it is ayncbronous with either the contraction or the dilatation
of the cardiac cavities and depends upon the current of blood through
the valvular orifices, or whether it \s produced outside the heurt. As
the majority of abnormal cardiac sounds are produced within llie heart,
Iho presumption is always that a murmur is endocardial: if we should
liud it coin]taratirely deep seated, and synchronous with the Hyatole or
the diastole of the ventricles, and transmitted to the left of the apex,
or above the base of the heart, we may safely conclude that it belongs
to tb^ class.
When we remember that nearly all endocardial murmurs are pro-
duced at one of the valvular oritices, and that thc«o approxiinutu to
closely to each other that a circle half an inch in diameter may include
a portion of each, it is at once appureni ihat it must be imiH)H8ihle to
distinguish between difTurunt cuducardial sounds by liuteuiug for them
directly over their point of origin.
Sound loses its intensity by passing from one medium to another, as
will occur in tbe passage of sound from one cavity of the heart to an-
other, and any sound produced by fluid in motion is transmitted in the
din'cti'.n of the current wliieti cjiuses it. A knowledge of thesir two facts
will aid us greiitly in differentiating between endocardial ifounds. We
shall find that, as a rule, sounds produced in any of the caviUe« of the
heart, or transniitted into chem, are best heard over tho sjMice where
that cjivity is moet supertieiiil. For example, the only point at which
the left ventricle impinges directly on tbe chest wall is where the apex
ibont is felt: murmurs produced nt its uuriculur orifice ni-e hi-H heanl at
^ihis spot, while those at the tricuspid oriHcc am nin^t dj^iinct over that
|)ortion of the right ventricle which is superficial. The murmurs at the
nortic and pulmonary orifices are respectively heard with the greatest
distinctness whore these arteries approach nearest the chest wall.
Some of the endocardial murmurs, however, are produced by blood
Cowing in an abnormal direction. Therefore, the areas in which mur-
I mars pro<lunoil at tho various oriBces are most distinct will not always
tzoctly correspond to the positions in which the normal soundc are
loudest.
Before examining the heart by auscultation, we should ascertain its
superior and laleml limits by jicrcussion or by auscultatory percussion,
■ud, either by these methods or by palpation, determine the position of
the aper.
m
TUB MEAMT.
Tha mitral nrea, as the spiice is named -where tho mitral sounds may
be heard with maximum intensity, corresponds to a circle two inches iai
diameter, which includes the apex of the heart (.-I, Fig. 3:J). If this
orgiui is in its normal position, the circle, as shown iu the diagram, will
have its centre near the normal position of the npcx beat; but if, from
enlargement or other causes, the heart is displaced to the left, the posi-
tion of this circle is correspondingly changed.
Mitral mormurs, if caused by regurgitation, arc also heard diffused
for ft distance varying from one to three inches to the left of thi- apex.
Often they may be heard bciiind, aiuug the left side of the sixth and
iereiilli dorsal vertebrse, with nearly the same intensity as in front;
^-.
Xfy}
- —'a "n
•^.._."
ry
.—** ■■■"
-o.
I
FMl SS.. NijLUor EaDooAHDUt. Mi-quDiu. A. Mitral Aiva-. Jf , .vortlo anA ; C. uictMpUum;
H, |iutmaiuU7 area.
sometimes they may be heard in this position wheti They are not distinct;
in front.
Care must be Takc-n not to coofounil mitnil murmurs i\ith aortic rc^iirgitatit
murmurs, wliicii aro occasioiiully liuurd at the lower angle ot the left scapula,
and in the left axillary rc^vn ; or with aneiu-isTiml niurroura, whicb n:a.v also be
heard along- (he left liule of thn spinal column, m Uie same position as the mitral
regurptaiit imimiur.
A milnil regurgititnt mnrmnrdifferB from an aneurismnl murmur in
being heard behind only between the fifth and the eighth dorsal vertebraf.
The anonrismal murmur may be he:ird above the fifth vertebra, and, with^
diminished intensity, below the eighth as well us between the two. W
An aortic direct murmur, heard behind, should not be mistaken for
»* mitral regurgitant murmur, since It is heurd loudest abcvc the lower—
border of the fifth dorsal vertebra, V
Mitral ffKurgitaot mumiure may sometiroes disappear, even Uiough due to
organic lesious. In such cases. o'"<"fnt"silion of the second sound at the pulmo-
"^'■y oiniico may be tlio ouly abnuraial bik" remaining.
C AUDI AC JUUJUtVHS.
199
If a mitral muniinr is obstructive, or direct^ i.a., due to stenosia nf
the mitral orifice, it will bo henrd iit the :i|H!X, but will not be distinctly
Iransniitted to the left, uud will luit Iw Iiwird behind.
It is to be borne in niiiid that, in speiiking of the nroas of niitnnurs,
we refer only to the ptjsitiona ;»t wliich they niny bo hc-nrd with tlie
yreattst inUnsity. Sometimes a mitral mnrmur may be lieurd over the
whole 2>rwcordial region, or even over the entire chest, hut its point of
maximum intensity will correapoud to the area which ve have juet
described.
The tricuspid area of mnrmunt is limited to the triangnlnr B])Aoe {C,
Fig. 33) where the right Tentncle is superficial. These murmurs ore
ordinarily loudest over the xiphoid <.'«rtihige» or along the left bordtrr uf
the sternum, at the junction of the sixth or seventh costal cartilage,
and are scklom audible above the third rib. This latit-r feature distin-
guishej them from aortic and pulmonic murmurs. WIilmi the heart is
bvpertrophied or diluted, their inteu!<ily will suinetimcu be greatest at tha
junction of the fourth costal cartilage with the sternum. These mur-
murs are superficial in cbara'-ter aa o<jn]]>ared with tliost* occurring upon
the left side of the heart. If tnin»niitted in any <Hr**rlirtn, they will bo
heard more distinctly to the right than to the left of the parasternal line.
The jitdviOniirtf fina of murmurs corresponds to a small circle about
an inch in diameter, located just above the thir<l costal curtilage at the
left border uf the sternum, and covering the pulmonary artery (D,
Fig. iW). Pulmonic murmura are heanl mc*t distinctly directly over
the pulmonary artery. These sounds are never heard in the carotid
und subclavian arterieit. If due to regurgitidion tlirough the pulmo-
nary valves into the right ventricle, they may be moirt intense, an Inch
or an inch and a half below this area, near the left margin of Iho
sternum. They are not heard at the apex, and this distinguishes them
from some aortic murmurs. These, like the tricusjiid murmurs, are
comparatively sujierficial.
The 'lortiv arm of murmurs cannot bo so sharply defined as the areas
of the murmurs we have jnst described. Aortic murmurs are usually
loudest in the second intercostal space of the right side, where the artery
up]>roaches most closely to the thoracic walls; or along the right margin
of the stenmm from the second to the fourth rib; but they are often
heanl over tho whole sternum {B, Fig. 33).
Aortic murmurs are propagntetl to the carotid or subclavian artcricSj
and are frequently heard be^t in these localities. Occasionally they nra
louder in the pulinomiry area than at any other ]>oiiit. In eucIi in-
stances they are dititinguished from palmonary murmurs by being heard
uls<i in the arteries at the base uf the neck. Aortic murmurs are often
board liebind. niong the left side of tho third and fonrth dorsjil verte-
bne, and with diminishing intensity for a considerable distance down the
spine. They are frequently very distinct at the apex at the bean.
r
Aortic rognrgitont mnrmnrs aro often londeet over the lower piirt of
he sternum, though we expect to fiud them most dtBtinct a shori <iiii-
:inc(> bubw the uuriic vtilves. These murmurs arc frc-queutly uutlibk in
the loft ttxillftvy region, and at Ihu lower angle of tho scii|)uUi. Tho
patient may often hoar tlieni himself, eajHHiially when lying down.
Exceptionat. — Aortic miimiiirs may sometimes be heard over the :irter)«s
when tliey are nut diHtiact at the ba«e of the heart. At other tini«^& they are
audibh; ut the biLse ot the heart ouly ; uad atiU a£:a)D. tliey may be distuict over
the entire piiLiordiul i-L'^-iun.
Itcgurgitiint aortic murmtini are frequently heard in all the arteries
which are accessible tn ausrultatinn. It should be remembered thiit the
aortic murmurs are tho only ones that may be heard above the clavicles.
ik>th tho obstructive and the regurgitant aortic murmurs vary much,
in intensity. Sometimes it is nef^essiry to listen intently in orih r to
hear them ut all. In uther eased they arc so loud that they may be heurd
at some distance from the patiput
The rhylhm of a murmur refers to the relation which it bears to the
cardiac pulsation^ and consequently to the first and second sounds of
the hc:'.rt. In determining the rhythm of a murmur, we mu^t tirst as-
certain which is the first and which lis© second sound of the heart. This
vill not be u dillicutt task if the heiu-t is pulsiititig slowly and buth.
suunds are distinct; for we know tbitt tho first sound is the louder and
longer, and that it is u88<.iciated with tlic impulse of the apex against thu
chest wall. In sume instances only une vt the valvular sounds can be
heurd at tho apex or at the lui^o, and in such eases a nmrmur would
very niitnmlly ha mistaken for the other sound. In every case of doubt
we rau^t feel for the citrotid pulsci which is always synchronous with the
first sound of the heitrt, and will therefore enable us to determine the
rhythm of tho murmur.
The quality of endocardial mnrmnrs gives lis no information regard-
ing their place of origin or the conditions which produce ihein. except-
ing in cases of presystolic niitnil mtirmnrs, which will be presently de-
scribed> and ana?mtc murmur?, which are always soft in character.
Cauxex of Emlwardiftl Munnurn. — Presystolic mitral and tricuspid
niurraurs, preceding as they do the first smuikI uf the heart, must occur
while tho blood is passing from the auricles into tho ventricles, and
while the valves arc thrown out upon the current (Fig. 34). They aro
always caused hy narrowing fsteiiosia) uf the auriculo-vcntricular urifice.
which obstructs the onward flow of blood. Such a murmur, if produced
upon the left side, will be loudest ut the apex, but will not be trans-
milted to the left of the ai>ex, and cannot be heard behind. It is called
« roitml presystolic or obiitrnetive nuirmur. This is perhaps the only
murmur where the quality of the sound is of any 8pccl;il diagnostic
Talue. According to Italfour, the qtndity of these murmurs is charao<
tctietiu. though uot exactly the same in all cases. It may bo quite ao-
CARDIAC aVItitVliS.
aoi
corately repreeenU'd by vocalizing the eymbols Rrrb or Voot. If
a murmur which precedes the first 60und of the heart is produoeii upon
the righi aide— whicli is extremely luicommon — it is called a tricuspid
obstructive murmur, and its ureu is limited to the triuugulur space i\ al
the lower portion of the sternum (Fig. 33).
Systolic murraura, or murmurs iit:i:oiu|Kinyiiig or foHowiiig the first
Bound of the heart., must occur with the contraction of tbu ventricles,
the closure of the anriculo-veutricular valves* and the propulsion of the
blood from the ventricles into the arteries. They may be due to lesions
at any of the valvular orifices.
The mitral, syetolic or regurgitint. murmur is produt^ed at the mitral
orifice, and itt due to thickening, corrugation, ur udtiei^joii of the valves,
which prevents them from perfectly closing the ori&ce, and thus allows
SUUL
B
VkSt S4— AnucVLUt SmoiA A. C. CoBlnwttMl auricle; B, D. dIUbvt T«iUflck«. Mllr«l umI
tricuspid Tidres open : Mtnlluau- valves dosed.
the blood to repirgitate into the left anricle. It may also result from
rnptnre or undue shortening or stretching of the cohimna? carncjc of
their tendons, which normally keep the valves from jriving way bofor*
the column of blood. This murmur is generally si^ft an«i blowing, and
may be musical in quality: it will be londest in the mitral area. It will
be transmitted to tho left of the afwx. and may be heard posteriorly
along the left side of the spinal column from the fifth to the eighth
dorsal vertebra. It is seldom beuni in this situation with the &ame in-
tensity a^ at the apex, but occasionally it is distinct behind when it is
not audible in front. If a mitral murninr is cauit-d simply by roughen*
ing of the ventricular surface of the valves, it will not be heard beside
the sixth or seventh dorsal vertebra, though it may be heard about th»
inferior an^de of the scapula., and in tho left axillary region.
Sometimea endocardial murmurs are produce<l by dilaUitiun of the
veatriclee, which jirevents perfect closure of the mitral valvee. Such
202
THE HKART.
jnnnnnrs have been termed curahh miiral regurgitant intinnurnt u
they disappear when the tonirity of the muactilar fibre haa beconif suffi-
ciently restored to contract the cavitieB to their original «ize These
murmurs iire probably caiusecl by dihitation of the ventricles without a
f^orrespondiug clougntiou of the diubcuIi papilhires in coneeqneno^ of
■which the chorda! teudinea) are too short to iillow tlie voltes to close.
Tht.' tricuspid systolic, or regurgiUint. murmur will be hcjird in the tri-
cusjjid area, and if transmitted iu either direction will be louder to the
right than to tlie left. It will not bo beard at the apex distinctly, and
never lo the left of ti^e upex or behind. This niurmur baa generally a
blowing ipiality.
If tho aortio systolic, obstructive or direct, cinirniur is of urganio
origin, it will be caused by constriction of the aortic semiluuar valves,
sU"
\
1
'//
It
.n5
Flo. St.— SnrroLB or tk« Vkmtuclbii. A. C, AurirW tllUtInK-, B. P, v«nttidMCODtr«etl>tK S^inl-
lunar va1v«> op«n ; mllnii uni UicuspM vkIvm dowd.
or by roughening uf their ventricular surfaces, or possibly by ilisease of
the artery. It will bo produced while tho blood is passing from the
ventrlrles into the iirterieii (Fig. 3*)), and will be heard in the aortic area
over the serond intercostal space of the right side, or over other por-
tions of the sternum as shown by the space ft (Fig. 33). It will also
be heard in the arteries of the neok. and frequently nt the left of the
third and fourth dorsal vertebra; posteriorly and possibly with dimin-
ished intensity farther down the spine.
If this murmur is loudest over the pulmonary artery, as occasioually
happens, it may l>e distinguished, from murmurs produce^] at the pul-
monary uriticc, by the fact that it is transmitted to the carotid and sub-
clavian nriches.
A systolic murmur produced ut the pulmonary orifice is likely to be
a hemic murmur; but if of organic origin, it is usually due to obstruc-
I
iinuhr to that just described w oocnrring si the H>rttc v«1tm«
These mannnn are fOBetimei e«a$e4 br preasnie on the mterj from
ibi^ed fbuuU; or bj coasthction of the artery from pleuritic adh^
or fibroid phthi»is with cuniraction of the long. Soeh a munnur
win be heard most distinctly in the polmonarr area (D, Fig. H),
and wX UDt br audible in the uteriea at the base of the neck.
DLi:<TOLlc Mt'UtCKS — A mDrmur accompanring or folloTtng tlie
sound of the heart oociLrs with the iliastole of the rentriclea,
id miut be due to regurgitation of blood from the arteries through the
semilunar TalveSr on either the right or the left side.
If a marmur, accompanying or foUoving the aecond sound of the
^lieart, ckccurs at the aortic orifice, it vill be due to regurgiuitioii uf blood
from the urtery iuto the left Tentricle, and may be called aortic diastulirt or
irgitanL It vill genemlly Ih* soft and bloving in cbiira<-U'r, though
may be harsh. It irill he heanl in the aortic area, but U8u:il1y most
distinctly a short distance below the TtUred; it will be propiigiitcd down
the sternum and it may sometimes be loadest at the ensiform appendix.
EjTfjitiomat. — In s»m< inxtancvs sucli murmurs nrv ven* dJxtinct at ihr npcx.
In ihe axillATT rvi^ioii ubuut tiie lower unele of Uie left scofiulu, or uver ail \argn
sap<rQci:iJ arWri«8.
If produced at the pnlrnonary onlire, a diastolic mnrmiir is i)iie
to regurgitation through the pulmonary Talves, and is vallvd a
pnlrnonary diastolic or r^nrgitant murmur. Sneh mnrmurs are ex-
tremely rare.
When such a murmur does occur, it will be hoartl in the pulmonary
area, or an inch or an inch aud a half below this space, and it will not
be transmitted to the large arteries or to the luwer part of the sternnm*
By this Utter fiict it may easily be Jidtingui.shod from a similar nmrninr
at the aortic orifice.
Thus, we may have eight distinct Vftlmlnr murmurs, four of which
are obstructive aud four rc>gurgituut. Two of thcDc, viz., the rpgurgi-
taut pnlmouary und the obstructive tricuspid murmurs, are »o very rara
thut thoir existence is doubted by many skilled diaguosticiana. Regurgi-
tsul triirugpid murmurs nre rare except lis tho consi'quoiicc i>f illetroso of
the left side of tlie heart, which gives rise to such dilnUition of iho right
Tentrirle that the aurlcnlo-veulricnlur orifice becomes too largo to be
closed by the tricuspid ralves.
We may hare two or more of these sounds conibine<l in any ciise;
thus, it is not uncommon to obtain a mitral regurgiUnt murmur iieso-
cinted with an aortic obstrnotive, und perhaps also with iin aortic
regurgitant murmur; or wo may hnVe both the mitral obstructive and
regurgitant, with the aortic obstructive and regurgitant murmur.
Murmurs are common in the left side of the heart, but rare io the
right side.
304
THE HSART.
According to my obserration, Ihe various murmurs occur iu the fol-
lowing order of frequency: mitral regurgitant, aortic regurgitant, aortic
obstniotive, mitral obstructive or presystolic, and tricuspid regurgitant.
Vestuicular MritMnis. — There are certain niurinurs occasion ally
heard in the precordial region, wbidj are neither of valvular nor of
tuemic origin. They are most frequent during tlio acute etage of en-
docarditis, but tliey nlso occur in chronic endocarditis. They some-
times prect'du und sometimes fulluw etulucurdltis, iiiul in suine iiistanccH
they are apparently induced by simple irritiibility of the heart. They
accompany the first sound of the heart, and are loudest at the apex.
These murmurs seem to bo caused by roughening of the endocardium or
of the chordiP tendines, or by irregular contraction of the musculiir fibres
of the ventricles. They are of coniparatirely rare occurrence, and then
are usually mistaken for v:ilviil;ir ninrninrs. They may be distinguished
from the hitter by their rhythm and by their sout. These murmurs are
most likely to be confounded with mitral regurgitant and aortic or
pulmoniiry obstructive murmurs.
A ventricular murmur, though beard at the apex witb the lirst sound
of the heart, is ner-'er transmttted to the lefl; wliereby it is distinguished
from the mitnil regurgitant murmur, vliich possesses the same rhythm.
A ventricular murmur is uerer heard ahwe thr hnse- <tf thf heart, and thns
is distinguished from aortic and pulmonary murmurs.
Frequently in exaniination of the heart, impure sounds are ob-
tained, which closely resemble faint valvular muramrs. They are gen-
erally heard just at the cud of inspiration, und usually cease when respi-
ration is suspended. These are not constant, but may come and go
during the examination.
Cottj/trittul j$titrriiurs arise from im|H'rfect L-losuro of the foramen
ovale, which allows the blood to pass directly from the right into the left
auricle. This occflsions a murmur which is audible over the base. of
tho heart. It is heanl with tlie systole of the ventriclea, and is not
transmitted into tiio arteries, or to the left of the apex. It may thus he>
distinguished from aortic and mitral murmurs. This murmur always
occurs in curly life, and is associated with a ryimotic appearance of ihe
countenance. \Vhen tho child reaches the age of ten or twelve years,
other endocardial murmurs usually eupervene.
Ifivmit vtuntn/r/i form another variety of adventitious sounds dne to
changes in the composition of the blood instead of to nnatomieal changes
in the heart. They are also termed aniemic, or inorganic murmurs.
They are always systolic, genemlly most distinct over the aorta, and are
diffused through the vessels of the neck. Stmietimes they may be heard
in the second intercostal space of the left side, about nn inch and a half
to the left of the pulmonary .artery.
The ha;niic murmurs which are produced in the aorta are dne simply
to change in the composition' of the blond. Those heard to the left of
ANOMALOUS HEART HOUSDS.
205
the palmonary nrtery eepni to bu prodiu-Ofl by slight dilatutiou of the
left ventricle, with coiide<|Dent imperreut closure of the mjtr.tl valve»
and mure or less regiirgitHtion of blood into the unricle.
These murmurs are inconstant; they ofteu come and go during the
fixaiaination.und fiuuUy they pennuneully disuppeoras proper treutuient
removes ihe unaMiiic condition of the blood.
The foDowing t-hanicteri sties distingniah them from organic mnr-
mnra: they nlways accompany the 6i'ft eotind of the heart; they are soft
and blowing in eharncter; ihoee which ure arterial mny be heard OTcr
m:iny uf the aortic branches and ure often loudest over the carotids in-
stead I'f ovt-r the aurtj, where the aortic obstructive muniiurs would be
most distiuL-C. TbotiC whiuh art; mitral may be heard a vuriabli> diut'inco
to the left of the pulmonary artery. They ure inconstant and likely to
be present when the lieart's action is mpid, but absent wlien it is slow.
They are incapable af supplanting the uornuil heart sounds, or even of
making them less dititinct, and are usually associated with the venons
hum.
The£e murmurs are also attended by the symptoms and signs of gen-
eral ansmia. Except in complicated cases, they are not ai^sociated with
the signs of other cardiac disease.
ANOMALOrS HEART SOL'JJDa
In rare instances, sounds may be heard over the pr»cordtal spacw»
which are not endocanlial or pericardial. These result from the action
of the heart upon the lungs, and usually cease when the respirations oro
Buspended.
With the systole of the ventricles, a loud blowing sound may he oc*
casioned by a large pnlntomiry cavity situated near the heart. Hore or
less distinct blowing sounds are frequently heard when the systole of the
heart occurs just at the end of inspiration. These cease when the jm-
tient holds his breath.
Friction sounds may be produced by tlie action of the heart npuu
the overlying pleura. Generally these may be easily distinguished irum
peri(:ardial friction sounils by their seat, and by their disupivearanee with
the cessation of respiration. The pericardial friction sounds are heard
most distinctly along the left border of tlie sternum: hut t^oniids pro-
duced within the pleura by the action of the heart are heard nutst clearly
over the outer portion of the mammary region. They are aUo usually
associated with friction sounds over other portions of the left lung.
Ordinary pleuritic friction sonnds are sometimes obser^'ed in the pre-
cordial region: but these disappear when the patient holds his breath.
The sounds caused by the action of the heart* upon the luugs occa>
aionally resemble bronehitil nilca: but as these are limited to the pne-
oordial t<p:H-e, they are not lil^ely to be mistukeu fur sounds due lo pul-
ZDonarv disease.
ieoG
THE ilEAHT.
SUBCLAVIAN MURMURS.
Sabclavian murmurs are often heard just bcucatli the clavicle, at the
outer portion of the infni-ciaviculHr region, more frequently upon the
left timn upon the right side. Mu^itof these aeeui to nie to be produced
b^ the prf8«ure of the stethoscope; but niunnun' frequently occnr in
this locality, and over other purls of the subohiviau arlen*. which are
not due to external ciiuseB. They are supposed to reeult Xruni pressure
upon the artery, either by ronsolidated hmg tissue or by cicatririal
bands resulting from ph>urisy: but their ex:irt cause is not knorn.
They are most frequently usiiociuted with consolidation of the apei of
the lung.
TtrnoESCEXCE of the superficial veins of the neck and upper part of
the trunk is a c^ign of curdiae or pulmonary disease, and of aortie unen-
rism or otlier intni-thorauic Lumors. The condition is caused by direct
pressure on th« veins, or by increase in the intra-thonieic pressure from
pulmonary disease, and consequent interfi^renco with tho return of blood
to the heart. It is always most noticeable when the jmtient is in che
recumbent position.
This turgescencj inuy be cither tcmponiry or perniunent. If the
former, it is uiost marked in expiration or after iittacks of cougiilng,
and it will entirely disnppeiir upon deep iuspinition.
Ttmpornry { nrtjescenve ol these veins is generallv due lo congestion of
the pulmonary circuit, resulting from disease of the lungs, which com-
presses the capillaries, and consequently causes distention of the pul-
monary arteries and of the right side of the heart, and, through it, of
the descending vemi cuv:i and its branches.
Permanent turf/escciue most commonly results from disease of the
mitral valves, which either obstructs the onward current of blood into
the left ventricle or allows free regurgitation into the auricle. Thia
gives rise to engorgement of tlie pulmonary circuit, which cannot be
relieved by doep inspiration. Permanent congestion may bo duo to
obstruction of the desceudinar vena cava by a ihromhns, or more fre-
quently by the pressure of an aneurism or other tumor.
Lm-alizMl hift/imce/ue, confined to u single vein and its branches,
is always the result of a thrombus, an embolus, or of pressure upon the
blood •vessel.
Venous pclsatioit with marked pulsation in the jugular veins is
observed when there is' permauent engorgement of the descending ven:t
C2iva, wliich generally results from extreme emphysemii or stenosis of
the mitral valves with secondary tricuspid regurgitation.
Pulsiition in the jugulur volus is nsuully observed just above tbft
rsyocs sioirs.
307
claTiclos. though sometimefl it extends over the whole course of the vsb-
Be\. It U most marked in the dorsal decnbitiu, and is more dii>tinDt
npau the riglit than upon the left side, hecauw thp current of blood
from the right venirii-le. through the auricle^ finds its way more rcadilj
into the reins of that aide.
Venous pulsation mar precede the inijmlse of Iho apei and the fir«t
■ound of the heurt, or may follow it In other words, it may be either
iresyBloIic or sistulic.
Prayftolie renons pulsation is dac to regurgitation of blood into the
Teinfl doriiig the conlniction of the tturiclei.
SyjftiiUc TYiious jmhn/iun is due to contraction of the right ventricle
with regitrgitiition of blood through the tricuspid valves into the auricle
and thence into ihe veins. When slight and tempomry, this is termed
relative venous pulsation; when permanent, it is known as absolute
Tenous pulsation. In order to be of value in the diagnoein of trioB«pid
irgit4itiou, it mnst be risible during both inspiration and expiration.
Pulsiitiou of The jugulur veins mcy be simplv (he transmitted impulw
from tlie carotids. In such cases, there will bo simply » lifting impuUer
instead of expiutsion of the blood-vessel, and the vein will not bo tortuous
as ID true venons pulsation.
Pulsation in the i-rinn o« the had' of the hnntls has been repeatedly
noticed by Peter, of Paris, in advanced consumptioti, and occasionally
in other affeotiuns. It is increased by compressing the wrist, and there-
fore must be jiropagated through the ciipilbiriofi from the left side of the
heart. It ma}' be mure readily seen tlmn felt.
Peter thinks this phenomenon due to pttndysiaof the muscular fibres
of the arterieit, through excess of carbonic Hcid in the blood. This r.ire
phenomenon, when seen, indicates the ne;ir approach of detith.
Collapse op the JcorLAH veins i^ said to occur with the systole
of the ventricles, in some cases, whore there is a^lutiuation of the two
sarfaceii of the jwricurdium.
The VESuis JiiitMrit, venous hum or bruit d« diablf is a con-
it humming sound frequently obtained over the jugular vein just
above the clnricle. or in the inter-cliivicular notch. It is gonemlly awto-
ciated with an arterial hcemic murmur. It occasionally occurs in healthy
persons, bat is most often found in those who arc anttmic, esiHKsially in
chlorotie women.
Thist sign is most apt to be hoiii;d when the patient is sitting or
standiug.and is usuiilly soft und humming in character, but occasionally
mnsical. hissing, or even loud and roaring
Interimtlent vt-nou* inm-mura syuchrununs with Ihe pulsations of the
heart, are among the rarest sigus of carduic diseasti. Tliey may be pro-
systolic, systolic, or diastolic. The presyjstolic murmurs arc beani only
when the patient is lying down, and must result from regurgitation of
blood from the right auricle into the open vein^t. The systolic murmur
3C8
r/Zi' HEART.
is usually heard moat distinctly just above the cUiTiclc on the right side.
It is due tu regurgitution from the right ventricle through the uuricle
and inUi the veins. Tlie diajitolic iiuiriiiur i6 i-xtreniely rare. It is said
to require, for its production, hypertrophy and dilatation ot the heart,
■with aneurism. These mnnnurs may be mistaken for arterial murniura.
They may be distinguished from the latter by slightly pressing on the
blood-Tessel, which will prevent the venous hum, but will not so affect
the arterial murmur.
THE SfPHTGMOGRAPH.
By the use of the sphygmograph we are enabled to obtain a graphic
statement of the condition of the circulatory system, written, as it were.
.©t-^l
Fid. 80,— Markt'i &>mt<]mooiui>s.
by the heart itself, ^len all the ponditiona are favorable, thie stated
nit^nt furnishes interesting information to physiologists; bnt so much
depends upon the Adjustment of the instrument, its proper working.
Ho. 37.- NiiNMAi. lUuuL Pcuu tTcimii).
and the pressure made upon the artery that np to the present time th
instrument has been of littlo clinical vahie. When all the conditions
are perfect, the tracings of the pulse may indic-ate: the time occupied
by the systole and the diastole of the heart;
the force of the heart's contraction; the resist-
ance to the onward eurrenl of blood, or its re-
gurgitation thruiigh the valves, and the tenaioa
of tiie arteries.
The tnicing is <:oinpo8ed of n series of cii rves,
each of which rej>reseTits a cArdinc pnl^uilion.
In the tracing of the normal radiid pulse as
shown ^Figfl. 37 and 38) each completed series
contiistH of a line of uscont, a summit, and
H line of descent. The line of ascent a 6
iu the normal condition is perpendiciiliir to
the plan*: of the base. It is produced an the blood is jin»pe1]ed into
urLi.!-), ..ud iudiuutett the force ot the heart by its height, aad
F»0. M.- StiiutAi. KJtiitAi. Vtuat,
Sixauc Trace Fnl^iuiki).
THE HPHYUmnitlAVU.
209
the rapidity of the current uf bloody by ita direction. When the blood
is retarded in its passage from the left ventricle into the aorta, as in
r». ».— Aownc UBtnuxnon (IUn>BX).
constriction at the aortic oritioc, this liiic will run more or less obliquelj
to the right, uccording t<* the anioiiiit of <»b!«trtu^tioii ^Kigs. .'{!• and 40).
hmm'-MM
fill, ki.— Auimc OBBTRCcnnx (FoncKj-
When the palsatioti is forcible, the altitude is much greater than when
it is weak. The summit b (Fig. 3T) iu the normal condition a mero
Flo. 41.— KmLU. RaoinuiiTATKiit.
point. Ir reached at the InHtaut when the artery in most ftilly distended,
immediately after tlie sv^tolo nf iho left vent rifle. Wlien the vessel ia
lUOffT Aeui.
■^^-i- J^
r^'V.rv-. p-^ f;^
LriT ABU.
Fio. 4J.-Aircpsna or Amjuoiijco Aoku (LooWki.
incomplcteiy tilled the sumiiiii is rounded, ur llie line of descent m«y
run almost horizonuUy for a sliort distance. Examples of this ar6
fonnd in mitml regiirgiiaiiuii (Fig. 41j. or m-Ik-u the iirtery is [»artiallj
<iCCluiieti by an anenri^m (Fi^. \'l), and whon frep regnr^iiation ihrongll
Via. 4L— AtMcna OanwcnoM .uto KaacioiTATiox iljuauty.
the aortic vrtkts [irerenis full distention of the wrU-rv {Figs. 43 and 44).
The line of descent b c (Fig. 37» corresponds to the period of nriprial
u
«10
THE HEART.
■jBtolo and cardiac diastole. The length of the lino indicutes the nipid-
itj of the heart's actiuii. When tli& liciirt \s, bcutiiig rapidly, the line i»
short; when buiitiiig bluwly, the line i.4 itorres[ioiidiiigly luuficthcncd. The
uiidulatiDu^ in this line (/ t'/(Fig. 3T) wtm known us the first, second,
and third secondary wave*. The firi»t secoudary wave tl is jtroduced by
the natural oontrnction of the artery. The second wave e corresponds
to the impulsu occasionally felt, which is termed dicrotivm. The third
>M\j\)\r\KN
Vlft. v.— iRoirimT HTmrncpar mox OBarHL'CTH)!! in tdb Artkrjdlss, dps to BaiOBT'a
liuiOBii or Tee Kidneys,
irarc / is not often jireitent. The depresaioii g murks the complete
closure of the aortio valves. A t<mall notch, in the line of descent is
often seen near the siiinniii.
Instead of having the form sliown in this figure, the line of descent
may rnn obliquely doM'uwaril in nearly a straight course. It may have
a generally convex or contavL- form, and the position of the' secondary
waves may vary in distance from the points b and e.
Couvfxily of the line of descent or small secondary waves (Fig. 45)
Ni^r^-vi "sjxKjvMx
Pio, 4C.— ^KXiLE I'l'lhe (FoarsR).
are due to increased arterial tension, as when there is incipient hyper-
trophy of the heart in consequence of contraction of the arterioles in
Bright's diaeuse.
Concavity of the line of descent is due to diminished arterial tension.
Sudden dropping of the line of descent indicutes aortic regurgitation
(Fig. 43).
In the normal tracing, the first secondary wave is found on a level
no. 47.— llrnui. CditmrKKmoii <Ha*ouo.
with the junction of the nnddle with the upper thinl of the line of
ascent; but with loss of elasticity of the artery it occurs nearer the sum-
mit, as in the senile pulse (Fig. 46). The same condition of the artery
is indicated by ubsouee of dierotism.
In mitral stenosis or constriction, the line of ascent is oblique, the
summit rounded, the line of descent prolonged, and the secondary wavea
are absent or indistinct.
TU£: tiPUyuMOUHAPH. 211
Froiti whit hfts Itcen aiid. we learii tlmt tbe sphygwographio tracing
is no: liiagDOstio of any ilUt;:i;3c, :lh will be at utice apjtarent in looking
ovor the tmciugs tiiken in dttTcrent am&i of tlie uinie disease (Figs. 39
and 40, 43 and 44); but the general ui»pourauce of tbo curve mjiy indi-
cate Hpeciul conditions. The spfniul points to notice In tbe tmciug ore:
FtB. 48.^liTau. CoMtunriDN aao Titiuir«np RronuinrATioM 4llATt>lK>.
the height and the obliquity of the line of aacent; the acutcness m
rotundity of the summit; the length of the line of descent; tbi- con-
Texity of the line of descent; and the nearness to the summit of the
eccondary waves.
Sanderson considered this instrument principally useful in detecting
Via. «.— llnwuBiCffir t»v Oilaiahok ur tuk iIuht iIIavi'Kxj. Uij[h uoe ol iiMat; ffud^te
MUuK of Uue of lieaoeut
iucreaeed arterial tensiou consequent upon hypertrophy of the left ven-
tricle (Fig. 45).
Francis £. An^tie thought that when the instrument worked per-
fectly, if .ncctimtely adjusted, it would tje of value in the diagnosis, not
only of commencing hypertrophy of tbe heart, but also of aortic regurgi-
tation (Fig. 43), and especially of aneurism of tbe aorta (Fig. 44),
CHAPTER XIII.
CARDIAC AND ARTERIAL DISEASES.
PERICARDITIS.
Pericarditis is an inflammation of the pericardium, acute, subacute,
or chronic, usually associated with myocarditis or endocarditis or both.
Anatomical and Pathological Characteristics. — Acute peri-
carditis, like inflammation of the pleura, is characterized by dryness
and reddening from hyperiemia of the subserous ve88el8,and by infiltration
and swelling of the serous and Subserous tissues. This is followed by
desquamation of the endothelium, loss of the normal glistening charac-
ter, and the appearance of a highly albuminous exudate upon the surface
of the membrane (pericarditis fibrinosa). This is usually localized at
first, but becomes more widely spread by the cardiac motion, and later
assumes a roughened, shaggy aspect (hairy heart). The inflammatory
lymph may cover the entire surface of the pericardium, but is apt to be
confined to the upper part.
In the acute form of the disease, serum is usually effused in small
amount. It sometimes becomes enclosed in. pockets formed by adhe-
sions, but is sooner or later absorbed. The opposite walls may become
permanently adherent by organization of the exudate into fibrous bands
which connect the two surfaces, or the cavity may be obliterated by
complete adhesion of the two surfaces. The pericardium itself is more
or lees thickened. In subacute inflammation, the effusion of serum be-
comes abundant (pericarditis serosa), its appearance and quality viiry.
ing with the amount of serum, fibrin/ red and white corpuscles present.
The pericardial sac, when greatly distended, assumes a pyramidal form, its
base downward, its apex at the base of the heart, and in enlarging it en-
croaches upon the lungs and diaphragm.
Milk Spots. — Frequently opaque, yellowish or gray raised and sharply
defined patches termed milk spots are found on the surface of the
pericardium, otherwise normal. They are due to hyperplasia and in-
creased density of its fibrous elements, and probably arise from friction
of an enlarged heart against neighboring parts (Hamilton, Text-Book
of Pathology, page 558). Extravasation of blood into the sac, with tlie
fibrin and serum, characterizes the hemorrhagic variety of pericarditis,
commonly associated with cancer scorbutus or purpura.
In the purulent form, or pericarditis purosa, bacteria are found in
the yellow or greenish fiuid which may have been purulent from the
first or have become so secondarily.
PERWAHDfTia.
sia
Ghrouic [lericanlitis la usually consecutive to the acute form, and
often pre8eut8, iu addition to the adhesion and flbroiia baiidH, extensive
thickening ami oalciireoua depusitii. Extenaion of the inflammation mny
result in myocanliti* with weakening, atrophy or fatty degeneration of
the heart muscle, followed by dilatation of the cavities. The walla
may undergo compensatory hypertrophy; extreme dilatation of limited
portions of the rentri<;nlar wall constituti'i^ what la turniiHl cardiac
luienrism.
Etiology. — Acute rheumatism is the moat common cause of peri-
carditis, as of endocarditis and myocarditis, hence their freijuent coei-
iateuce.
Other not infrequent antecedent disorders arc Bright's disease, alco-
holism, syphilis, tuberculosis, typhoid fever, and uoule infectious dis-
ease; also cancer, jmrpui-a, pernicious auitniio, and scorbutus, which
produce the hemorrhagic form. In early life the exanlltemata often
cause this affection. It may also arise from ]>enetrating wounds, severe
contusions, and by extension of inflammation from neighboring parts;
occasionally no cause can be detected.
iSYMrroMATOLOGY. — The affection may bo divided into three stag^]
similar to those of plenrisy — a dry stage, a stage of effusion, and a staj
of absorption.
The most common symptoms are : pain in the prscordial and epigai
trie regions, shooting to the shoulder, and augmented by movements
or by pressure; more or less fever, the temperature rising from one to
Four degrees; but in fatal cases sometimes fulling again shortly before
death; a small, wiry, irregular i)uldt>, running from !)() to ]'.!0 tx^ats piT
ruiniite; iwlema, dyBpntra, and ucfasjonally dysphagia. Any or all of
sliest) symptoms may lx> ahaient; usually there is u history of coincideut
or preceding rheumatism.
The essential fiffu? iu the order of their occurrence are: irritablttj
ttction of the heai-t; friction fremitus and murmur; increased cardiaa^
dulness, ultimately obtaiued over a triangular area extending consid-
erably to the left of the apex; feebleness of the heart's impulse and
vtunds, both of which are iuteusified wheu the patieut leans well for-
ward.
In thsjirsl W/i,^, upon inspection and palpation, we discover nothing
except an irritable action of the heart, with slightly increased force, and>
in the latter part of the first stage, friction fremitus.
Upon auscultation, agnizing friction sound may sometimes be heard
very early in the disease along the left Imrder of the sternum, usually
most distinct at the fourth costo-stemal junction. This sound nwy be
distinguished from endocardial murmurs by its rhythm and seat, and by
the fa(!t thnt its intensity is ineroasod by pressure itnd by a full inspira-
tion. In the latter part of this stiigo. friction soimdn of a hamher qual-
ity may be obtained. Those may be either feeble or very intense.
In th$ sccont/ stage of the disease, the signs vary somewhat with the
amount of effusion.
On inspection in children uud vouug adults, with elastic chest valli,
bulging of the pr*GordJal region, extending from the second to the sixth
rib, may bo noticed. Tlie respiratory movements of the left lung are
somcwliat impeded, and the apex beat is carried npwnrd and to the
left into the fourtli intercostal space.
Palpation coutirnis the signs obtained by inspection. The impulse
of the heart is feeble, especially xvhen the patient is lying njwn his baolt;
bat when ho is leaning forward, it ig mucli nioro fon-ibh- tlwn in either
the erect or ihe recumbent position. This Is an important fact in the
diagnosis. When the pericardium is greatly distendeil, the diaphragm
may be forced downward, so as to cause bulging in the epigsistric region.
Undnlntion of the whole priecordial region, due to the action of the
heart upon tlie surrounding fluid, may fi-ef|ucutly bo felt, and occasion-
ally fluctuation can be detected.
Upon percussion, both the superficial and the deep-seated areas of
duluesB lire increased. At first the latter is increased in its vertical
diiimeier, und dulness is noticeable principally above the base of the
heart in the second intercostal space, where the sernm first collects.
Tins is esi>ecjany mar]ce<l when the person is in the recumbent posture.
Von Stoffella. of Vicouu, hits noticed in tiK-ve caaos a duloe»s over the base of
the heart, in tvciit«lK--iicy change to r«;»unaiicc when the jiatieiit &its up (Internti-
Uotiale klinifiche Ftundgchau, FcIj., If-W).
^^ hen the effusion becomes somewhat greater, aemm collects at the
lower part of the pericardinl sac; dulness is then increased in the trans-
verse diameter at Iht- level of the apex, and thy area of dulncas becomes
triangukr with it« base ilownward, corresitondiug to the form of the
pericardium. Thisi trianguhir sbape remains, however great the effu-
sion may be. In extensive efTusion, the duluess nuiy extend from the
first rib above to the resonance of the stomach belnw, and laterally from
Uie right nipple to a point about two inches beyond the left nipple.
E. Pins. ID n-ell-marict-d cases, lius fretnienlly olies47rv<xl, wht'o Ihe patient is
recurabcDl or sitting, a small afoa on tlte left Ride |Hiatt'riorly. ovt>r whk'h th*?re
is (]uIq,'.s« with broDrhial hi-c-^thing- and inoi'eaAed vocal resonance, but no rdles
or friction sounds ( W'ienrr iMdizininche Pi'tim, Marvh. 1990).
This IS mo«t marked in a circular space the size of a silver dollar, extcodinp
*rom a p.ijnt at>oiit three flng«ra' breadth below tb« an^eofthc scapula to withia
two of the lower marsrin of the lung*. If tlw patient Iwnds forward, and e>ip«Hially
it Ite aB^nm"*. the kDf«>elbow pojilkire, diilncM largely diitappears. vesitrulor i-wo-
&an^-« taking- the plai-* of abnormal sounds. These plienomena aiv prolwibly due
to prvssurv upon the lung, which i» relieved by a furvranl displacement inotdenl
to Chang* in p^wuure.
The position of the apex beat having been determined by palpation
ftttscuttationr the exisleuee ^^ dulne«s to the left of (bis point and
pEuiLAHDiTia. ai5
1>elow it becomes an important element in distinguishing pericardilia
from euhirgfiiieiit of the lieiirt: in the hittor the apci beat corresponds
very nearly to the limit of dulnesH on tlie left.
Ill tin.' difffi-pinia] diii^iiosisof p»Trciii-(tial effusions. T. M. Rotcti, uf Boston,
cdamderft an iirt>:i. or HntnesA in the fifth intorx--OKtih.l space of X\\& rii^tit side, about
an ioch froin the border of the st«raum, a very importnnt si^n.
The friction sounds nsuuUj lieard on »uacalt8tion in the first stage-
generally disappear when plTnsion occurB, in consequence of the separa-
tion of thi^ jiericardial surfaces; yet they may remain at the base of the
heart throughout the disease. In the second stage, the heart sounda
are feeble and distant, but may be rendered more distinct by cnusing
the patient to lean well forward; sometimes friction sounds may be
reproduced by this means.
Pulmonary sounds are not heard over the area of flatness in the
prsecordial region.
//( the third gtntfr. the signs of tlie Re<H)nd stage disappear, the bulging
gradually diminishes, the apex beat becomes more and more perceptible
and returns to its normal position; tliero is a gradual diminution in the
area of dulness: friction tioundH may return and remain until resfdutiuD
has taken place, or until the two t-urfaces of the pericardium have be-
come adherent: the respinitory sounds may again be heard in the prse-
ootdia.
Exceptional. — Occ&KJonaUy f rictioa sounds cnnlinue lon(( after apparent re-
covery.
We have no means of determining when adhesions of the pericardial
surface have taken |dace unless the extenial layer of the sac has also
adhered to tlie chest walls. When this has occurred, the intercostal
spaces are seen to be depressed with each systole of the ventricles, and
ultimately pemianent depression of the pnecordial region may take
place. In some cases, when the heart is considerably hypcrtrophicd and
diluted, dragging in of the epigastric region is caused by each pulsation
«f the heart.
l>i.ioNosi8.— Pericarditis is liable to be mistaken for pleurisy or en-
docarditis or for mediastinal tumors.
The first stage ol jiUuriJty causes pain and friction sounds similar to>
those of pericarditis, and. if it happen to involve only the anterior por-
tion of the left pleura, considerable care will be necessary to avoid an
error in diagnosis. The distinctive features between the two affectiona
are presented in the following table:
PeBICARDITIS. PUECRIST.
Biitory.
Commonly of rheumatic origin. Non-rheumatic.
2111
CARDIAC AJfJ) AUTEHIAL DlHEAtiEti.
PEMCJUtDms.
Pleurisy.
Symptom*,
Pain UI1UEII7 iQ the pnecordial re- Paio usually in th« infiu-udlluT'
(ion. region.
Sitpt*.
Friction soundi confined to the re-
poQ of the heart and syochroQCUK
with its muvements. und not affected
by th« respiratory uoveiueots.
Friction sounds, thoug'h they may
be confined to the prscordtal region,
are >^n(.Tally heard farther to the left.
They are not synchronous with the
puUatioDs of the heart, but occur with
the respiratory nioveineDt«, nod al-
most invariably oease when respira-
tion !■ suspended.
Symptoms due to preamre by mediastinal tumor/t on vessels or norveft
or bronchi are prominent; not so iu pericarditis. There is also accom-
panying enlargement of the glands of the neck, and absence of some of
the symptoms uud signs of inHammution whirh characterize pericarditis.
Malignant growths also cause marked and peculiar cachexia and have no
itory of rhenmati»m.
For the distinctive features between endocarditia and inflammatioD
of the pericardium, see endocarditis.
Pboososis. — Acute rheumatic pericarditis usually ends in resolution
vithin three weeks, very rarely iu doath. It niay^ however, become sub-
acute or chronic
Adhesive obliteration of the pericardial sac tends to weaken the
heart muscles, and, if associated with a crippled condition of the valves^
18 unfavorable; usually such adhesions result in cardiac hypertrophy.
Slight adhesions always remain but are of little significance.
Fluid effusion is absorbed in most cases in ten to tifteen days, but
largo pericardial eflnsion may cause sudden deaths or by long-continued
embarrasjimcnt of the heart's activity give rise to atrophy or fatty de-
generation and consequoDt danger of sudden death from pulmouury
cedema or cardiac imnilysis on slight over>exertion. Purulent and hem-
orrhage pericarditis are always dangerous. Pericarditis accompanying
nephritis is serious.
Tbeatment.— With the first symptoms of pericarditis, the patient
should be put to bed, to remain absolutely quiet until convnlescenco
has been established. Hot poultices should be kept constantly applied
to the whole anterior surface of the Cliesl. Opiates should be given io
just sufficient quantity to control pain. Depressing measures of uU
kinds must be avoided.
If the cause of the disease can be ascertained, it should be removed-
Bbenmatism will call for alkalies, guaiacum, or small doses of colclii-
cum. The latter must not be given in doses sufficient to derange diges-
tion or cause depression. Salicylic acid should not be given on account
i
PERICARPJTIS.
21 :
of its depressing cfiEecU on the iie:irt, but the salicylates arc loss objec-
tiooKble. If this affectiun follow depressing fevers, the supporting
mcttsuros which uro required for the latter should be more uiwiduuusly
applied. If it result from Bright's disease, sulinc cathurtic;^ \ix mod-
«nite doaos, diaphoretics, especially viipor or hot-air baths, dry cupping
orer the loins, and small doses of digitulia will be indicated. In most
cases, iron is a ueeessary remedy, and quinine vill nsually be bcuellciul in
tuuiutuiuiug streugth.
The diet should be eoueeutnited and nutritious, and, so far as possi-
ble, fluids should be avoided. If effusion takes place, its removal will
be favored more by the mean« caIculat<HJ to maintain the strength than
by the various drastic cathartics so often prescribed. In many cju'tee,
Kood effects will follow the judicious use of hot-air baths, to promote
diaphoresis; or of potnssiam iodide, bitartrate, or acetate, or fluid extract
&f scopariue, to cause diuresis; or of fluid extract of euonymus or small
doses of elatcrium, to induce catharsis.
If pressure on the heart from pericardial effusiou becomea excessive,
the question of aspiration will suggeat itsiilf. I would recommend this
operation in casea where heart failure seems imminent, but it should bft
held as a last resort.
During convalescence from this disease, the greatest care Is necessary
for ten or twelve weeks to avoid expoeure or active exercise. The heart
is always weakened by such an attack, and there is a tendency to dilata-
tion, which should be guarded against by small doses of digitalis, strych-
niue, and arsenious acid. To promote strength still further, we should
make free use of iron and good diet. The patient should avoid every-
thing which would cause the heart extra labor.
If acnto inflammation of the pericardium doea not terminate in re-
covery within three weeks, the disease is termed chronic perirardiliii.
This condition may be characterized by a collection of fluid in the peri-
cardiuni or by adtieaion of the two surfaces of this sac. If the fluid be-
comea purulent it is termed pyo- pericardium.
In the former case, conntcr-irritation. diuretics, and ottthartice are
indicated: but in both caises, iron and cardiac tonics must bo constantly
employed, and excessive action is to Iw avoided. If the effusion be piirii-
leutfOr if a nou>purulent accumulation be sufficient to cause great irrogn-
larity of the heart with muffling of its sounds, or to throaton collapse.'
aspiration shonld be performed, prcfenibly in tht.- fifth intercostal space,
two and a quarter inches to the left of the meso-sternal line, i>., near
the junction of the sixth costal curtilage with the rib. Some recom-
lueud a point between the left side of the eusiform cartilage and the
luljaceut border of the costal cartilages. In pyo-pericardium. aspiration
may be rei)e]ited aeveral times, but with small hoi>c of permanent relief.
Incision, followed by antiseptic irrigation and temporar)' drainage, has
been recommended.
^18
VARDIAC AND AHTERIAL DISKASES.
PNElTMO-HYDROPERirARDIUM.
Pneumo-hydropericarJinm is one of ilie nirMt of cardiac ilisoaaes.
As the name indirate^, it is a condition in which air or gas and fluid
occupy the pericar*iial sac.
Etiology, — Air or gne may enter the pericardial Rae througli a pen-
etrating wonnd or llatulous tract couimunlattiug willi the irat-hea,
bronchi, leKojihagiiin, stumoch. or possibly the inlestiiiui}; ur ga^ may in
rare instjtncf.s rfsiilt from denonijiosition of fluid within the sjit; [Da
CoBta, Metlical Diagnosis; ako Hainilion, Text-Book of Pathology).
SVMPixiMATOLuciy. — The eswntial sigHs of the affection are tympanitic
reeon&iu'e over the air, ami Hatneae over the Jhiid, diaiigiug as the patient
shifts from recumbency to the sitting posture; and, on auscultation, a
spladhiugKonnd synchronous with the pulsation of the heju-t and entirely
iude[>eiidcnt of the respiratory moremeutfi. The heart sounds have a
metallit? quality. The syniplofua are similar to those of ppricarditia.
PiAWXosis. — Pneumo-hydrotlxjrax and wrtain conditions of the
stomach might possibly bo mistaken forpnenmo-hydropericardinni; hrit
there is no danger of an error in diagtiosis if wo rememher that the
signs of pneumo-hydrothorax are foun^l on the side and posteriorly; and
that the splashing sotutds sometimes ^iroduced within the stomach aro
heiird below the prweordial region.
I'koosiisis Axn Tkeatmknt. — The casfs are usually speedily fatal.
"When they are nrolonged. tho treatment must be expecUint.
HYDROPEKICARDUrM.
nydro])erieardium is a tmnstuhiiion ur non-Inflammatory efTusion
into the pericardial sac similar to that of hydrothorax.
Anatomical and Patuological Chailvcteristics.— The liquid is
of a pule yellow or greenish color, alkaline reaction, ealtish taste, is not
spontaneously coagulable, ami lias a specific gravity of 1005 to 1024.
The c|uantitr varies from a few ounces to several pounds; the peri-
cardium in the latter case being markedly distended and presenting the
appennince of an obliiso cone with base downward.
Long-continued or excessive pressure of this effusion greatly impeiles
cardiac action, and the heart mu.tcle weakens and degenerates.
ErioLfuiy. — llydropericardium ugually accompanies dropsical effu-
sion into the other closed cavities, dependent upon heart, renal, or pul-
monary disease; rarely it is duo to an altered condition of the blood ac-
companying the cancerous and other grave cachexia?.
Stmptomatolohy. — The symptoms and signs are simihir to thoaa
attending the efTnsion of pericanlitis, hut without friction sonnds or
other svmptoms of inHnmmation.
DlAUKmsltj. — The diagnosis depends on the history and the manifesto-
ACUTE ESDOL'ARDiTlS. t\%
tioos of the cuiaatirc discus^.', with iiicroascd disturbuico of the heart,
enlarged area of cardiac duliiosd, and signs peculiar to the presence of
fluid in the pericardium. Exploratory aspiration may be em]ik>yed if
necfssary.
Pbuusosis. — If the efiFnsion ia large iu amount and accompnnics vtU-
vuhir lesions, it may ranse sndden death from preaRnrt* npon an ulrcmly
embarrassed heart. Treatment should be chiefly directed to the uuutoitive
diBease, from which death usually occurs.
ACUTE ENDOCARDITia
Inflammation of the lining membrane of the heart may bo acnto or
chronic The former ie nsnally n non-alcerative affection the result of
rheumatism, but an ulcerative form also occurs us the product of septic
infeiHion. It has been taHousIv termed ulcerative, iufectionsr septic,
and by Virchuw, malignant endocarditis. Chronic endocarditis may be
«uch from the beginning, but it usually follows the simple acute form
of the disease.
ASAToMicAi. AX» pATHoi.rtoirAi. Chakaoteristics. — Normally tho
endowirdiuni from within outward eonsifits of a single layer of jtolygonal
endothelial cells, a thin elastic basement membniue, and a layer of nucle-
ated white flbroiKi tissue joinetl to the cardiac muscular structure by
looae arevhir tissue. The vulvcs of the heart are reduidicjitiiins of the
endocardium, thoae at the aoriculo-Tentrinular septum containing also
a few striate^l mnscnliir fibres. Blood -vess^'ls ramify in the loose areolar
tii^sue, but nowhere penetrate the three layers of the endocardium; these,
like the cornea, receive nourishment from the lymphatic siiaoes.
A few veflseU accompaay tbe muscular tJbre« of the mitral and tricuspid
Talve«.
In the early stage of (trutf pndotfirfUih, the endocardium appears
slightly opar|ue or distinctly cloudy; later it is roughened, but redness ia
rarely viaiblo after death. Tho i>iib-eudonirdial mpilliiry plexus is in-
jecte*!. The lymidi b|hiccb are crowded with inflammatory proiluels. The
fibrous lityer, chiefly, but also the areolar tissue. benomcH inflltrated with
round cells; as these proliferate, cloudy swelluig occurs in the nativu
fibrous celts, which appear, as the disease advances (Hamilton, Text-
Book of Pathology) to become homogeneous and to be in great part
absorbed. The aUccted membrane becomes thickened; proliferation of
cells and tlieir irregular accumulation gradually forces the endothelium
and bfisement structure Twfore it, iiroducing minute papillnry i>rojec(ions.
Swelling aud consequent distention Anally retiiilt in destruction of tfas
bas«raeut layer, and endothelial desquamation at the summits of thn
projections; upon these flbrin is deposited from the blood current. As
the growth thus increjises by proliferation witjiin and fibrinnus accretioo
vithout, it takes an irregnlar verrucous form, spreading at its summit
220
CAHDTAr AITD ARTERFAL DtSEASEH.
snd constricted at its bnae. These vegetations diBvctIoj> most luxuriantly
upon the valvular margins whore most friction occurs, especially along
the ventricular margin of the aortic valve. They niuy attain the size of
tt pea. Thi« j>roces$ is attended by no vu£cuIarizatiou until far advanced,
when the veii&els ut the base extend for a short distance into the vege-
tation (Plamilton, hn: cit.).
Etiiiuxiy. — Acute endocarditis occnrs most frequently in those
under thirty years of age, and is most often the result of acute rheuma-
tism. It also occurs in those suffering from gout, ditibcteit, uleoliulieni,
Brighfs diseast>, scarlet fevtr. typhoid fL-ver. diphtheria, pneumonia,
syphilis, and tuberculosis; chorea appears to be an ucc-asional cause.
SYMi*T(tMAT(ir-(»(iY. — The usual sjTiiptomH are: a sense of UTiea^iness
about the heiirt, fever, a short cough, dyspnce-a, and an anxious counte-
nance,
The tompenitnre rarely reaches 103^° F. In some cases vertigo and
other cerebral symptoms may occur, or gastric disturbance, but none of
these arc constant features.
Among tlio ,iit/uji, inspection communly reveiila turgeacence and an
anxious expression of the face. Thu cardiac impulse may \*e visible over
an enlargwl area.
In the iM'ginning, the pulsations are apt to be forcible and irregular,
vith a corresponding pulse. An endocardial thrill is sometimes detected
by pulpiition.
Percussion gives no increase of dulness in uncomplicated cases.
Auscultation usually reveals a soft, systolic 'murmur, due to endo-
cardial or valvular thickening or roughening; these, however, may be
present without u murmur. Often the 9e(tond sound at the base w
doubled from inco-ordinated action of the two sides of the heart. Mur-
jours may occur from lesiooA at any of the valves, but are most frequently
heard at the apex.
DiAo>*0!<i8. — When some of the above symptoms appear in the course
of any of the cjiusative diseases, and these signs are obtained over n.
heart the sounds of which were formerly normal, we may reasonably
suspect inllammation of the endocardium.
Acute endocarditis, when occurring independent of jiericardiiU., ia
liable to be mistaken for the latter disease. Pericarditis may be dis-
tinguished from uncomplicated inHumniation of the endocardinm by
the quality, rhythm and seat of the murmur.
Acute ZKDOf:ABi>rns.
Pkricarditu.
Uurinur blowing.
^uoJffy of murmur.
Di-stinctly riibbmfj^ or rrictioo itoiinc
tv-utid-Iro KliuHliii;; ; iucreaaed in m-
tetiKJly un tlie imtieol's bmidiDK tur-
wunl ;uitl lukiu;; u deep iiuipiruUoUt
also by pressure ot stethoscope.
ACUTE ENVOCAHJJIT/S.
221
Acute bsdocaboitih.
PKRICAJlUrnH.
Hhs/thm of murmur.
Murmur not exactlj* synchronotui
witd th-i valvular boiiuos. ac;! ort4;n
<M.'cup« dtinii^ both the systole nml the
iJioAtolc o( the heart ; is not cua^ilant.
IStinnur synchronous with the (h'»t
Bound ot the heaii, :ii)(l ilcwa tiol <.h:cui-
witb tbe diustote tmlesti r<?^'urt;ilation
takes placf.' throuf^h the uurtic! orpiil-
moQar>' semilunar voJi'cs.
Stat of miirmur,
Uurmurloudestatapcxof honri.and Murniiir heard loudciiL at bord(!r of
djffiKed b«yond the prs&cordia. Rtcmiim nftir the Tonrth or Hfth Mt
co«tal ctkrtilage. Limited to prse-
oordiu.
PnooNosis. — Acute rheumatic endocarditia naunlly runs its course m
two to four weeks, and is seldom fjitJiI unless coniplirated with other
disonlere. l.*ne iittai'k, however, renders the part mora viihiemblu tt*
sabecqueut disense. In fiivonible aises, endocardial innrmure deprewsw
or entirely disHppoar during eouvnlesoeiico, but permanent v:ilvular
leaionH remain in about twenty-Sve jwr L-ent of all eases of acute mitral
eudoL-arditis (IjOomis' Practical Medicine). Theae, e^iwciully in chil-
dren, are usually rapidly compensated for by cardiac liyi>ortrophy.
These permanent lesions otvan cannot be detected until contraolion of
tlie influnimatory products takes plac^, some veeka or months after
subsidence of the acute iuMammation.
The pro^osia is rendered correspondingly grave by marked antece-
dent de]ireciation of peueral health: by the coexistence of disease of the
-verioardium or heart muscle; by an inlercurrence of pulmonary an<l other
dis<*a8es:by the development of typhoid symptoms; or the presence of signs
and symptoms indicative of cerebral, splenic, hepatic, or renal embolism.
Tkeatmf.nt.— Endocarditis is nearly always the result of rheuma-
tism, chorea, pya-inia. or the acute esantheniatous fevers. The proper
trentnipnt for tht-^e affnrtions is that which should in the wain he em
ployed iu the secondnry heart disease.
Perfect rjniet should he maintained, not only during the active stage,
bat also during the convalescence.
In the very inception of the attack^ a full dose of quinine will occa-
sionally cut it phort. [juter, this remedy and iron are very useful. Dur-
ing the treaimont, the patient should be keja iu a warm room ut TO*^ to
75° F., and the chest should be specially guarded from exposure.
Sihsi^tn re^-oTHmends a liniment of tincture of Iwlladonna and chloro-
form sprinkled <in ootton-wool and kept applie<l to the prjpoordial region.
Great depreesion caIIs for alcoholic stimulants and nux vomica or digi-
talis The latter in modenttc doses, combined with quinine, arseniona
acid, and iron, is needed during convalescence, but oaro should be taken
not to overstiniulatc the heart.
£irogjftV>na/— Nearly all cas«s of endocarditis ar« a«flociat«d with or follow
222
CARDIAC AND ARTERIAL DISEASES.
otljt>r ili»va.se!«, uikI ure uUendetl by syiiiptoiiiii which demnnd supporiiiig treat-
ment : IhiI nuw utitl then one ucctirs without appnrent cause in » robust |>orson
of full liahit In such wisp. genei-.il hletnliDg wotiW uudoubledly prove henefl-
oiiil hv i-elieviii}' lh« over-hurdened heart.
ULCERATIVE ENDOCARDITIS.
Ulceraiive ciicIncartlitiB is a destructive hilliiiTitmitiou of llio cudocAr-
ilium duo t<i iufei.'tinii, urtuully running a rapid ami fatJil couriw. Kither
or both sidiis uf the heart miu he its seat, ttut most frequeutlv the left \&
involved. On llie surface cf the otidncardiiuii, cliiefly on the rulrcs,
may 1>b found gray fleahy vegetutioua springing from the i^ub-siToiis
tissue, frequently u^risociatud with greenish-colored dots and coutaining
perhaih) minute jiurtilcnt cavities.
Micro-orgHiiiania are always jireKent, pyogenic bacteria, piieuniococci,
or tulwrcle liacilli domiahhig with others of a hnrndess nature. Ulcers
may c(Mixist with vegetJiti<uiB or they may mark the sit* of those whiith
have disuppearetl; their edges are irregular autl thickened, aud their
floors purulent; )>erfoi'ation of tho valves is a cummon result. Not in -
freiiuenlly these uli:ers are the ftourtie of septic omhnlisni indistaiitorgans.
Etioi.i>ov. — I'IcerativR fnilncaniitis may t>e paiiwil hy vurioiis putho-
getiiu bacteria which gain entrauf^e to tlie circulation in the ditTereut
speciiic affections mentioned when speaking of the etiology and treat-
ment of acute endocarditis, but most ufteu during pywmia; occasionaUy
it arises idiopathically.
SYMl'ToMATtiLOdY. — The aftcctiou often lias symptoms and signs
similar to tho.^e of myocarditis.
'I'lic usual pyijipt-jins may he those of severe enteric fever, the attack
being often usliered in by a chill, followed by prostration, dtdirium, or
comii. The leinpcnituro usually ranges liigher than normal, from two
ttt four degrees I*. The tongue is often dry and bro^ii; vomiting and
di.-rrhuL'a are common. The pulse U nii>id and iiTcgular, and sometimes
there arc pric<Hirdiut pains and palpitatiou uf the heart, with dyspiiom
and occasionally articular pains.
The evidences of embolism are often seen.
Sometimes no idgns whatever are present, in other instances auscul-
tation reveals the signs of valvular disease, and repeated oxamiuatiun
may show rapidly progressing valvular changes.
Diagnosis. — The absonco of cardiac Bymptouis in mauy cases is
likely to mislead the physician into the diagnosis of iuteruittent or
lyphoid fever, nr of pyajmiu; but if attention is directed to the heart,
and it is kno«*n to have been previously healthy, the oocnirence of a
systolic mitral or tricnspid murmur, with the symptoms jost mentioned,
renders the diagnosis reasonably certain.
Piioososis.— The prognosis is always grave, the disease usually ter-
minating in death from the primary septic condition or from secondary
pyfttmic itivolvcmcnt of the bruin, kidneys, spleen, liver, or other orgaud.
VUBOmC EyDOtARDlTia.
m
evidenced by hemiplegia or alt)uminuriii or sudden enlargement oud
teudcniess of the spleen or liver.
TliEATMEST. — Ulcerative eiidooHrditia rMulta from ]>y»mi:i or sepli-
Ctt^niia, and consequently requires the mcHt viguruua supporting mea-
sures. Large doses of quinine and aUrolioUo stiinulantit are indleuted.
Sanaoni recom iiends sodiani RuljihiM-urbolutf' in thirtr-gniin doses*
with inunctions of curboliztd uil {Lomlxu Proiht inner, .Iiir:., J881t).
CHRONIC E.NIKX ARDITIS-VALVL'LAR DI*?EAt^E OF THE HEART.
In chronic endocarditis the non-nloerati\'e inflainnmliou, which ia
lesBJioute from tlu* tttart tliiin in the acute disease, Wcomer- jirutracteil,
cell intiltnitiou and hyperplasia Iniing followed by organisation und
marked contraction, uspeeially lit the haa« of the vegetation. The
thickened tissues cunimuuly become atheromatous in patches, these iti
turn undergoing colcilioilion, us seen in the yellow areas aud nodules of
concretion scattered over the surface. Fre«(Ueutly it is ccincident with
a like condition in thb walls of the aorta. Indolent ulcere fometime»
exist where calcareous scales have been itetached or where an atheroma-
tous patch has softened. These changes may tjccur on any part of the
eudociirdiutn, but the h>L-aI efTeets of chronic endocarditis are motiit dis-
tinctly recorded in the valves.
Following the slight thickening of the acnt* stage, there is grenl^^r''
hyjterplasia of the areolar and white Hhrous tisane, esitecially along tlie
edges of the valves. Organization with inevitable retnictioii jirodnco*
incOTUpptcnce of the valves. Xarrowing of the aortic orifice may \i\^n
result from the occurrence of the same proc*;ss in tlie fibrous ring which
normally exists at the ha^e of the vaKej* at the cardio-nortic junclion.
Complete culciticatiou of this ring is an occasional result.
Atheroma and ealcurcons depcisit* also occnr in the valves.
Adhesions mav form between the valves! and the nortie wall. VegC'
tutions often fringe their ventricular margin. Ulcen.tion prone to fn).
low fibrosis und atheroma may perforate the vnlTeentirely. or from jniitial
destruction give rise to valvular aneurism. The mitral valves are sub-
ject to similar changes, and, as the free edges of the valves are continu-
ous, general contraction narrows the orifice in marked cases In a mere
alit like a buttonhole.
The chordivtendinew are involved in the process of thickening and re-
traction, and roar l>ecDme agglutinated into one or more short, fibrous
bands which draw down the cuntructoil mitral margin, converting the
valves into a funnel-shaped prnje«:tion into the ventricle.
The tricuspid valve is seldom so affected. Aortic regurgitation or
obatruction produces dilatation of the left ventricle followed in favora-
ble cases by compensatory hypertrophy of its walls. Like conditions of
the mitral orifice produce like efTects in the left auricle.
224 CARDIAC AND ARTERIAL DISEASES.
Theoretically, similar affections at the tricuspid and pulmonary valves
produce corresponding changes in the cavities and walls of the right
heart; but practically tricuspid stenosis, and stenosis and regurgitation
at the pulmonary valves, are exceedingly rare. Tricuspid regurgitation,
with dilatation and hypertrophy of the right heart, is usually the result;
of serious lesions of the left heart.
■ Chronic valvular lesions, though sometimes occurring alone are apt
to produce disease of other organs, by obstructing the circulation.
In the lungs, we find congestion, oedema, bronchitis, apoplexy, brown
induration, and lobar pneumonia. The kidneys may become congested
and enliirged, and are not infrequently the seat of embolic infarcts or mul-
tiple abscesses. The same is true of the spleen. Continuous engorgement
may cause parenchymatous, fatty, or atrophic degeneration of the liver,
or chronic catarrh of the gastro-intestinal mucous membrane; and
occasionally embolism or apoplectic extravasation may take place in the
brain.
Endocarditis may produce at the orifices of the heart either obstruc-
tion or insufficiency of the valves.
Stenosis or stricture may be the result of thickening of the valves
from the presence of calcareous deposit, atheromatous or fibroid tissue,
or extensive vegetations ; or of adhesions between the valves, or of indura-
tion, hyperpJasia, and contraction of the margins of the openings. Rarely
it is a congenital condition.
Incompetency may be due to perforation, tearing, or inflammatory re-
traction of the valves or to rigidity from calcareous deposit; to rupture
or abnormal shortening or lengthening of the chordae tendinete, dilata-
tion of the ventricle without compensatory lengthening of the chords and
their muscles; and to spasm of the columnfe carueae.
Etiology. — Chronic endocarditis is more frequent in men than in
women. It usually follows the acute non-ulcerative form of the disease,
but niiiy be chronic from tlie beginning, especially when associated with
chronic alcoholism, rheumatism, gout, or old age.
Symi'T0MAT0LO{4Y. — Chronic endocarditis sooner or later causes ir-
regularity in the action of the heart, lividity of the lips, oedema, and
dyspnu'a on exertion. Dizziness and vertigo with facial pallor and
sometimes syncope arise from cerebral anemia; sudden loss of conscious-
ness with subsequent paraplegia may arise from cerebral embolism or
apoplexy. Headache, tinnitus aurium and muscae volitantes are com-
monly due to cerebral congestion.
Often cardiac pains occur, frequently shooting to the left shoulder
and down the arm. Sometimes tliere is true angina pectoris. Cardiac
dyspno'a and palpitation are common. The pulse may be rapid, weak,
irregular, intermittent, small, wiry, or full and compressible. The so-
called water-hammer, collapsing, jerking or piston pulse is charac-
teristic of aortic regurgitation. The pulse in other valvular lesions is
CHnomC ENDOCARDITIS.
236
not diftgoostic, bnt indicatca the force of the he:'.rt, the tone of the ves-
sels, and the condition of the circDiation.
If the piihnoiiftiy eiroul.itioh bt* einbarrossed, ciug'i, dysjincwi, oppri'S-
cioti.aiid proIustuexpeL'turutioii lire jirt>»eiit,('3pecinlty on exortioD. Blood-
sUtiiifd iij)utuiu is cuiuiuuii, mid hiemoptysis not infre<|Uent.
CiuueHil vuiiouu cugorgemeut its uiuiiifeated by cyanosis, tenderuesB
and onlurgcment of the liver aud upleen, aiiorexiii, iiuusea and vomitirtg,
and eouietirucs jaundice; also by nlhnminuriA with casts, scanty and oc-
casionally bltxjdtitiiiued urinv, h. ricking cedema commencing in the
lover liuibti, and elTusIuu intu the serous cavities.
The sigus require careful discrimiuutiun. Aortic obgtruction, com-
monly maiiifcHting the ftymptonia of cerebml aniemia, \i charucterized by
ft luird. wiry, but regular pnlse; enlargenu'nt uf the left heart ; ii systolic
murmur with the first sound usually hai'sh, londest at the right seeoiul
intercostal space, occiu^iomilly at the left or over the upper part of Uie
sternum. This murmur is conveyed into the vessels of the neck, islieard
behind, and toward the apex but with diminichcd intensity, and is not
tnmsmitted to the left of the aj>cx. The pulmonic second sound is feeble.
Aortic retjurffitation exhibits no peculiar early symptoms. It istOiar-
aet<eri£i>d by a full, strung, but collapsing pulse. Tin* h'ft lieart isetilargbd;
the i.iirolidd beat forcibly, aud distinct capillary pulsatiuu may souictimt^a
be seen beneaih the finger-nails aud the mucous membrane of the lips, aud
at ihtr fundus uf the eye. It muses a diastolic munnur, soft and blun ing,
occurring with or fnllowing the second sound, which is must distinct over
the lower part of the sternum, bnt is sometimes beard behind aud in the
arteried of the ntM^k. It is more widoly diffused than any other murmur.
.l/iVrtr/r'^^/rHtyiOK causes marked pulmonary symptoms and signs, and
is acconipiiuied by a soft, small pulse aud a purring thrill most distinct at
the apex: by left auricular enlargement, sometimes but not usually elic-
ited by percussion; and by the mitnil presyslolir murmur preceding the
first sound already noted as representetl by vricaliztng the symbols, R rr b
or V o 0 t. It is apt to be of longer duration than other murmurs. Its
maximum intensity is about half an inch above the apex beat, it is loader
when the patii^nt is erect, is not transmitted to the loft of the apex boat,
2B not ht<ard behind, nor in the arteries of the neck.
Mitral rsgnrgitatioH commonly prodncefl the symptoms of pulmonary,
hepatir, and renal congestion, and is accompanied by a eomprcssibla
and irregular pulse and enlargement of the left heart. The murmur
pro<iurf>d is soft and blowing: it is systolic, accompanying or replacing tha
firstst^mnd; and is herird bmd^st at the ajiex. It is trmsmitted to the
left, and is often beard behind beside the sixth and seventh dorsal verte-
br» opposite the mitral area in fronL It ii not prcpagsieU into the
arteriea of the neck. The pulmonic second sound is intensified.
TrieuHjtiil ref/urt/itatiou.MBU&Uy secondary to Icfiiims of the left heart
or to puImon(ir)'disea»e8,and when marked, producing symptoms of paa-
tS
^25
CAKDfAC AND AHTEHtAL DISEASES.
aive congestiou of tlie brain, an<l of the liver and other uhdominni nr-
gatiB, exhibits the following signs; piilftatian of the jugulars, enlnrgoineat
of the right heart, a conii>amti\*ely feeble Kvstolic inurimir replacing the
first suuud, and londest in ihe tricuspid area. It h transmitted U* the
right if at all, is not heard at the apex, K^hind. or over the carotids, and is
seldom audible above the third rib. The pulmonic second sound is feeble.
Tncuspid oMntelion and puhuonic reijurffUation are so rare as
hardly to merit mention. Tho former causes presystolic, the latter a
diastolic murmar; the former harbh,the latter soft; the former heard moet
distinctly over the lower pnrt of the sternum, the tatter over the left
second intercostal space, but propag:ite<i downward. The second pul-
monic sound would probably he heard iu tricuspid obstruction, but
would bo absont in pulmonic regurgitation.
Pulmonii- oMrurtiou causes enlargement of the right heart and i^
systolic murmur with the first sound, of maxiintim intensity at the loft
second intercostal space, occasionally transmitted toward the left shoul-
der, but never downward to tho apex nor over the norta and curutids.
It is not beard over tho lower part of the sternum or behind. Thero
may be an attendant bruH rle (liable of the jugulars.
Diagnosis. — The dilTerentiat diagnosis between different valvular
lesions must Iw made from the foregoing symptoms and signs. In case
of single, or clearly defined double valvular sounds, little confusion need
arise in detcrmiuing their diastolic or systolic character if their rhythm
be referred to the carotid pulse. This iu most cases can be felt on deep,
digit:il prtissurc beneutli the angle of the jaw. just in front of the ante-
rior margin of the sturnu-oleidu-mustoid. Not iufrcijueiitlr an aceurute-
diagnosis is impossible when the action of the heart is rapid, irregular.
and tumultuous. In these cases better results may be obtained by aus-
cultation after proper exhibition of digitalis. In tho diagnosis of
chronic endocarditis, too much siguiGcauce must not be attached to the
presence of viilTular murmurs, as serious disease nuiy (.'xist withtmL
them. Such cases are indicated by the various symptoms already nien-
tioued aud by feeble or intermittent action of the heart, with increased
area of cardiac dulnoss doe to hypertrophy or dilatation.
Chronic endocarditis or organic disease of the heart may be confused
with functional disease of the heart, pericarditis, antemia, aneurism,
fatty degcncitition, cardiac dilatation, aud with certain congenital de<
formitics of the heart. The diHerentiul poiuts are as follows:
C'HBONIC KNlMtCARUITIS.
Palpltatioa comes od ^aduoUy.
FCNCTIONAL KEXBT bISEASC.
HUtory.
Frt»jucutly hblory of rlieuuittlisiu,
f;out, or syphilis.
Pulpitalion paroxysmal, comes ot.
sudik-oly. iiutcousluut.
History oftcu imiiils to ludijp-stign,
hynt^ria, the nervous dtalliesui ur ex-
cessive use of tobacco or tioXt^t^.
VHROmc ENDOCARinriS.
CSRONIU ENDOCARDITIS. FUNCTIONAL HKART DIftEAfiB.
Symploms.
Anxiety not mariced till luLu in ditt- Aoxiety, worry and nan-oufiness
«ase. Palpibiiion ur^iially brought on pi-ominenl. Pnlpitation usuiilly witli-
by exertion. Uy^pnu:;!, cyariosi*. oi- uiit exerlion. No evidence of onfanic
coo^i. dtaturbacicu ollKrr limn aoeentift.
Siffn*.
Ealai^ment or llie heart, change in No etilargemeot of litmri. Mtirmiira
Kpex beut. Murmurs may b« diii^*- if present me iucoiistnut, alwayi* *vsio.
tolic: they may r(.>plnc« heart sounds;
tbey are usually constant.
lio. Atv dui' t«> iuiioniiii ."ind disappear
on troalment. Heart ttouDds pi-esent
though feeble.
CtlBONIC RNI>0OARDITIH.
Pkricarditib.
SigfiM.
Usually cardiac: enlargement. Mtir-
mura constant and u-iilt^ly dilTii^d;
rommonly tiynchnmuns with hcntrt
sounds which tliey may ivplace.
CBBONIO BXDOCAJtDI'nS.
Pattf^nl may appear robust Pulse
nruiy be full and •t1i'«in<^. Ilenit en-
lur:g;ed. Murmurs coojiitanl, widely
diffused. No venous hum.
No eularKvinent till second Magv.
Klui-mtini continpit to narniw limits;
moHt ilisliiict al left fourth ooftto-ster-
iial urticiilatiou ; uoiuetinies increased
on presMiit wiih s1«IJio»*--oih;, on devp
in^pii-atioii, imd on forward iin'linatioo
of (KXtient. Miiriiiurs int.-ons(ant and
not synchronuu!^ with valvular sounds.
Heart sounds not supplanted.
AX.«MJA.
Pallor and lauiiude. Pulse weak,
i'ompressitjie, Hoait normal wr*.
Mui-nuir inix>n9tant and often loudest
over v:u-otld)9. Venous huui.
ChBUNIC KNUUCAROlTUi. TUORACIC ANCt;RISH.
SgmjituHis.
No marked symptoms at boginninf;. Marked symptoms siKniflcant of
pressure, oa. l)onng |iain, d,\-spl)agia,
aphonia.
Heart enlarged. Pulse alike on both Henri of nornml siaw. Pulse often
«tdes. No dilating impuUe. Murmur dilT«>rpnt on two sides. Dilatini; im-
frequently widely transmitted. pulse. Pei:ultar bruit localized. Never
li-uusmitted luwartl ajwx.
The iliagnosis ot fntty heart reeU oliiofly upon the histor}* of the cnsc,
the Bbsence of distinct sig^s of organic lesiooa, and the oecurreuco of
Cheynt'-Stokea rosjnratton.
(^HQi'Hiittl ihfnrm\he» of ihe heart ixm\ he AUx\ug\x'i%\\et\ hy the his-
tory, tho blut-nt'ss of tlie siirfjioe. iiml \\\v ownrreni-e of a systolic nnir-
niur not traiisunitted lo the left of the apex or to the arteries and heard
only over thi< base of thu lietirt.
CARDIAC AND ARTERIAL mSEAHBS.
IP Proonosib. — Organic Talvnlar heart disease ie rarely if erer curable,
out in duration and fatality it varies widely in different caeea according
to the cause, extent, seat, and progressive or noii-iirogreesive tendency
ol til© lesion; the degree and rupiUity of compensation; the presence of
compliciitious; the age. sex. and condition of the patient and his will-
ingncBs and eapaciiy to follow :i proper mode of life and treatment.
infanta and old people endure valvular dipcase poorly. In older
chddren nnd adults, the lieait tends to compensate more quickly.
Women are oftener affected than men, but they hare a better chance of
prolonged life because t)f It** exposurL- tu severe strain and alcoliulic and
other excesses with the re^nltiug jirterio- sclerosis, and angina pectoris
01 organic origin. Ardnous and exposing ocoiip«iion8 and a reckless or
pasiionate disposition intluence the prognosis unfavorably. A progres-
siMj trend of the disease evidenced in the |Mi«t and pn^ent liistory is
uiipropUious, etipeidally when associated with or dependent upon renal
disorder. Evidence of dilatation without compensation or of coexistent
arterio-acleroeis is ominous. The gravity increases with the number of
if'fiiona^ and is grenitJy aiifrmented by tlie occurrence of diseases which
weaken the heart. Heart disease dependent upon uncomplicated chorea
18 not usually serious. In any case prompt relief following the use of
heart tonics is a good sign.
In aortic xtenosis^ compensatory hypertrophy is nsually prompt and
may \ie efficient for years. The danger lies in failure of compensation,
or in cerebral embolism, which is more frequent from this than from
any other valvular disease. Death may also result from sudden heart
failure or from pulmonary o'doma after secondary mitral insutKciency
and left Tentricular dilatation.
Aortic regurtjiUttion, though frequently existing for years and with-
out much discomfort, is the moet apt of all valvular diseases to cause
audden death, mitral stenosis ranking close in this restiect. It is most
severe when suddenly developed (Loomis' Practical Medicine), and
grave when followed by signs of mitral insutticlency, dilatation, heart
failure, renal, or other visceral disease. Peath may occur from these or
from cerehnil aniemia and syncope, from cerebnil apoplexy or embolism,
or from asphyxia due to pulmonary congestion and ledema.
Mitral 8feno»i8 renders the patient liable to pulmonary congestion,
oedema, or apoplexy, and not infrequently ends in sudden cardiac failure.
In mitral reffttrf/itftfinn, the prognosis is fairly good as compensatory
hypertrophy is usually equal to the necessity, at least for some timo.
Danger results from its failure and consequent general venous engorge-
ment, giving rise to dropsy of the lungs, serous cavities, and limbs.
Death from heart failure or from asphyxia naturally follows, bat only
about two per cent of patients with mitral disease die suddenly.
Trxmsftiii stenonts and /wiomjt of the pulmonary orifice are seldom
met with, but, when present, are necessarily graTe conditions.
Tru-uepid rtgurgitation is exceedingly graTe, whether the result of
CHRONIC SNDOCARDlTia.
239
chronic pulmonary disease or aecoodary to lesions of the left heart, tn
this condition, sudden increase in the* puhnoDary eugor^ment and
death from stifToeution is u conetant danger.
The symptoms usually iudicutire of a fatal imne in valrular disease
of the heart are: great anxiety, with sense of oppression, followed by
pallor, vertigo, syncope, and muscular debility, and irregular, weak,
intermittent, and rapid pnlse of I'JO beats or more per minute, epjte-
cially when accompanied, on palpation of the prawordia, by a pnrring
tremor. Great anasarca and fluid efl'uAinn into the serous cavities,
dyspucua, ht^moptysis, and cyanosis are bud sign&
Tkkatmext. — In the treatment of valvular lesions, three things are
constiintly to be borne in mind. The lubur of the heart must be ren^
dered as light as ponsible, the blood must be kept in u healthy condition,
and the strength of the heart must be maintained.
With the first object in. view, we interdict rapid walking, mnning,
or henry lifting, and enjoin the patient to avoid climbing stairs, and
indeed every act or form of exercise, mental or physirnl, which causes
dyspncBa and palpitation. Wo attempt also by proper treatment to n*'
move all obstruction to the circulation; hence, pulmonary and other dia>
eases must receive appropriate treatment. Even a simple broncbitlf
may be guftioient greatly to olwtruct. the pulmonary circulation. Porta!'
oongestion, or obstruction in the aystemia capillaries which may be con-
tracted as the reeult of nervous irritation caused by the retnjne<l excreta
in Uright's disease must be relieved. Remembering that alTectiona of the
lungs. livor, alimentary canal, kidneys, or skin may have caused tho
carduic disoaae. or may greatly aggravate it, we naturally look for
these, and seek to combat them by appropriate treatment
With the second object in view, we aim to maintain free elimiuaiion
by the kidncy«:, bowels, and skin, and recommend vegetable tonics, iron,
and nutritious diet, with regular habits.
To accomplish the third object, besides the means already suggested
for relieving the heart of work and for furnishing it with jiropcr nutri-
tion, we prohibit the use of tobacco and of all other depressing agents
and ndminister various hrurt tunics, chief among wbi<:h are digitjilis,
arsenic, and cactus grandillnni; belladonna and squills have a tonio
effect ob the heart similar to these, though less potent. Tn many cast
nnx vomica is a most useful remenly.
Other heart tonics of value, alone or combined with digitalis, are:
itrophanthus, beat given in tincture, ti].?. to x. ; sparteine eulplmte, gr. ^i ;
caffeine citrate, gr. ij.-iij.; tincture of convallnria, tri x.-xx- ; and nitro-
glycerin. The latter, in doses of gr. y\yf repeated within twenty minutes
if necessary, is of special valne when a prompt cardiac stimulant is needed.
Amyl nitrite acts in a similar manner. Sparteine seems of roost ralne,
when given in full doses, in regulating the rhythm of the heart. Though
the remedies directed to the heart itself are of the greatest service in the
tf
1^0
m.
treatment of valvular •lisease, tliey sliotild not be usetl indiscriminately,
for the apparcut weakness may eometimea be much more effectually over-
come by medicines wliieli act upon some other organ. Moderate exercise
ia Bometimee of great value in maintaining the strength of the heart
muscle.
In aortic obstruction or reijurgitation, it \b especially important to
ftvoid taxing the ]>on-ur of the heart, and to maintain it« strength by
cardiac tonics and a good supply of rich blood. Nature always attempts
to eomjicnwite for the obstruction or regurgitation by hypertrophy of
0 left ventricle; but a time finally comes when the compensation fails,
en digitalis should be given to strengthen the muscular walla. Ten
minims of tho tincture thren times a day is the ordinary dose, but the
amount may be gradually increased until the heart pulsates regularly
and with normal force, ]»roviding the kidneys act freely and the Rtomacli
18 not deranged. Twenty minims may be given as often as every two
hours, without danger, if there Is a free secretion of urinej but if the
w stops, the digitalis must be at once suspended.
When conipen&ution ia complete, so that the heart beats regularly
and with normal force and frequency, good hygienic surroundings, with
regulation of diet and exercise, are all that is needed. Exaggerated liy-
I'ertrophy with t(Mi powerful systole demands cardiac sedatives.
hi mitral uhi<lnu:tuiH or rtgurgitatimt, digitalis is usually most beno-
»i*L It should !« given as just recommended for aortic disease. When
It loses its effect, arsenioutt iicid or nux vomicji should be tried, alone or
With the digitalis. Other diuretics, vapor or hot-air butha, and cathartics
will be re<^uircd from time to time, to relieve pulmonary congestion and
(Edema or genend dropsy.
From the experiments of Germain Sec {La Trihune Mriliaik, 1890)
wctose, a well-known constituent of milk, appears to be diuretic. Cal-
omel in small doses is also a stimulant of tho renal function and is
specially indicated when the liver is tugorged.
It is important to continue the use of cardiac tonics in mcdinm dosea
two or three times a day, for many months after the distressing symptoms,
for which tho physician was lir»t called, have passed away: but tte
amount must always be carefully regulateil, so us not to over-stimulate
the organ.
Biscase of the pulvwuartf vaftvs requires simihir treatment to that
recommended for mitral affections.
Jh tricuspid r«fftirtntfttvm, the same general rules laid down for the
treatment of other valvular lesions are to he followed; but unless mitral
disease coexists^ digitalis will do more harm than good, hy iu'.rrdtirj
the vonous congestion of tho brain and of the abdominal organs.
MYOCAHDITIS.
&SL
MYOCARDITIS.
Myociirditis or inflammatiou of the muscular fibres of the heart may
be acute or chronic.
Anatomical AND Pathological CHAttACTEttisTics.— TheuRtial scat
of myociirditifl is the wall of tlif left vi-ntricle. Very acute iiiHunima-
tion is marked by infiltration and swelling of the muBcnIar fibres to-
j;ethcr with their sheaths^ aiidtonde to their rapid disorganization nud
the formation of small abscesses circumscribed by connective-tissue
proliferation. Exceptionally the process ends in diffuso purulent infil-
tration.
Ahscestttis weaken the wall of the heart, give rise to dilatation, niptnre,
or }inenrii<in of the or(,^in, and tiuiy theinaolree diHcliurgc into the peri-
canlial sac, producing pyo-pericardinni, or into thu ventricle, causini
pyaemia.
Chronic myocarditis is essentially interstitial, and eventuates in cir-
rhosis, making the organ larger and heitvier thiin normal, viirjing in color
from gray or pink to a bluish hue. The muscle becomes Inngh and in-
«kistic and either inereuaed in thicknesii or attenu:ilod. The proe^^s is
gradual, and may begin in the purls adjacent to the endonirdium or the
pericardium or may primarily involve the intermmnculjir wrptn.
New colls, tending to organize, produce pressure — atrophy of the mug-
cuhir fibres or fiitty degeneration from disturbed nutrition. The growth
of fibroid tissue may be so extensive as largely to replace musciilur
elements, or it may exist only as cicatrices, scattered at irregulir inter-
vals, commonly most marked at the apex (Hamilton, Test-Book of
Pathology).
.■\« ft result, the atTectod wall i;* luiigh ami k-jitliery. either distinctly
nitenuatf-'d or much thickened and of » gray color. 'J'his fibroid tissue
sometimes undergoes calcification. The entire vail of an auricle hi
been found in such a condition.
ETiOLrt*iY. — Acutft myocarditis is usually of septic origin, either oo-
cnrringas a part of pyemia or developed in the course of typhoid or
other infections fevers. The chronic form usually accompanies rheu-
matic endocarditis and periourditis, but may occur alone, llnber. how-
ever, holds that it rather follows arterio-sclerosis of the coronary artery.
Syphilis may also pro<luce it (Hamilton. o/>. cit.).
.Symptomatology. — .irw/r vitfiyantUin is a rare affection, and of it«
symptomt and signs vc know little, ajMirt from its association with en-
docarditis or pericarditis. If, during the progruKs of either of these
diseases, the heart's action becomes intermittent or irregular, and ther«
is a tendency to syncope, it is probable that the muscular tissue of the
organ ha* Itccome involved.
The symptoms and signs frequently observed are: extreme pallor of
the countenance, with coldness of the sDrfM« and a tendency to syo-
233
CARDIAC AND ARTERIAL DISBASBS.
oope; also pain nud opprHsion at the pr^fwrdia, with drapuoes unoiint-
iiig to nrthopiin-a, and sighing respiration. The action of the hetirl is
feeWe, fluttering', and irregular. The area of cardiac duhiees remuiiia
nomial uiiIbsh dilatation or pericardial effoaioii exists. Both sounds uf
the heart are aharp and valvular, the first very closely lescmhling the
second. They may goirietimes be reprtwent^id hy the /«, /// (-•haract4?ristio
of the ftptal lieart. Wltli these symptoms and sigas, the patient may
complain of severe pain in the head and limbs, and there may be de-
lirium or hemiplegia. All or only a part of theso may be proscut or
sbeenL
The 8ym\iioma ot chronic mtfocarditis or JJbroid diseajie of the hoart
most frequently noticed are cardiac pain, cBdema, and dyapncea, but all
of thMe may be alwent.
The«rif»«are: a weak, irregular, and rapid pulse and feeble apex beat>
with coincident enlargement of the cardiac area of dulness. Beiluplica-
tion of the first sound is also sometimes present.
DlAON'OSis. — If an acute affection of the heart is attended with pallor
and coldness of the surface, syncope, pain in the cardiac region, and a
feeble, fluttering, and irregular pulsation, we may fairly suspect acute
inflammation of its muscular walla.
Neither the symptoms nor the signs nor these combined are snfficient
to distingiiish accurately B'Ar{H>/ '/iVfl^f 0/ Mp A««r(^ from dilatation or
fatty degeneration. In both, marked feebleness of the heart is present ;
in fatty degeneration, tho heart is not so commonly enlarged as in the
diffuse fibroid disease; the former is usually associated with anaemia, Lhe
latter with general sclerosis, L-hronic nephritis, or syphilis.
Aoconliu); to Riegel. the patliOf;uouK>iiic Hign of cliroitio myocarditis ia
irregulanly of a«.*lion of the liearl, a total lo-ts o( rhythm ii[»pBaring early in the
disease and reiiminin^ irrespective of the intlut^nce of tli^ituliH and olher a^nts
ill i-esloriag tlie ronctional tictivily of i\vi oi'iT'io aiii] ilispellini; di-o|isy am) other
symploiiis ol dL-fieifiil Iieart iK>wer {ZeitHcUrift fiir klinigehe ^fedicin. \S>*9).
Irreg^ularity, tliuugh tv feature of iiiuny otht^r cafdiac coniliUons. is in tlieni aU
wayx a late «yniptoin, due to secondary weakn«!)s, and it diitappears when hefkrt
tonics Itave I>een effective.
PuooNOSis. — Theoretically, the prognosis in myocarditis is always
grave, especially in the acute form. Practically, a satisfactory prognosis
is r.iroly possible, because an accnnite diagnosis can seldom be made.
When occtirring with endocarditis and pericarditis, it adds to the danger
of death from heart failure, cardiac aneurism or rupture, or from pul-
mbmiry cougestiou and a?dema, or embolism and pyemia. The chronic
lorm may terminate in generul dropsy or in death from cerebral anfeinia.i
Trb.\tiient. — The treatment for myocarditis is that for its associated
td frequently c^usitive diseases.
Patients suffering from endocarditis, pericarditis or any obscure heart
trouble, from typhoid fever or other debilitating iliseabes, in wliom royo-
MYOCARDITIS. 233
carditis may be even remotely suspected reqaire: perfect rest in the re-
cambent position; avoidance of all mental or bodily strain; nutritious
and easily assimilated diet; the maintenance of elimination from skin,
bowels, and kidneys and moderate stimulation of the failing heart
vith alcoholics, strychnine, digitalis, the ammonium compounds, or
nitrites.
CHAPTER XIV.
CARDIAC AND ABTERIAL DISEASES.— a)H/iH!«d.
SlMPhB CARDIAC HYPERTROPHY.
i^ynon;/m.«. — Enlftrgemunt of the heart; hjpersarcoaiB cordis.
Siniph' cunliiu'. hypertrophy consists of hy]tertrt]phy (if llie miiscnljtr
walls of one or more of the cardiuc ciivtties without titilargenient of tho
cavity itself.
AsATOMicAL A3»D PATHOLOGICAL Characteribtics,— Simple caf-
diac hypertrophy untittendcti by (iihitation is compamtively rare and is
seldom >jeneral. It may bo localized in any part of the cardiuc muscle,
but it affects the wall of tho ventricle more frequently than that of the
auricle, being oftenest confined to the left aide. The iaterrenlrinnlttr
septum is not mtually much implicated. In well-marked eases the orgaa
U always large and heavy, and changed in shape according to the seat
of hvi)ertrophy. The wall ia not uiuommoniy donbled in tliickuess. It
is re<lder and more rigid than normal, the enclosed cavities remaining
patulous after death. The affected wall of the left ventricle will be
eitra-friable; that of the right, tongh and leathery (Loomifl' Practical
3Iediciuo). The hypertrophy results from increase in the muscular
structure of the heart, whether in number or size of tho indiridutil fibres
or in both. The increase does not involve tho connective tisisue tu any
extent in simple hypertrophy, but may extend to the column^e carnese,
especially of the left ventricle.
KtioLOGY. — Simple cardiac hypertrophy may arise from functional
over-action of the heart, due to prolonged or severe muscukr etTurts, to
nervous or mental cauBcs. or to the effects of alcohol, leu, and coffee. It
may result from slight obstruction iit the valvular oriflccs or to embar-
rassment of the heart's action from displacement or pericardial adhesions.
It may be ]>rodured by obstructed circulation outside tho heart, as from
constriction of great vesaelji or pressure upon them; from degenerative
changes of the arterial system, such as eudarterilis oblitenms, atheroma,
and loss of elasticity ; or it may be caused by the obstruction resulting
from contraction of the arterioles associated with Bripht's disease, alco-
holism, and syphilis. It may be due to local or to visceral diaease,a« em-
physemai cirrhosis of the lung, or pleural effusions which interfere with
the pulmonary circuit. FhyEiologieal cardiac hypertrophy occurs ia
jkregnancy.
Stmptomatologt.— The symptoms are not marked, though there ia
SlilPLJi CARDIAC Ul'l*J£iiniOPtiy.
23d
a tendency to corebrul hyperaimia, oud palpicatioD on exertion or excitd-
meut; a dry cougb nmy be preseut ut times, frum flight pulmonary con-
geslioD.
The signs in tbis iilTection Yury with Ibe extent of the hypertrophy,
and with the porLiuu uf the orguu involved. The esaeutial signs ure:
inoreueed area of dulness aud increased force of impulse while the heart's
action remains re;{ular.
InsjifCliou in ebildreu frefjuently reveals a prominence of the pr»-
cordi:il region when the hypertrophy \& gti^uenU, but in adults this can-
not be detected. The action of the heart is regular and forcible. If
the loft ventricle alone be hypertrophiod, the apex beat will be farther
than usual to the left, and tlie visible area of the impulse increiiHed, often
exteniltng over the whole praecordia. If the right ventricle i« affected,
there will l>ft strong epigastric pulsation, anil the npex beat, if pcrceptU
ble^ will be below and to the right of the usual position.
Palpation confirms the signs as to the position and force of the apex
boat.
On percussion, the areas of superficial and deep<seated cArdiac dnlncsa
are found Lo be increased. The latter in simple hypertrophy of the
left venlricle seldom extends more than an inch to the left of the nor-
mal position. A larger area is almost always associated with more or
less dilatation. In hypertrophy of the right ventricle, the duluees ex-
tends considerably to the right of the storuum.
In hypertrophy of the ventricles, auscultation finds the first sound
of the heart greatly increased in intensity, and the elements of muscular
contraction and impulsion are especially nuirkeil. The second sotind is
also increased in intensity and more w^idoly diffused than normal. The
action of the heart remains regular as long as hypertrophy compensates
for the obstruction.
The reiipiratory murmur is diminished or absent over a portion of the
precordial region corresponding to the displacement of the lung.
Diagnosis. — Simple cardiac hypertrophy may be confused with scr-
erai affections, which will bo coneidereil to better advantage nndfr diag-
nosis of hypertrophy and dilatation of the heitrt, from which it is distin-
guished by the larger size of the heart and greater irregularity of action,
with more of a heaving impulse in the latter. Again, in hypertrophy and
dilatation of the heart, valvnlar mnrmurs are more commonly present
than in simple hypertrophy; otherwise the symptoms and signs of the
two iiffcctioni are substantially alike.
Pkor.N'Osi.s. — Simple ciirdiac hypertrophy as a compcuBatory process
is usually favorable, providing the causative factors be not snch as to
produce eventual cardiac or vascular degeneration by their persistence
or progrtssiveuess. Cases dependent simply upon mental or muscular
excitement are not serious under a properly reguIateKl mode of life.
'When there is a marked tendency to cerebral congestion, especially ia
236
CARIilAC AND ARTERIAL DISEASES,
alcoholic subjects or those in whom arterial degeneration Visa taken
pluce, this affoption is Huble to eTBntuato in cerebral apoplexy.
Tkkatment.— Usually, hypertrophy of the heart should be farored
rather than retarded; but in Bonie instances, Hymptonis of cerebral con-
gestion appear such as pain, fuhiees of the hitail iind vertigo, which re-
quire prompt attention. Uleeding will temporarily relieve those, but it
ia not lu be re i-oni mended. Tincture oS acunite root in doses of two or
three drops every two lionrs until relief Is obtained is the most efficient
remedy in su<.'li iTistuuoes. Veratrtim viride may be used for the sumo
purpose.
It must not be forgotten that similar symptoms are caused by pas-
sive congestion depending upon cardiac failure, and that in such oaeed
the nconite would be harmful. These latter cases I have found most
quickly relieved by riux vomica. The causes of the hypertrophy should
be sought and removed ae far as possible.
HYPERTROPHY AND DILATATION OF THE HEART.
Hypertrophy and dilatation of the heart, also called eccentric cardiac
hypertrophy, affecting the muscular walls and dilating the cavities, is
caused by yielding of The walls to excc-ssive pressure, which may result
from the same causes which induced the hypertrophy, or from regurgita-
tiou of blood through incompetent valves.
Symptom ATOi-ooY. — Dyspnu-a on exertion, oedema OBjwcially of the
ankles, and occasional vertigo, and pitlpitatiou of the heart are cominun
symptoms. In this affection, the action of the heart remains regular if
the hypertrophy is sufficient to compensate for the dilatation; but it
becomes irregular if the dilatation predominates.
The essential signs are: increased area of visible impulse, with dis-
placement of the apex beat downward and to the left, and a peeuliiir
heaving iuipulMo with increased area of duluess. Endocardial uiurrours
»re nearly always present.
Inspection and jmlpation show that the area over which the cardiac
impulse may be seen nnd felt is greatly increased, sometimes extending
over the entire left side. The impulse often has a peculiar heaving or
lifting character, sufficient in some instances to shako the bed on which
the pitiient is lying. The apex beat may sometimes bo two or three
inches lo the left of the left nipple, and us low as the eighth rib.
lI|Kin percussion, the area of dulncs» is increased to the left and
downward, in proportion to the enlargement of the organ; if the right
reutricle is affectwi, it is also inorejised to the right.
In ansentiation, both sounds of the heart are prolonged, and may
often bt* heard over the entire chest. If valvular murmurs are present,
they will be loudest in the nonnal areas, described in a previous chapter
(Fi^. 32), but they may also be heard in some instanees ovr the whole
thorax.
BTPBRTROPHY AND DILATATION OF TUB IIBAUT. -237
DLA.GN081S. — Eccentric cardiHC hypertrophy niny be mistuken for re-
tmction or f^iisoliducion of the lung, curdiuc UiUtatiou, jjcricurdial
effusion, cftrdiuc diepkcemeut, thoracic auourism, or for simple ciirdiac
faypt-rtrophy.
Uetraction of the luntf due to pleuritic udhesiuns or pulmonary cir-
rboHiH, T>y exposing a larger surface of the heart, may increase the area
itt 8ui»orfieiul cardiac duluesa and thus eimulate hypertrophy; but the
history of former trouble, pulmonary Bymptoms and aigne of more or leas
promineuce. and the nurmul condition uf the pulise, heart soundtt, and
force of the apex beat distinguish, it from cardiac hyperlr(»phy. The
dielinc-tive features between eccentric cardiac hypertrophy and cotutoli-
dnti'iii uf the hintf are &» follows:
ByPBETROPHY and dilatation of CONSOUPATIOM OF THE LCVQ.
THE HGABT.
Stfmptoma.
Cough Dot promiDent. Cough prominent
Intpeetion,
Impultto nt apex forcible, aoUon tu- Force of apex beat normal.
mulUiouH.
Paipation.
PuUe ftiU and stfong. HuIm normal or weak and rapid.
/Vrciuwion.
Outlini; of ilulaesa quadrilateral and Outline irregular and extending b^
tfonflned to prwconlia. yond tim limiU of the heart.
Auacultfition.
Heart tioundK intensified. Heart sounds normal. Bronciiial
breathing', bronchophony, and ri.\^&.
Eo-centric cardiac hypertrophy diffem friim dilatation of the heart as
Iwtow:
Hyfertboput akd dilatation of Dilatation or tue heart.
THE ITEART.
Stfmptovu,
SyrapboniN of cerebral hyperwiuia. Pro{;ressivi> geaeiul weakness, nod
cedema of feot.
Jn«pecJion.
Face Unshed ; e-arotids proniiuent ; Fuoe jialo or livid, v^ins turgid, pvr-
apex l>eal hea^nng and forcible, and hapH ptit<uLUng: jugiilai-x ; a]>ex l>eat
distinct over lai-ffe area. feeble, not alway<( vJKible. tlinu^'h it
may be seen ovt^r an area larger tlian
usual, but lesatlianthutof bypeiltropltj
and dilatation.
/\t/jH]flV>ll.
Apex beat forcible; pulae full and .\pex beit diffused, we«k ; pulse
strong. weak and iire^lar.
Aiucultation.
Bounds intensified ; first sound pro- Sounds feeble, and flrat sound short,
longad.
238 CARDIAC AND ARTERIAL DISEASES.
Eccentric cardiac hypertrophy and pericardial effusion and hydro-
pericardium have the following distinctions :
HYPERTROFHT and DIXiATATIOM OF PeRICABDIAL EFFUSION.
THE BEABT.
Symptoms.
Slowly developed and not promiQent. Symptoms acute in pericarditis.
Palpation.
Apex beat strong-, displaced to the Apex beat weak, carried slightly to
left, and depressed. left and apparently raised.
Percuasion.
Outline of dulness quadrilateral, and Outline triangular, and extending to
not extending to left of apex beat. left of apex beat
Auscultation.
Heart sounds distinct Sounds feeble.
No friction sounds. Friction sounds have been present in
pericarditis, and may be still, at base of
heart.
Eccentric cardiac a3rpertrophy and cardiac displacement differ thus:
Htfertropht and dilatation op Cardiac displaceicbht.
the heart.
Symptoms.
Cerebral hyperaemia. None characteristic.
Palpation.
Heaving apex beat over great area. Apex beat of normal force ; area
not necessarily enlarged.
Percussion.
Area of dulness increased. Area of dulness not necessarily in-
creased.
Auscultation.
Sounds intensified. Sounds normal.
Eccentric cardiac hypertrophy differs irom thoracic aneurism aa
shown below:
Hypertrophy and dilatation op Thoracic aneurism,
the heart.
Symptoms.
No aphonia, dysphagia, or boring Boring pain, dysphagia, aphonia^
pain. etc., due to pressure.
Palpation.
Impulse heaving and below fourth Impulse dilating and above fourtk
rib. rib. Aneui'ismal thrill.
DILATATION OF THE HEART.
239
ETPCBTROPHY AKD DILATATION OF TaORACtO ANlCrMSH.
THE HEART.
Pvrciation.
Dulueiiis increastnl to ihe lefl untl DulneHs iiu.ivusctl U|iwtinl,
downwanl.
Auacnltation.
Beart sounds intensified. Bruit ; heart sounds normal.
pEooifosis. — The prognosis dopends largely upon the remoTahilitj
of the causti.. or, if thiD U pcrmauont, upon its jirogressive or uou-pro-
gresfiive cliaructcr. Kxistiug hy{>crtrophy, though suflicient to meet the
OTiliimry dcmuuds of the case for years, may bf rendered inefficient by
undiH3 musculnr atmin, oxhuuiiting diseiises, great and continued enio-
tion»l disturbances^ or in seine cases hy pregnancy; the latter condition,
however, is not contni-indif'-tttwl in modenite cases.
When great force mnut be bjibitnally exerted by the ventricle to
overcome increased resistance duo to obstruction or regurgitation, the evil
^ffoctA arc apt to be manifested in chronic cungcstion of the lungs, in
degeneniliun uf the arteries geiiendly, or in rn{>ture of cerebml vessels
which may alrejidy be ihe seat of atheroma.
Tke.\thkn't. — The treatment of this condition is essontiallr that of
chronic en<locarditifi with valvular disease of the heart, with wliich it u
nearly ulwuys iiA«ociaied.
As long !ta hyiK'rtrophy is perfectly compcusjitory, uo treatment is
demanded excei>t in case of excessive cercbr.il congestion, witli danger of
apoplexy, when cardiac sedatives are indicated. (_>t)ierwise the hygienic
and medicinal treatment suggested for dbfease of the heart should be
carried out.
T>ILATATION OF THE HEART.
Stffionijmf. — Passive aneurism of the heart; cardiectasis; cardiac
diktat ion.
AxATOMKAL ANif PATHOLOGICAL CuAaACTERtsTlcs. — DUatatiou of
Ihe heiiri refers to an :dinormal increase iTUhe cavities of the heart, irre-
ipective of ihe condition uf its walls, nliich may lie relatively n*trnuii or
attenuated. The aurinlcg are most frequently affected, and the right
ventricle oftener than the left. Tho8hftj>eof a dilated licart depends
upon the amount of dilatation, and npon the cavity or cavities invoKt-d.
The shape may be irregular from bulging ofa single auricle or ventricle;
or more uniformly enhirged, from stretchinrr of nil the cavities. The walls,
if not normal, may he atrophic or slightly hypertrophic and may be tho
It of various degenerations or infiltrations according to the cause of
le afTcction.
EtroLoiiY.— Pilatalion of the heart is dependent npon a disparity
between the power of the cardiac muscle and the intra-cardhio pressure-
CAHIfJAC AMV ABTSRXAL IH8JU8S8.
twwlinif t/, rH.rogr«riTe change; sex and occnpauion, » itt-
[J^^Ufft; ana hweaity, are remote factors in iu prodnction.
''«irig *»u«fc, include all the conditions which weaken the
\. J ^'rominent among these is atonj of ite moscubir
'r*« Trom »n«mia, chlorosis, exhausting febrile and infectioua
'r»ri««rr»5niB of innerration incident to sexual, alcoholic,
'««MM-(»; or r:«rtain nervous disorders, as Graves^ disease. The
'"* ""*y ''« weakened by degeneration. This may result from
"I *""" '•'"'''>nury artery by embolism, arterio-scleroBis or con-
"I'l imrldiirdiul aclhesions; or it maybe secondary to rhea-
y» '»'• "yiiliilitic pericarditis, endocarditis, or myocarditis; or
y '"'fiur, (lilt) to old age or to pressure from amyloid or fatty
' ''"* K''"wths, or chronic pericardial effusion. The exciting
'itiit 01, |„ iri(!ron„Q of intracardiac pressure. This may occur
II'* <l iMiMWd, riiid from the pressure of tumors upon the aorta, pul-
' y* "•■ other grout vessels; from general increase of arterial
"""luttMl with Hrig]it*s disouso; from obstruction of smaller ves-
'""I'Umt to prolungod muscular efforts, or to fibroid phthisis
(ioiii((4ti „f the lungs; or from local vaacular degeneration duo
■111. "yplilUs, liiul gout, notably to endarteritis obliterans.
•MAToUKtv, — Tlio most frequent symptoms are: rapid and
Togulur, iutorniittoiit pulso; cardiac palpitation and sensations
Itm iiuil uitwuitioss; sighingrespirationjdyspncea, and syncope;
irgttK(>onoo of tho veins, and congestion of the various organs,
w\\\\\ of tho lungs, jaundice, or albuminuria.
losl tiu|mrtant sitiHS are: fecblo and irregular action of the
t^nlnrgotl an^u of dulnoss, oval in form, and not extending far
of \\w u|H«x lH*t ; and foebleness of the heart sounds.
'pM'urn, tho impulse of the heart's apex may not be visible.
*U. it i* Ukoly to extend over a wider area than iu health, and
of utftximum intensity is not easily determined. It is ooca-
r an utuhtUtory character.
neut diUtMtion *nd varicosity of the jugular wns is a sign of
right auricle.
(VAtiiMv, the tk^MNC hMt is found below the normal position and
of it, and th* hwrtV action is im^hir in rhythm. The im-
WWe^ which eiwble« u* nwtlily to distinguish this aifeoiion
pHTx^l^hy. »wr hyjvMfT\»phy with dilatation. A purrinir trvmor
vwtU t* obtained* eejwciallv when thei* is mitial neipirii:^-
»k^tt *hi*w* the »r«« of ouduc dahwes inv'W*si?d to the r^b.:
r\^t K-wKttws aw inwlTifd. and to she left whea the Irf: u- .-
•*J^L .tuV.t*tss due to dilated aarvie« may extend upwir:. t- z
t ;?.Sifm»v**.
*.-v* wiiiataaaj an ^wJ tf«Uia«^ wtoA eoabJw as to i
I>ILATATIVN OF TUB HEAIiT.
UX
thu Jiseasc from pericariJitii, in which the signs, upon inspection and
palpation, are nearly identical.
My misonltation both sonndaof the heart nre found short, abrnpt, und
fcohle, und frequently of equal length. The second sound muy be in-
uudiblo at the apex, and the tirst may be reduplicated.
Jf valvular munnura have been present, these become lens intense,
and sometimes of a swirling character. The respiratory sounils over the
appor portion of the left lung are often feeble.
l>iAOXosis. — There is usually little difficulty in distinguishing dila-
tation of the heart from all other afTcctiouG, excepting pcricurditiL
The distinctive features between these tvo are aa follows:
DllJlTATIOK or THR BBART.
Pericakihtis.
Hintnry.
Chronic.
.\Cllt«.
Palpation,
Impulse fe*ble and irr^ular, felt ImpuUte feeble and [rregular, felt
bf/otraofl tu Utel^ftof its normal pa&{> abotv iu normal po«J(ioo,aDdlncreaa^
tion, and uot materially affected by in force when the patient Icaaa for*
leaning' Uie patient's body forward. wrard.
/VrcMWion,
Oval outline of dulneiWt which does Triangular outline of dulness, wliicli
not extend far to tlie left of the apex. extends coouderably to the left of the
upex beat.
Auscultation,
n>-art ftound^i feeble, sliuri, and vul- Heart Hounds feeble, iiml nut »o
vular, and not ult«red by pusiUon. markediy valvular, but intensilled by
leaning the tK>dy forward.
fstoligiH is a term which has been applied to a condition in which
hTentricle cannot completely empty itself. It is nearly always asso-
ciated with dilatation of the right ventricle.
In this condition, the ini]UilKe of the heart heeomea very feeble, and
shortly before death the valvular sounds or ninrmurB whi<:h may have
been present become almost inaudible, or they may be supplanted by a
continuous humming eouml. Tricuspid regtirgitation, with pulsation
in the jugular veins, is likely to be developed during the course of this
affection.
pKOoxoF^ls. — The prognosis is unfavorable according as dilatation rel-
atively exceeds compensatory hypertrophy, the gravity depending upon
degenerations of the musctUar wall, and upon the degree of obstruction
to circulation. ANTien compensation is good and no eomplicationa exist,
the patient may live for yei^rs; but associated valvular lesions, pulmonary
afft(.tiaiis, Blight's disease, general anfcmia, hereditary predisposition
S42
CARDIAC AND ARTERIAL DISEASES.
to beiirt disease, and weakueas from an; cause reuder tbo progcoais itn-
favorablti.
DvBpnwa anci irrcgnlar and intermittent pulse, tendency to dropsy*
and ejncope are gravu signtt, indieutiiig that death niiiy occur suddeiilj
at any time, though tlic piitient may linger for twreral months.
Tkkatmest.— The tresitnient of dihitation of thi? heart and of asys-
tolism should be the same as that recommended for chronic cndocarditia
with valvular disease of the heart.
Though the dihited cavities cannot be reduced lo normal, compenaii-
tory hypertrophy of the walla may be induced and sliould ho encouraged
by avoiding; all unnecessary exertion; by improving general nutrition
with an abundance of easily digested food, tonics, and regulation of ex-
cretion; and hy careful stimulation of the heart by digitalis, strophan-
thus. spnrteiue, conTaUaria, or caffeine, and in suitable cases by moderate
exercise.
ATROPHY OP THE HEART.
f Synonym. — Phtliisis of the heart.
Atrophy of the heart is an extremely rare affection. It consists of
simple attenuation of the walls of the heart, the cavities nsually remain-
ing of normal Kize, but in some casea both the thickness of the walla
and the eize of the cavities are diminished.
The affection is sometimes congenital. It may be caused by old age,
chronic wasting disease, or by constriction of the coronary arteries.
DiAOXOSIs. — A diiignoais can n»rely, if ever, be made during lifaj
but in the congenital variety we may possibly detect decreased area of
cardiac dulness independent of pulmonary emphysema.
FATTY HEART.
There are two recognized varieties of fatty hejtrt: one, iu which
there is a deposit of fatty tissue upon the surface of the heart or he-
twecn its miieculsr fibres (irifiltnition), and the other, in which the mus-
cular fibres themselves undergo fatty degeneration.
Etiology.— The first vuriety of fatty heart is attributed, by Kennedy,
to a fatty diiitheaia, and is assori.'ited M'itli obesity ; tlie second vuriety
results from atheromatous degenerittion of the aorta, old age> nlcoholism»
gout, or some prolonged wasting di.sease.
SvMPTOHATOLOOY. — The ctvmptoms of fatty disease of tbe heart are
practically the siinie in both varieties, and they are of tbo greatest im-
portance from a diagnostic point of Tiew. The most prominent of these
are: melancholia or irrit:»bility of temper, partial loss of memory, or
hesitating speech: palpitation of the heart, dysjjtiani, and angina pec-
toris. Other symptoms which are frequently noticed are: pallor and a
FATTY UEAHT.
S43
snllov njipearaiice of the surface, witli conge^tiun of the ears anfl lipa;
weight and pain in the heiiU; a sense uf paiii in the e|MgiiEtnuni; Houtile
vision or toita nf Tisioii; iiiul the an-us senilis. Pseudo-apnplexy, and
Chojrue-Stokcs respiration, when present, are Bymptonis of the greatest
valiio.
Fscudo^poplexy consists of attacks iu which the individual suddenly
loses conticiotisness and fulls. It differs from true apoplexy in the
mpidity of recovery. When theae attacks first make their appeamnoe,
they seldom continue more than a minute or two, the patient coming
out of them feeling perfectly well; but, as the disease progresses, tliey
become more and more frequent, prolonged, and severe, and are at-
tended with paralysis; even then the patient usually recovers completely
iu a few days i:t most.
The Cheyne-Stokea respiration, which appears late in the- disease,
consists In the occurrence of a series of inspirations increajting to a max-
imum, nud then declining in force and length until a st-iite of np|>iiront
apn(£a is established. In thii« condition a patient may remain for such
a length of time as to make his aiteudauis believe liini dead, when vk
low inspiration, followed by one more decided, marks theconiniencfnieiit
of a new ascending and descending Beries of inspirations. Although this
is an imjwrtant symptom of fatty heart, it must not be forgotttm that
H occasionally occurs in dilatation uud iu valvular disease of the organ.
Jn fatly infiltration of the heart, obesity is a symptom of impor-
tance. In fatty degenemtiou, loss of weight, after a person has been
fleshy, is u valuable symptom.
Among the si ynnoi fatty ihflf ration of tJic heart. an: a pulse usually
alow — forty or fifty per minute— full, and sometimes even bounding;
increased area of cardiac dulness on very careful percussion.
In ffiift/ ifefffiienttioH, the pulse is weak and irregular and usually
rapid. Auscultatiou over the apex will occisiunally reveal slow pulsa-
tion; and even when the pulsation equals seventy per minute, it often
conveys to the ear a sense of slowness.
The inipulso of the apox in weak, and the intensity of the sounds
feeble iu either variety. If valvular disease ooexiets. a soft systolic souffii
may sometimes be detected by careful auscultation over the aorta.
On inspection aud palimtion, the inipuUc is either indistinct or ab-
sent; the apex remains in its normal position. The pulse in fatty de-
posit i« slow and full; in fatty degeneration tt may be alow or rapid,
iHit it usually appears to be rapid at the wrist, even though the heart'
is beating slowly.
By percussion, the heart is found of normal size in uncomplicated
fat^ degeneration, but slightly enlarged iu fatty deposit
In anscultjitioTi, the lirst i^ound is frequently absent, but If present
it will be fcoble, short, and valvular, having lost nearly all of ita muscular
element. The second sound is usually short, clacking, aud distant.
Ui
CARDIAV AND AJJTSHJAL DISEASES.
A soft, blowing imirmnr may frequently he heiird over the aorta with
the first sound, especially if the pntienl ia in the recumbent position.
Exf^ptional. — Sometimes the }ieuK souittW in tliit ditteusi! are like tho»« of
Ute I'cetuH in utero. ttaiiit:timt;:» they ui*e luetiUlio or i'jii^in^% unt) il is Biiiii that
Ihe HecoDt] sound is someUiiiiJft prolcingeil ami intensified.
Stokcft conftideretl the occurrence of pseudo-apoplexy with a soft nou^e
in the aortic iireii, with the first sound of the heart, and a bIow pube
positive evidence of fatty degeneration of the heart; but these signs are
seldom combined in the same individual.
A combination of several of the im|Kirtant Kymptoms and signs which
have been cnumeratod is often present, and may justify a positive diag-
nosis.
DlAGKosis. — The physical signs arc not always well marked, aud a
positive diagnosis is often impossible. Fatty heart is most likely to be
mistakpn for functional affections of the organ, from which it can orjly
be distinguished by careful »cnitiny of the syniplomB anil signs
already enumerated, and the exclusion of hysterical affections and other
functional causes. A distinction may sometimes be made by cansing
the patient to walk briskly, when if the trouble is functional the heart's
action becomes more regnlar and stronger and the sounds more distinct,
whereas if organic changes are present the pnUations become more
irregular and feebler than before.
Pbognosis. — The prognosis is unfavorable in fatty degeueration.
Fatty infiltration, when excessive, will produce degeneration of the mus-
cular fibres from pressure; much can be done in mild cases by a proper
system of diet and exercise. In either case, but especially in fatty de-
generation, death hy syncope is apt to occur suddenly and without warn-
ing, from excitement, overexertion or diBteution of the stomach or
bowels by a too hearty meal or flatulence.
TttEATMEyT. — The general treatment consists of cardiac and general
tonics and is the some as for valvular diseases. Patients should be
cautioned to avoid Uuiiig anything which c^uisea dyspnoevi.
Arsenioufi acid is one of our best remedies in caitliuc degeneration, as
it not only increa«ea the power of the heart, but also relieves the neuralgio
pains, which are among the most distressing itymptoms of this diseesc.
When the affection consists of fatty deposit on the surface of the he^irt,
or between its muscular fibres, much may be accomplishoil by regulat*
ing the diet. The patient should live principally on lean meat, avoiding
as far as poaaible all fat-producing food, ttuch as sugar, surch, and nico*
holic stimulants. He should take as little fluid as possible, and should
wear warm woollen clothing, even in summer, to favor free diaphoresis,
and should take systematic gentle exercise. These measures will lesaeir
obesity aud strengthen the weak musclea.
SYPHILITIC DISEASE OF THE UEART.
ANEURISM OF THE HEART.
%\6
Anenrism of the heart is » rare affection, consisting of bulging of
thut portion of the cnrdirtc walls which has been softened by inflamma-
tion. It usually occurs at the upex of the left ventricle, and ocoasion-
ally iii?olvcB the interventricular septum, bulging into the right
oarity. Rarely, it inelades nearly the entire rentricnlar wall, which in
such cases is thin and (]ilate<l, ami chit^tly fibroirs Trom lo^ of muscuUr
fibre. Occasionally it is (taccutat«d. sometimes rexiching the size of a
cocoanntf and connected with the ventricle by a narrow neck. The
walla vary up to a quarter of an inch in thickness. The endothelium,
though atrophied, usually remains intact. Commonly old stratified clots
line its interior.
Etiology. — Cardiac aneurism may develop from :iny condition which
weakens the wall of the heart, such XMa dtseaye f>f the curonar}* arlorieSf
fatty, fibroid, amyloid, or atrophic degeneration, or abscess whether or
not the sequels of myocarditis, endocarditis, or pericarditis.
Diagnosis aso Prognosis. — vV diagnosis can seldom be made before
death, which usually occurs from rupture or heart failure due to weak-
eniug of the muscle or mechunicul interference with its action.
Treatment.— The treatment must be entirely symptomatic: when
there is much cardiaic pain, roBtjand polaiwium iodide in mwlerately large
doses are most efficient. I'hcre are no symptoms or signs to distingulslL
cardiac aneurism from myocarditis.
RL'I»TrRE OF THE HEART.
Rupture of the heart may follow myocarditis or fatty degeneration cf
the heart. In the latter case, it seldom occurs in persons less than sixty
years of age.
STMrroMATOLooT. — The symptoms are: sharp, sudden pain in the
priecnrdia! region, faintnoss, collapse, and apeedy death; though soma
patients have lived forty -eight hours after the accident.
Death is nsnally so sudden that an examination cannot be made, but
the signs must of necessity be those of distention of the pericardium by
fluid, with extreme weakness of the heart. Treatment would be ud>
availing.
STPHILITIC DISEASE OF THE HEART.
A few leases have been obscrrcd where heart disease seemed to have
resulted from constitutional syphilis. Syphilitic affections of this organ
consist of fibrinous exudations into the connective tissue, which may
either soften and suppurate, forming ulcers or small abscesses, or be
converted into masses of hardened fibroid tissue; and it is not im-
prububle that, us suggested by Corvisart, vegetationa on the valves may
in some co^ra have a syphilitic origin. An accarate diagnosis is imjiod-
aiblu. No treatment can be liuggested where a diagnosis cannot be mmle.
246
CARDIAC AND ARTERIAL DISEASES,
TrMORS t>P TFIE HEART.
The heart is very sehlom the seat of iieophisniB. Congenitul angio-
mata may exist ill its walls; aurcomata and L-jircin'miHta iniiy [ifnetnite
it Xroiu adjacent organs. Hydatids are niruly Jouud. Of ihc*o uo diag-
nosis vnu ha nuide. The. prutiitosin U nece^oartly tiiifavonible in tliu eiise
of progressive tumors. Tbo frmimsiii uu»t bu symptoumtic.
MORBUS C^ERUI.EUS.
Sptio»i/itiif. — Cyanoftis, the bhie diitease.
Horbns Ctprnleiis i^ ilio rQeiiltof cungeiiitnl malformation of the heart.
Cyanosis, usually nuirked in the t';isi*«. it* jwcj-ihed. to gt-m-ral vpnouB con-
gestion due to obstrnction in the riglit hi*jirt, but it bait also betfU Rnp*j
posed to cc6ult from admixture of venous wirh arterial blood, 'i'hol
morbid conditions, found post mortem, may bo pnteney of the ductus
arteriosus or foramen ovale, dcticiciit inicrvcntricular septum or luir-
rowing or complete closure of the puhiioiiic ohtico. Two or more of
theiie abnormities are not infrequently combined, the first mentioned,
being the defect mast often present.
iSyjiPTOMATiiLOoy. — The unfortunate subjects are usually small and]
feeble young children. Cyanosis may bo slight or it may amount to a deep
purple or blue color. It occurs early, but may vary at different times.
The saiMjrficial temperature is low, giving rise to chilliness. Cough^j
dyspncBa, and frequent attacks of palpitation are common, appearing]
after or inLTe!iiie<l by exurtion or excitement.
As siffitx, inspection, in addition to the bluenesa of the surface, often
reveals priecordial bulging and abnormal pulsation diffused to the epi-|
gastriuni. I5y palpation, especially at the base of the heart, a thrill may
be obtained. Percussion allows enlargement of the right heart; dulnesa,
according to Gerlmrdt, nmy often be elicited along the left side of the
sternum, as high as the second rib, owing to the enlargement of the
conus arteriosus and distention of tbo puhnonary artery. AuBcultation
may discover a systolic murmur over the region of the pulmonary artery,
and rarely a diastolic murmur. A systolic murmur during the first
three years of life is said to be invariably of congenital origin,
DiAfiNORis. — In the r>ondon Lancet, May, 1ST9, Sansom formulates
the following propositions relating to the diagnosis of congenital diseoso
of the heart in children.
First, in cases of congenital cyanosis, in which no cardiac raurmnr ia
manifest, there is probably })atency of the foramen ovale. fl
Second, in cases of cyanosis with murmur varying at inter\*als, and
heard over the sternal ends of the third and fourth costal cartilages and
intercostal spaces, there is probably patency of the foramen ovale. M
Thinl, in cases of cyanosis with loud, unvarying systolic murmur,"
with maximum intensity internal to the posttiou of the apex beat, but
NEUROTIC OR FUNCTIONAL DISEASE OF THE HEART. 217
heard also at the buck bctvuen the scapolie, there ia |irob:1>Iy itni>errec-
tion of the rentriciihir septttin.
Fourth, in cases of oyjitiosifi and of marked nnf^mia. in cliildren who
maiiifL'St a ]>roi)oiiiiced Buperficinl tivstolir. nnirniur nt the biise I'f the
heart, there is probably constriction of the pulmonary artery ut jt« ori-
fice. Snch murmurB may be associated with aneemic mnrmnrs which are
hoard nbuvi- ttie oliivicles.
Fifth, ill ca«c8 of cungonitul iifTection of the heart in which there is
evidence of considerable dilatation of the left chambers, it is probable
that enUoL>;irditit) ulTecting tlie vulvus has coiiiitituted a oumplicatiun.
pRotiN'Osls. — Mu(it Bubjectri iii congenital niiilf{»rmation of the heart
lire but a few houra or days after birth, and vt-ry rarely reach advances)
age. The prognoaia is be^tt in cases of eongemtal stenosis of the pnl-
monary artery.
Tre\tmext. — No specific treatment can bo recommended, but the
«ame general rules should be observed as iu coses of mlvalar disease of
the heart.
KEUROTIC OR FCN'CTIONAL DISEASE OF THE HEART.
Fanctional disorders of the heart are characterized by peculiar sensa-
tions and by eliange in the f requeuey, force, or riiythm of tho pulse anil
Apex beat, mid in the dmraetcr of the heart souuds, sevcml of these
being eomnioniy iisitociati-d.
The affection ordinarily manifests itself by frequent paroxysnuil at-
tacks of palpitation and irregularity of the heart's action. It is aptly
ctated by Balfour, that if a patirnt come complaining of disease of the
heart who has not nlitaiuetl the opinion of a physician, we may, in the
majority of cast's, ut(i(un> him that It is only a functional alTection, and
that no organic <lisease exists; for the latter generally escapes notice
until detected by the physician.
Etioloot. — Tlie variations from the normal conditions may be tran-
sient and paroxysmal, or more or loss constant.' They may aHfln from
emotional causes, as, joy, fear, or shock, and from hyfteria, or hypochon-
driasis. They ai-e often aHROi-Iated with cliorea, exoplithalmic goitre, and
'Other functional nervous derangements. They may re-snlt from ovor-ex-
crtion, from the exhausting influence of acute diseases, or from reflex
irritation, especially of gtistric, hepatic, or intestinal oriffin, or from
excessive venery. They may be due to antemia or to poisonous agencies
acting through the t-irculation. whethirr referable to lithsmia. gout,
rheumatism, lead poisoning, or inordinate Urte uf nleohol, tobitcco, tea,
and coffee. Heredity and the nervous diathesis are also potent factors
in their causation.
SVHPTOHATOLOOY. — Ctrdialgia and palpitation or a snhjectire sens^
tion of the cardiac impulse, are the most constant ^rmptoms of func-
248
CAHDJAC AND ARTUHIAL DISEASEa.
au-
:i
lie
i
tional disonso. and uiiually give rise to much anxiety. Abnnrmitlly rapid
pulse (tachycardia) or abnomiaUy slow pulse (bradycardia), or irregU'^
]arity. intermittency, weakness, or fulness of its beat, and morbid pn©^
cordial ijoundd and aeiiiuitiuii» frti(|uently occur. Vertigo, tinnitus au-
riuiu, uiid j)hoi:oj>hobia are not uuuummuu, and markod ]>seudo-angii
peulorie may occur.
Tliough tlie physical signs of the neurotic affection are in no waj
cbaracterislic, physical diagnosis is of importance in excluding organic
disease. _
By inspection and palpation we find the apex iu its Donnal poaicioin
bat U8u:illy the impulse is comparatively feeble, thuugh the stroke may
seem sharp and cjnirk. 'V\w. artion of the heart is usually irregular.
Percussion shows the heart to he of normal size.
In ausoultjttion, hoth sounds of the heart are abrupt, and may be ii
tensitied. Occasionally the first sound has a metallic character. Fr<
quentlyancemic murmurs are found in the aortic area, and also in a space
vhich luis been improperly termed the pulmonary area, viz.. a limited
area, an inch or an inch and a lialf to the left of the stenium, in the
secuud intercostal sjiace. The murmur In the latter position is appar-
ently due to slight niitral regurgfitatiou dependent upon a Meakeued
condition of the left ventricle whif^h allows dilatation to such an extent
that the mitml valves are unable completely to close the auriculo-
ventricular orifice. In such cases the dilatation disappears, and the^
murmur ceases aa the muscles regain their tonicity. f
DlAOXOSis. — It is of great importance to make au accurate differen-
tial diagnosis between iunctional and organic heart discajjc. The chief
points of distinction have been already noted in the differential diagnosis
of chrouic endocarditis.
The symptoms of functional disease of the heart may be associate
with the signs of organic lesions merely as a coincidence. In such ii
stances an exact diagnosis would be exlremely ditScuIt. It could only"
be made by repeated careful examiuations and by the evidence afforded by
treatment, under which many of the functional symptoms may disappear J
PiiOON09ls.^Functional disorders of the heart usually continue for
months or even years unless the cause can be ascertained and removed
by proper treatment, but they are seldom if ever dangerous to Iife» ill
true angina pectoris be excepted. ™
Tkeatmkst. — The first thing in these case^ is to impress upon the
patient the fact that his heart symptoms are not due to organic diseaBOi
aud that he is likely to recover entirely. This must be done after ^
careful and painstaking exauiiuation. Since neurotic affections of thA
heart are usually due to antemiaf hysteria, uterine irritation, sexual
abuses^ or the excessive use of alcoholic stimulants, or of toliacco, or of,
tea und coffee, we should ascertaiu which of these operates in tlie
before us, and advise accordingly.
>sia
i
TACHYCARDIA.
Wi
General tonics are usually Indicated. In a fen* cases digitalis will bo
found »errioeable in controlling the action of the heart, but sjmrtL'ine
sulphate gr. \ to i., tinct. of KtrophanthuR niv. to x., tinct, of couvul-
luria TUX. to xv., or fl. ext. of ra^tiis gmndiflora irii. tn iv., tliree times
a day are, as a rule^ more pfficient. In many cases strychnine and in
others bromides are specially heneficiat, and occaaioniUly nitmglycerin,
amyl nitrite, aconite, or veratrum viride may bo beneficially employed
in small doses.
TACHYCARDIA.
Tachycardia is a term which may be broadly applied to an abnormal
rapidity of the heart, occurring either aa a paroxysmal or as a more
permanent affection, whether or not accompanied by weakness, irregular-
ity, or lutormitteney ol the pulse. The )>ul8ationti may run trom une
bnndred and twenty to even three hundred per minute. If the uctiun
is rapid and the impulse forcible, it is L-unimonly termed ]mlpitution.
Tachycardia may be a symptom of organic or of functional disease;
it also occurs as an idiopathic ntTertion and is occasionally hereditary.
In some instances of paroxysmal tnohycarclia as described by L.
Bouveret {hiteruational Metllral Annuai, H, p. 252) in a report of
eleven collected coaes, the heart, normal in the intervals, is seized with
paroxysms of rapidity, which, if the attack bo of short duration, may
fXeach two and even three hundre*! beats a minute. If tliese attacks
'are prolonged for several days, symptoms of cerebral hyperiemia with
embarrassment of the pulmonary and systemic circulation commonly
ippear. In such cases, change to the normal action may occur snd-
'denly, and may bo followed by decided prostration. Four ont of the
eleven caaes died of asystole or sj'ncope. Instances of hereditary tachy-
cardia have been known in which the heart heat with infantile rapidity
through life seemingly without detriment to the individual.
The so-called irritable heart of soldiers so well described by Da
Coeta (Medical Diagnosis, page 405) is characterized by habitual rapidity
complicated by paroxysms of palpitation and pri«<^ordial pain brought
on by exercise, with frequent attacks of headache, dizziness, and cuta-
neous hypenes thesis.
"With the paroxysmal form of tachycardia in addition to the palpable
tod risible rapidity of the cardiiic impulse, ])hysicul exploration may
elicit signs of iKilmonary congestion. lu irritable heart, Da Custa says
the action is rapid, often irregular and rather abrnpi and jerky, the fi»t
sound short and sharp like the second, but sometimes very faint.
pROQXOiitis. — In severe paroxysmal caseii, the prognosis is uncertain,
Tsrying with the persistence, frergueney and severity of the attacks.
Tbeatment is that suited to functional disease.
250
CARDIAC AND AUTERIAL lilHEAiiES.
BKAI>YCAIU)IA.
Bniilvcunlia ur abuuniml Hluwueiw uf th« pulse though often seen
in slight (Jt'greo, \% much rarer us a wcn-miirked cbamcteriBtic than
rai)nl pulse. The freqtitjiiej' iiiny full as low as sovcuteen heats per
minute (Balfour, EUiubiifijh Mett'iatl JonnutK 18D0). !n one variety both
heart and pulse betit alike, in another the pnlsations of the heart wiiilo
normal in frequency at the apex are so weak that all are not felt at the
wrist. Prentiss' classification of the causes of slow pulse is as follows:
distjjiiie or injury uf the nerve CfUtre causing paralysis of the eynipa-
tfaetic nerve or irritation of the pneumogastric nerve; disease or Injury
to thf trunk of the vagus, increasiug its irntability; disease or injury
punilyzing the sympathetic; diiwase of the ciirdiac ganglia; disease of
the heart muscles; action of poison? upon the uerve centre or endings
{/iiti-^nKftiounf. MMicol .I/uift^f/, 1S!^I] ). I have seen a few cjises that
seemed the direct result of prolonged aeverc paiu. When well marked,
it is usually iin unfavonible sign, owing to the tendency to pseudo-epi-
leptic and pseudo-apoplectic attacks. Death may occur during these
seizures or from aetheniJL It may be a symptom of fatty heart.
Treatment must aim at gencml nervous and cardiac stimulation.
ANtJIXA PECTORIS.
»
Angina pectoris is a term applied to attacks of severe paroxysm
cardiiic p>tin, associated with a sense of impending death and minor
plieuornena commonly symptoaiatic of serious organic leiiious. A dis-
tinction is to bo drawn clinicully and etiologicuUy between true angina
pectoris of organic origin and pseudo-angina or hysterical angina de-
pendent upon diathetic or toxio influences. True angina most fre-
quently atticks men of advanced yeurs. but the faleo variety is coiumon
tound in comparatively youug neurotic women.
Ktiologv.— True angina pectoris seems in most cases to depen
upon arterio-seleroais and other diseases of the coronary arteries tending
to their contraction or obliteration, and consequent deficient nutrition
of the heart. According to Liegeoia (£H//cr/i'/ mcdtcah ties {'(jsprff, 1888)
three-fourths of all cattes may be ossigneil to Bcleroais or atheroma of the
coronary arteries or aorta. Not infrequently the affection appears to d^
pcnd upon cardiac dilatation, valvular disease, fatty and other degenerative
changes, aneurism, or pertcuriliiis,any of which may disturb the circula-
tion through the coronary aitvriuii. Douglas Powell believes vaauuiotor
disturljance an essential factor in the iiinjovity of casijs uf angina pectoris
{British .\hdiml Jounuil, 1801). Sometimes no cause for the disease
can be diiK-overed. Among possible causes may be muntionvd organic
affections, such as cancer involving the pneumo-gastric or cardiac au
ANeJNA PBCTOHtS.
251
thoruoic picius of the sympathetic {Lyon MeiUcale^ 1888), chrooic DctintiB
aud pigroeutary »ud.grantilur degeueratiun of nerve celU {Ln Semaiiu
Atetlirafe^ March, 1600). Ilie iiiimt'tliate oaiiiie of thi* iMiroxysm iimy
be emluli^jin uf the euroiuiry artery, but it is ii:iu:illy huiiiu mental or
physical exertiou, sexuul deraitgement, error of diet, or exee&i, iiifluctic-
itig the vtutumotur ineohauisin. OeeasiuuaUy the gouty aud rheiiitiatic
diatheses, by vitiating the bloofi supply, are undoubted etiohigiciil fac-
tors both in producing the primary diiieaBe and in favoring the j)arox-
ysra. Pseudo-angina may be dne to reflex oauises or to direct central
irritation. The former are eonimonly of gastric or hepatic origin, such
as indigestion, gastric catarrh, tiatnlence, or the presence of gall stones;
the latter include cerebral an<l spinal ncnrasthenia and locomotor ataxia.
Symptomatology. — The most characteristic symptoms of true angina
pectoris are agonizing sternid or prspconUal pain probably oansed in moet
cases by over -distent ion of the heart, with a peculiar fear of impending
death. This pain usnally radiates to the left shoulder and down the
arm, often stopping at the elbow, but frequently extending to the ring
and little finger. It is often severe up the side of the neck and Itehind
the ear. It sometimes extends to the right side and may ocraslonally
be felt in the thighs. The pain has been variously likenc<l to a stab, a
thnist with a red-hot iron, a sensation of suffocation, or grip of nn icy
hand. Pallor and fear are depicle^l on the countenanee, and respira-
tion is frequently interrupted as though the sufferer had forgotten to
breathe. Tlie pulse is usually, though not always, feeble and irregular
or intermittent. The duration of acute attacks is usually from half an
hour to two or even three hours, ami they not infrequently terminal© in
ayncope or death. If the patient sunivea the first attark others are
liable to occur at irregular intervals, at first far apart, but ere long
nearer together until one finally proves fatal. Attacks of pseudo-angiua
are generally of longer duration but of lees severity.
No characteristic siijns accompany either variety of the affection, bnt
Talvular dit^eiise, fatty degeneration, or dilatation of the heart is com-
monly present in true angina.
DiAososTs. — Angina pectoris pro^wr may be confused with the
hysterical form, or, if mild, may possibly be mistaken for intercostal
neuralgia, acute pleurisy, or myalgia. It may be distinguished from
pseudo-angina pectoris by the following pointa:
Tbuv akou<a PECTOmS.
Hysterical or psKmo-AKOiKA
PECTORIS,
nutory.
Usually in men over forty; cordino
lesions, eflpecialiy arterio-sclerosiA of
the coronnry arl«rie« aad Tatty <le-
gene ration. Atlackn caused by exer-
tiun any time of day.
Ofteneat in women t any age ; neu*
ralf^c diathesis, but no cardiac )eslon«.
AttacksspontaneouB ; usually al night.
»52
t'AHDIAC AND AHTJ£iUAL J>iSEASBS.
TBCB angina PECTOMfi.
Htstehical or pmiotdo- angina
rEOTOUlS.
StfV'ptomti.
Pain very severe and of short dura-
tion.
CompantivesilaQce aofl miniobility;
often speedily fata.]. Not tt:lievetl by
aotl-neuralgic remedies.
SigjiM.
Murmurs and enlaiyeiueDt frequent. Xo organic diseasflL
Pain less severe and of longer dura-
tion.
Comparative agritatlon and activity;
seldom if ever fatul. Believed by >
neuralgic medication.
It may be differentiated from intercoxtal neuralgia by tho history
presence of tho characterietic painful points in the latter diseapo. In
tnya/gi'/i, the character and seat of tho pain, the tendornoas of tlio mus-
cles, and other symptoms are sufficiently dic.g:no8tit!. The pain of tfciUe
pleurisy is attended by cough, pyrexia, aud distinct pliysieal signs uot
present in angitm.
Phoos'osis.— The first attacit of angina pectoris ia often fatal within
two or three hours, and sometimes a suddeti sharp pain is the only warn-
ing of instant death. More frequently thd patient survivus the first
paroxysm, but after a few mouths dies in the second or third attack.
Sometimes [tiitients live for many years subject to occasional attacks
which gnidiially be<*i)nn' more and more frequent until finally resulting
in dtMith. A cousidcrabla number, however, recover under appropriate
treatment or at least live nanny years with but few and light attacks of
the cardiac |>ain. In ]>aeudo-uugina, the proguoeis is favorable provid-
ing its cause can be removed.
Treatment. — For the paroxysms, alcoholic stimulauts, opiates, or
inhalations of aniyl nitratu Tll.v. to vi., or of chlontfonn are most eRicient,
Chloroform, though appareutly a duugeroua remedy, has proved harm*
less, proni]>t, and etiicieut when administered us reconmiended by Ci. W.
Balfour, of Edinburgh (C'linicul l^eetures on Disease of the Heart,
187(>). Half a dnu-hm i.t poured upou a sponge at the bottom of a wide-
niouthed bottle, from which the patient may brtathe ad Ubitum until
relieved. The patient drops the bottle as B«)on as he becomes partially
unconscious, and it rolls away. NitrogIy<!eriu has been recommended
foi the cure of angina pectoris, and from the published reports it ap-
pears that numerons cases have been benefited by it. 1 have found it
of mnch value in stimnlating the heart and relieving the painful parox-
ysm, but I have uot witnessed curative reenlts. It is administered
either in pill, tablet triturate, or solution. The dose adminialered to
relieve the paroxysm is ordinarily gr. -^^ which may be repeated onco
in twenty minutes until three or four doses have been taken or relief is
obtainedi unleaa itfi physiological effects are too strongly developed.
AMUINA PECTORIS.
353
When the eusceptibilitj of the patient to the remedy has been nacer-
tained, doses two or three times larger may somotimcs be given. To
prevent recnrrenoe of the attack, it may be giren three times daily, at
first in doaes of gr. y^g, but these may be increased to five, t<^n, or even
fifteen times a& mnch^ providing that it does noi canse severe headache,
giddiness, or overpowering somnolence. Dnring the intervals between
the attacks of angina, the same hygienic ruleii should be observed as ia
valvnlur disease. Arseniona acid should be given in moderate do9e«,
with or without iron, strychnine, and digitalis, acccrding to special
indications.
Huchard claims that large doses of potassium iodide (grs. xl. to 1.
daily) continne<l 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 iOasf/te de.* lUpitauXy 1890). The remedy ig cer-
tainly very efficient in relieving the pains of aneurism and sometimes in
relieving cardiac pain. In pseudcKangina, the cau^ must be aecertaiued
ard removed if possible. Remedies usnally should be directed to the
relief nf rheumatism, aniemia, or debility, or, most important, to the
correction of indigestion.
CHAPTER XV.
OARDIAO AKD ARTERIAL DISEASES.— CoH/r^t^fri
AORTITIS.
The symptoms ascribed to iicute exud»tivo inflammation of the aarU
have been described by Fmnk, Uizot, and others; but as stated by R.
Douglufis I'owell, the disease as ii primary uffection is of very doubtful,
if uot impossible, occurrcuco. We need not attempt to describe any of
the signs or symptoms it might jwssibly occasion.
ATHEROMA OF THE AORTA.
J
Stfttonyms. — Aortic endarteritis ; aihcromatous degeneration of the
aorta.
Atheroma of the aorta may be defined as a degeuerution of tlic coats
of the aorta, eoiisisliug of an irregular thickening and sotioniug of its
wallti, especially of its inner couL
II seldom occnrs liefore the forty-fifth year of age. H
AxAToMH AL ANii P.\THOi.onn_AL Charactkiustk s.—Thc disefls©
consists uf thic-keniug and fatty degeneration, usually followed by cal-
careous iuGUnition and occasionally by ulceration. It is primarily con-
fined to the iiitimu, but uot infrequently involves the muscular coat. It
begins with inflammation, occurring in sirattered jmtches, winch have
the milky opacity characteristic of the first stage of acute endocarditis ;
later these become yellow from fatty change. These areas may coalesce
to some extent, and deposits of lime suits commonly tiikc place, giving
the surface a scaly or nodular upjMjarance and chalky hardness. Clcci-a-
tioii occaaionally results from rapid central softening of the patch and
distthurge of the debris. Microscopically, tlie thickened iutima early
shows round and spindle cell infiltration and more or less increase of
fibrous elements, but no hlood- vessels. Later the s]iotii of softening are
found to contain oil globules, crystals of cholesterin, and a gmuular
debris. These processes rofiult ut first in thickening of the arterial wall,
finally weakening, loss of elasticity, dilatation, and in some coses anej^
rism. V
The affection is uaually limited to the initial portion of the blooo^
vessel ; indeed clinical evidence of its existence beyond the transvei
portion of the arch is very rare.
KTioJ.ouy, — The chief causes are: gout, rheumatism, syphilis, cbroi
ATir F.ROM f\ OF TUE AORTA.
■2M
nephritic, high living vitb inHufticient exercise, aud the excesfiivo nse of
alcohohcfl. It fiomptimes rettults from uudue strain of the artery, as in
excessive mnscutar efforts.
SYMPTOXAToLOoy.— The symptoms of atheroma of the aorta are
always obscure, and its phy.iical signs, in many cases, are far from posi-
tive. Among the most prominent symptoms and sitjnt, we observe at-
tacks of pjilpitation or anginal p;iin atiil dyspiiu'a, whirb art? usually
brought on by exercise, but msiy ot'our independent of exertion. Dur-
ing these attacks the pnl?e is commonly very weak. Signs of gen-
eral atheroma may often be detected in the abnormal rigidity of the
temporal, nidial, and brachial arteries.
By iuspcL-tion and palpation, when dilatation has taken place, feeble
pulsation may be seen or felt iu the second intercostal space close to
the sternum, on the right side.
Ui>on |>ercu3S)on, there is found a somewhat increased area of dulness
OTer the ascending or transverse portion of the aorta.
On ausoultAtion early in tlie disease, there may be some evidence of
hypertroiihy of the left ventricle, as indicated by an increased impulse
and muffling of the first sound of the heart. These signs, however, are
not characteriHtic, as they might arise from emphysema or other cause
of obstructed circulation.
With the advent of dilatation, the Hrst sound of the heart becomes
more indistinct, while there is accentuation of the serond sound over the
uoi-tic valves, thought by some to be diagnostic of dilatation of the uorta,
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 pragresscs, tlic bruit becomes more distinct. It is some-
times rough in elianicter. 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 valvos incompetent to close the orifice, and allows regurgi-
talion into the ventricles.
When the heart is beating slowly and regularly, both the first and
eeoond sounds may he 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.
Ijater in the disease, dyspnoea becomes marked, the attacks of angina
are more frequent and persistent, and the symptoms of embolism, such
as hemiplegia, rigors, hsmuturia. auperficial hemorrhage-s, or gungrene,
may make their uppearance: or tlie formation of n sacculate*! iineunsra
from the aQectcd portion of the artery may be indicated by the sudden
occurrence of jtain, dyspnma, and faintness. Finally, sudden death may
result fiom heart failure or from rupture of the aorta.
DlAOMoai».— The principal symptoms and signs of atheroma of the
256
CARDIAC AND ARTERIAL DISKASESL
aorta are : p:iIpitation, pain, and djEpnoaa, with rigidity of the superiicia]
arteries, muffling of the first sonnd of the heartland ac^entnation of the
second, over tho aortic valrea. The* first heart sound is uenallr followed
by a more or leas distinct systolic mnnnur. Somctimea there is a diaa-
tolic murmnr in the region of the ascending or transren^* purtion of the
urch of the aorbt, with slight increase in the area of dulness daring thu
later stagce. The affection might be mistaken for simple diaeaw of the
aortic valres, or inorganic disease of the heart, with ani^emic murmnrs.
Though it may cause many of the symptoms and signs of atheroma,
fiUeast of the aortic vttives is not attended by a rigid condition of the
eaporficial arteries, or the peculiar neuralgic pains which usually attend,
atheroma, and it does not cause accentuation of the secoud souud at the
aortic ralves or an increased area of dulness at the base.
When anipmic murmurs are associated with functional disease of the
heart, they are not attended by rigidity of the superficial arteries^ bj
the peculiarly distinct accentuation of the second sound, by the systolie
shock, by the diastolic bruits or by increased area of dulness.
Treatmest.— 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 most be avoided.
AORTIC OR THORACIC ANEURTBtf.
An aneurism is a sao the cavity of which commnnicates with the
lumen of the artery.
Anatumical and Pathulooical Characteristics. — Aneurism m&y
exist as a fusiform dilatation of the artery, but usually, when well
marked, it is saccular, formiug a pouch-like projection from the vessel.
Tlie wall of the aneurism may be composed of all the coats of the veaael^
tliough (Tommonly the muscular tunic is wanting. Karcly, the walls aro
formed by a conden&atiou uf the surrounding tissues into which the
artery has rupturetl, called diffuse aneurism. It the blood effects sepa-
ration of the arterial cuats, a directing atioirigm is formed. The cavity
is generally lined with coueeutrically stratified blood clots of varying
agCf thickness, and consistence, which arc 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, u'sophiigns, or
through the chest wall.
Ktiology.— 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
AN£VRIS2S OF THE DSSCS^•J)INO AORTA. 257
of the walls oi the artery is the chief predisposing cause, vkelher duo to
syphilis, chronic aepliritis. gout, rhLniniatism, chronic iilcohoUsm, lead
or mttrcuriiil poisoning, or lo Si'vtinil of these comhineil. The immpdi.ite
cause maj he Atulden struiu. u blow, full or wound, or continued excesses.
ANEURISlf Of THE SINU8K8 OP VALSALVA,
Anenrism of the sinases of Valsalva is usually so small as to give
rise to no peculiar symptoms or signs, hut the indicutious of athe-
romatous degeneration, with a pulmonary systolic or diastolic mnr-
mur due to pressure of the aneurism on the origin of the pulmonViry
artery^ might lewl us to suspect the true nature of the leeion. The diiig-
nosis can rarely, if ever, be marie 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 producer and those
of valvular origin.
AMECRISU OP THK ARCS OP THE AORTA.
Aneurism of the arch of the aorta consists of preternatural dilatation
of the artery, which may be general involving the whole circumference
in a fusiform, cylindrical or globular swelling; or saccuhitedr forming a
pimch-like projection from one side of the artery.
Sacculated aueurisms are usually globular at first, but may subse-
quently acquire different forms, especially the conicaL
Aneurisms may occur in the ascending, transverse, or desnending
portion of the urch of the aorta. About one-half have their origin in
the ascending portion; a few involve both the ascending and the truus*
verse, or simply the transverse portion of the urch. Nearly one-fourth
nrise from the descending arch, and about the same number from that
portion of the aorta between the arch and the diaphragm.
ANBrRISM OP THE UESOENDIN'O AORTA.
Anenrism of the desceuding aorta ultimately causes & pulsating tumor
behind, at the left of the spinal column, between the thirtl dorsal verte-
bra and the poiut at which the uortu perforates the diaphnigni. Ero^ioa
of the vertebrie, with cousequeut curvature of the spine, is usually pro-
4laced by pressure. Subsequent compression of the spinal cord may
<!»nsc 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 Hptnal
column, The brnit. in an aneurism of the desoending aortu, may bo
distinguished from a mitral rcgurgituut murmur, frequently heard in a
similar pf>sition, by the fact that the aneurismal murmur is heard nob
only between the fifth and the eighth don'al vertebra, but also above
«nd below this position. The mitral regurgitant murmur is not heard
17
i
CARDIAC Jjrj> ARTEliUL DISBAHBS.
distinctly Above ttit- lower border of the fifth or below the upper border
of ifae eighth vertcbni.
Stupto^atolouv. — Tutiiors of thiii clumcter may somotimeii
diiLguosticaleU from the H^aiptoinH, wheu they cannot be located by
physical signs. The more prominent symptonis, though not indi-
riilu.tlly charocterietic, maybe suSicient for the purpose of diagnoA^^
when grouped together, and are of great value when taken in connectio^H
with the physii-al signs. Enumerated nearly in the order of thuir im-^
portance, they are: p;iin, dyspnom, palpitation, dysphagia, headache, aui^^
disordered vieion. ^H
The pain in aortic aneurism is persistent, of a peculiar wearing, nch^^
itig, or burning churacter, and is referred to the region of the tumor.
Frequently there are neuralgic exacerbations, with pain radiating in t
course of contiguous nerves.
byxpnofii of varying degree is geaerally present, and is usaally
gravatcd by much slighter causes thau those whi<;h would occui
the same symptom in other varieties of intrathoracic tumors. It t
qnently occurs in severe jmroxysms, which may be due to one or mo:
causes. Ordinarily, such attacks are ascribed to fipasm of the glotti
resulting from irritation of one or both of the recurrent larvngeul nerves.'
More probably they are due to paralysis of the abductor muscles of the
glottis which arc supplied by these nerves, with consequent falling to-
gether of the vocal cords, and obstmction of the glottis during iuspinu
tion.
The exacerbations of this symptom are due in some instances to a>
collection of mucus at the glottis; in otliers to the varying preesnre of
the aneurism upon the nerve which, at one time, completely msj>end6
iti function, at another interferes with it but slightly. The voice i&
|3bo modified more or less by the same cause, and mav be entirely lost.
Dyspntea is sometimes dependent upon narrowing of the tniobc*^
or of the bronchi from pressure of the aneurism. In such innil.'incce^
the paroxysms are probably ilne to a collection of mucui* which the
patient may be unable to expectorate at the point of stricture.
Paljntafion of the heart is generally produced by slight exertion: it
may he due lo irritation of the sympathetic nerve ur piinilysis of the
Trtgus from pressure.
Dtf»phfigia, due to pressure npon the cesophagus. is often present,
though it is a less frequent symptom nith imeurisnial than with other
uiunors.
HMdache, due to interference with the return of blood to ihe heart.
if! not uncommon.
Dimrdered vinion is due to pressure upon the sympathetic nerve,
and <-onsequent interference with the action of the iris. Ordinarily the
pupil upon the afTe<'ted side is strungly contmcted, but in mre iDatanoM*
from complete juinilysis of its sympathetic nerve, it may be dilated.
ANEVRia^ OF TUE DSSCESBINU AORTA. 35:>
ifmaopiyitis, to a eliglit ilegree, lit sin occatiional fivoiptom due to con-
gestion of the niucoua niembmne. Copiouii liiemoptms frequently oc>
cars at the close of the disease, when the Aneuriem nipturen Into the air
passogea.
The essential signs are: n pulsating tumor in the region of the norta.
with systolic and diastolic shock and sometimes bruits.
L'pon inspection, we often obaerre marked lividity of the face, neck,
and upper extremities; with turgesceuce and a varicoso condition of the
reins, and perliaps a-dema, due to obstruction in the return of Moud to
the heart from pressure of the aneuriitni upon one of the renie innum-
iiiattf or the descending vena cava. Occasionally a thick fleshy collar is
fmud about the base of the neck, due to capillary turgcscencc.
(Edeuia and turgesccnce are ordinarily limited to one side, and are
ciiuat'd by pressure on one of the veuns innominatte. If the pressure is
upon llie descending vena c:ivu, which la must likely to occur with an
niiourism of the ascending arch, these signs will be found upon botii
sides.
The snrfacd of the chest is seen to have a murble<l appearance, canscd
hv* the prominence and blueness of the veins.
A tumor may u«nally be olnierved in the course of the aorta, the
position of which will indicate the part of the blood-vesael affected.
When an aneurism originates in the sinuses of N'alsalva it caases no
e eternal tumor. AVlien in the a»ceiiding [wrtion of the aorta, if bulging
occurs, it will be seen in the second intercostal siwce at the right side of
tbe sternum; but if large, it may ext«nd far into the infraclavicular
>dgion, and even to the nmmmary.
Aneurism of the transvcrac jiortion of the arch causes a tumor at the
tipper part of the stcnium.
When the ilcMjcnding arch is involved the tumor generally preeenta
posteriorly at the left of the spinal column.
Brwittional, — In exceptional case*, aa ftneurism of the descentlinK arch of
the aorbi may bu fleen in front, and tn very rare iastaiicefi it may be found at
the right nf th>; ft|>in:il cohiiun.
Aneurisms of the descending aorta present {wsterlorly below the
fourth dorsal vertebra at the left of the spiue. V«ry rarely they are
aeen at the ri|.'lit of th*? a])inal column.
These tumors vary iu size from a slight prominence to one as largo
as a child^s bead. The alisence of a tumor does not necessarily prove
that no aneurism exists; for, while the aneurism is sniall, it may not
press upitn the chpi«t walls, and even when of considerable size the posi-
tion may l»e such that no bulging ia occasioned. The larger of these
tumors are ironenillv cnincal in form, and prei^ent very much the appear-
ance of an immense Iwil, covered by thin glazed integument.
««0
CARPI AC AND ARTERIAL DISEASES.
If pulsation of the tumor be observed, it will occur rhythmically with
the upox beat of the heart, rulaation, which cauuot otherwise be scoQj
juay sometimes be detected by briugiiig the eye to the level of the sur-
face of tliQ chest, us in stuiiditig behind the puticnt and looking down
over hiK shoulders. No pulMitiun will be visible if the uneurismal sac la
ocL-upied by fibrin or cougulattd blood.
If the tumor press on une of the main bronchi the respiratory move-
ments ou the corresponding side will be dluiiiiished or absent.
By palpation we may frequently detect a tumor, the impulse of which
cannot be seen; we can iiscertaiu the condition of the chest walla,
whether there bo perfomlJou of the costal eartiluges, sternum, or ribs;,
and may usually determine whether the contents of the tumor are fluid
or Bolid. The character of the pulsation is expansile, that is, alike in
every direction, and not simply lifting us is the case when a solid tumor
rests upon an artery.
Thf moBt valuable sign obtained by tliis method is the detection of
two pulsating points, us though there were two licaits, one beating in
the normal position iu the 6fth interspace, and the other above the third
rib.
ir the aneurism is BO ■mull OR lopKcap« observation by onlinuiT pulpalion it
may saiiii!liiaes be detected by piVMin^ firmly with oiiu hand ovtrr \\w aorta id
frout, and with tin; otber imslvriorly.
The impulse obtained over an aneurism may bo systolic, occurring
with the contniction of the ventricles; or it may be both systolic and
diastolic. The hitter, produced by contnit'tion of the artery, is usually
slight, but occasioniilly quite forcible. When found, it is a valuublesign.
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 suprastenfal notch.
Valuable information may be obtained in some cases from the pulse,
or from sphygmo^raphic tracings (Fig. 42). If the aneurism press
upon the arteria innominatn, or upon either of the subclavian
arteries, or if either of these vessels is obstructed by a congnlnm. tho
radial pulse M*ill be feebler u]mn the corresponding side. The carotids
are sometimes similarly uflected. If atheromatous degeneration of the
arteries be general, the superficial arteries, cspeciidly the radial and tem-
poral, will be found rigid and non-elastic.
Alterations in the movements of the chest walls and in the voca]
fremitus are also to bo sought by jwlpation. Pressure on the air pas-
sages will diminish the respiratory movements, and i^ause local or gen-
eral diminution or absence of the vocal fremitus, according as a bronchus
or the trachea is obstrncted or the lung itself compressed.
Percu8«iou must be performed gently, especially over large aneurisms,
as a forcible stroke might poeaibly rupture the weakene<} blood-vessoL
ASKUHlSJi OF THE DKSCKNmNG AORTA.
261
TTpon gentle percuHsIoii, the extent of diilneHs will not correepond tu tlie
size of the tumor, beuiuse af tbe overliipping borders of the lungs; but
by a more fnrnihlo stroke^ or bj nuscultatory percuaaion, vo may deter-
mine the limits ncc^nmtety.
The area of abnormnl duliiess is usually much smaller than in other
tumors, cuuKiiig syniptoms of equal gravity.
The Beiine of rftRi(<tJince felt upon percnsslon i« a valuable sign in dis-
tingitishing between aneurisms and other inlrathonicic tumors. Over
n tumor fillfnl with fluid, the resistance '\<i much lees than over a solid
growth or overnn aneurism filled with fibrinous deposits.
If tho aneurism present posteriorly, dulnoss will be obtained in Ibo
interscapniar region. If it press upon a main bronchus, or upon one
luug, causing I'uUupfie or congestion of this organ, dulness will be found,
over the corresponding side.
In auBCulUittuu, 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 contRiction
of the arteries. The impulse is usually attended by one or two sounds
which consist mninly of the transmitted heart sounds, bnt are in part
proiluced by dilatation and eontmction of the artery.
These sounds may bo associated with or supplanted by murmurs
somowhiU similar in character to endocardial oiurniurB, However, they
are ordinarily less intense, though they may be ecen louder than the
loudest heart murmurs. They are usually harsh in quiility, and are not
tninsmitted into the same regions as endocardial murmurs. Sometimes
neither soun<U nor murmurs can be detectetl over tho uneurisni.
If the tumor press upon a main hronehus, the respinitorj' 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 tho lung, and bring out the respiratory raunnur
where it could not be heanl during ordinary breathing. Vocal resonance
will be diminished or absent over tho obstructed lung, and absent over
tbe aneurism. If the lung be condensed by pressure, broncho- vesicular
respiration may be hcai*d.
If the tumor press upon tho recurrent laryngeal nerve, so as to cause
jNiralyais or spasm of tiie 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 curd on the corre»]>onding side, with
possible ]vareei8 of the other. Occasionally the pre^^ure is upon both
nerves, with consequent paralysis of both vocal cords.
Ferdinand Schuell {Munchentr mediciniscke Wocfietisclmjt, April,
1890) claims a new means for diagnosis of doep-scated thoracic aueu-
risms in tho aneurismatoscope. Tliia consists of a soft rubber tube
doaod at tho lower end and filled with colored fluid, a piece of glaaa
tabing boing inserted into the upper end. WlioQ this apparatus is
CARDIAC AND ARTERIAL DtltRAMO.
lUirtl.V liniorto<I into the a«ophtgii», it » mJ At the pilwriaot of .a
uhoiinmii "f tliu dMCouiIing »fch «re aoasniiicalal to the tube cm] am
iii*lii'HtiMl ill till) rUe anil fall of the Sud.
DiAHNiiNin.— Aneariflui of ib« thcnoe aorta m* be ooafeuaded
Willi wild tumaw; with aortic pokitMa, dae lo ngargitation tfarongh
tlioM'iniliiimr vuIvm; with paUning emprema; with dilauttoa of the
mirirlo; mi'l with ronwii'Jation of the anterior border of tbe long, with
iii)Puri«ii) of the pulmunary art«TT, and with anenriaBi of the arteria in-
inniiliiiiU». ,. , ^ , .. I
V,.noiu lurgoMonce. duptacenieiit of the heart, dolnen on fwrcns-
ilou, wnil DKMllfiufltioiw of the resptratorr soands, doe to pre-ure, are
iltflii common to tbt*e and to other rarieties of intrathoracic tnmora.
Variniio" in tho force and Tolume of the pulae on the two sides, expan-
illi> imlnBti'm of the tomor, with a sbock and bniit, are uulljr charac-
tj.riali'' "f unonriumB, but occaeionally even theae ogna may be caused by
lolid xrowthi. A diaatolic bmit and shock orer an intrathoracic totuor^
(ioioni|ii"iio<l by a clear second soond at the base of the heart, ifidiaguoa-
tic '»r wiif'ljriiirn, e^jHrcially if following a disiinct systolic brait and shock.
A nmmiur at th« ba*e of the heart, taking the place of the second
iound, when imociated with the signs of a tamor in the courK of the
aorta, i« raluablo evidence of probable atfaeromatons degeneration of
thtt aorta, iind the formation of an anenrism.
Tlifl dilfcreutial fearnrtrs between aortic and pnloioDary aneurisnu
U>d other diseaaes are pointed oat below.
Aneurisms may be distingnished from other intmtborftcic tumors b|L
ftttvntion to the hiiitory and symptoms as well as to the physical signs.
The distinctire features between aneurism of the aorta and aoli
tumors are aa follows;
AaroBUU cr thx aobta.
Solid tumobs.
Bigtorp.
Seldom or n^vi^r occurring' before the
iw*nty>nftli year of age. aad usually
not UDtil after the forty>flfth year.
Slight, If any, constltutioiuil disturb-
ance.
Ufuially maJignant. They may ot^
cur in early tUe, and not iafrequeoUr
before the twenty-fifth year. Om>«
constitational disturbance.
SymptOTTu.
Piilnixin«taot.and of a burning, wear*
fng, or iii.'tii(ig character and usually
agKruvaiRil hycxercDw; frwiuently »ub-
jfvl Ui nviinili^c exBccrtmtiuns. The
wvmpiomB and Bigns of prewiure vary
irorii itriie lo tjnuj, owiuKtuchaugesin
J^ djrectioQ of tJie prcMure.
Pain not so deep-seated as fo anei-
mm; may t>e sharp and laocinaiing'
iactiaructer; not alTccted by ejcerciae-
DOtsulij«^-t 14> neuralgic exacerbations.
The symptomti and sigus of pressure
are conHtaiit, and su.*sdily iacreaae
from day to day.
AyA'VHlSii OF THE AORTA,
£G3
ENBtntisM or Tas aorta.
Solid TtmoBS.
Sign9.
Ex|wnBiIf puli^utioQ, Often diitpar-
iXy bt-lwuvu Uiu iitdiulputsuM o[ lli« two
sides. Tlie urea uf diilaesi «mall in
proftoition to thessizeof thetunioraDil
Hie lenKtli or its history. Sensti of re-
sulunce sli^bt.
Nu piiUulion. cr if any, simply a
aligttt lifting impiil)^, i.-au»Hf(l by the
tumor resting' upon u large jirtery.
Usually DodiftpELrity in the pul!u> of Iha
two lilies.
Arva of dulness large, and nH>idly
increases. Sense of resitttaDce well
marked.
lowing symptoms and eigna:
ANECRISM or TBB AOKTJL aortic POtSATtOtS.
Symptom*.
upon the No symptoms of pre«&u re.
Symptoms of pressure
traclieu, oe-supliag'UH, or recurreat la-
ryngeal nerve.
Signa.
Pulsation In a limited spacA over the
ftrch of the aorta.
Radial pulse not exaggerated oo
eith^^rsidebyelevationof arm; usually
feelilt; uii one Bide.
Ini-reafced area of aortic dulness.
Artt^rial bruits, syKtoIic or diastolic,
generally distinct from endocardial
murmurs.
Pulsation not only over the aoria,
but Jn the carotids, subolavinns. and
brachials.
Piilfto sharp and apparently forcible;
hammer pulse exa^'g<*nii<Ml Ity elev»-
tion of Uiu arm. and alike uii both sides.
No increase in the ui'v-u fif <liilntffts.
Aortic regurgiLuot luui'mur, but no
special bruit over the pultating vessel.
Aneurism maj be simulated by jruhating empyema^ but ordinaril/
it can be easily distinguished by its position. If, however, perforatioi
of the chest walls should take place in the course of the aorta, as in i
<!aso recorded by Flint, the diagnosis would be much more difficult.
AMEUKISU or THE AUKTA.
PCLBATINO EMfVEUA.
Sffmptoms and Sign».
,^vnptoms and signs of pressure up-
«tt adjacent organs.
THilnesB condned to tlie region of the
aorta.
Arterial bruits. No pulmonary
nigtiR. uoleia there he pressure upon
the tiuchva, broDcbus, or luog itseif.
£:(panRi]e pitlKalion of tlie tumor.
Usually no symptomH uf pressU'O
upon the tracheu, ti-sopliugtiH, and
other adjacent organs.
Dulnefls or fiatnew* over llie pul»t-
Ing tumor, and also over the lower part
of one siae.
No bi-uit. Signs due to compression
of tlie lung by uuid in the pleural saa
Pulsation Komewnat similar to that of
aneurisms, Init usually lei^s expnnKile*
CAMPUC AXD ARTERIAL PI8KAMMB.
of ibm aortm it dntingBidicd fnm m 4Qmiai rnmridU
AvnTBaH or TmC JtOVTA.
DiLATXD ACSKXL
fl||Ba ■■# ■fi|i<oiiii dne to |ii imiiii F*w, if aar, tifgm^ aad
^OH mi^KO^wA ccgiBk PolMtkia fol< o( pncaune, P^lMtinn preceding
iMV^tbMiTMaleaf tfaftvcmridMaiMt apex beat.
Ik ^n bat.
OhIobh ia Uac i«swm of Um aonm. DuImcm wtfcfibatf ^r beyoad
Arlmrml brats vomtmm, bat propa- trgion of Ibe aoHa. aod wwlly at a.
fBtad aMMtl; oirer tlM aAenea, lower feircl ; osnallj eadooanlial inur-
muri [MTprgi'H ia direcciDaadiffi^raiL
from tboae of the aacatisiiial bnuL
Anetirum of tbe aorta u (1iffereotut«d from commliiiHtinn of the
lung by tbe pocition of tbe dnloew and br tbe aigiu npon »iiacnlu-
tion. If cbe ooiuolidation U doe to an anecriam, care mast be tftken
not to oTerlook tbe sigziB of the latter.
AxKraxaH or the aosta.
OovsouDAnox or taa ldirl
SiguM.
Dulaeai limited lo the ooaxaa of the
aorta.
A Bonnal rMpiratory murmur maj
often be beard ovcrtlie greater portion
o< Um aoeurlsm. Arterial bniit».
Dniaem act Umitad lo tbe
rqgioD. but extending cxtemallj, and
nsuall J invol vio^ tbe whole apex of tba
lung'.
KAlee and other sigm of cofuolida.
liDU. No bruits exDr|>t(atf poeaibly a
NV^totic&ubrlavian murmur.
Anenrism of the Pulmonary Arhry. — .Aneurism of tbe palmoi
artery 10 unc of the ntrest affectionti of the circulatory system. Froi
the few oaaca which bare been deKfibed, we are nnable to oblaiu an]
chartcteristic symptoms or signs. The principal indications which biive
bcL'u noticed are: extreme cyanosis, with dropsy and great dyspnu^
associated with a strongly pnlsating tumor, located in the second inter-
roiftal Kpace of the left side, and limited to this region. This tumor is
likely to yield a thrill npon palpation. Upon auscultation, systolic or
diastolic murmurs, or both, may be iletected, but they are not propafittted
altuve the clavicles. It is hardly possible to distinguish aneurism of the
pulmonary urtery from one of the aorta, which happens to prt-seut to the
left of thu Bteruum.
Tbe position of a pulmonary aneurism ia different from that of most
aneurisms of the aorta. An aneurism of the ascending portion of tbe
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.
Th« distinctire features between aortic aneurisms and those of the put-
ANKrRI.^M OF THK AOHi'A.
S6«
monury artery may be stated, from the symptoms and eigua which hare
been observed up to the preseut time, ati follows:
aKEUBISH or THE AOBTA.
An4*urtsni or tlie usceudini; atrh pre-
aeiiU to tlie right ot tlio Kt*-Tiiiiii). and
tfaoM of the deaceuditig arch usually
present behind at the left ot the third
dursul vert^bi-u, uuil v«pj' rarely in
front.
8ig:ns and symptoms due to pressiira
upon the truchea, bronchial tubes,
osaophaguB, bluod-veMeU. or recurrent
lurj-n^real nervt*, coninioii.
Bnuta, which may be propagated m-
to the carotids and suUclavians.
ANEraiSM OF Tm ptuiokart artert.
The tumor ik confined to the second
intercoettU space of the left side.
The Blgaa of pressure are company
lively slight, but usually tJien* i« rt>o.
gestioQ or thefuoe.anniuirca, and great
dyHpntcu.
Bruits, Dot propapited above the
clavicles.
Aneurism of ihe ArUria InnominiUa. — Aueurisma of the arteria
innoDiinata eauac pnlaatiug tumora similar to those of the aorta.
An aneurism of tlie arteria iuuomiData may be distinguisheil from
an aoeuriam of the arch of the uorta — first, by its position; second, by
the comparative absence of signs duo to pressure; aud third, by the
effect ou the pulsation of couipressiou of the subclavian and carotid arte-
ries. Such an aneurism is located entirely upon the right side of the
flteninm, 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
cesopbagu^, so as to interfere with deglutition; or upon the trachea so as
to cause dvBpnora. Compression of the carotid or subclavian artery on
the affected side greatly diminishes the pulsation in an aneurism of
tlie innominate artery, but doei^ not affect the pulsation of an aneurism
iuTolving the arch of the aorta alone.
PitooNOsis. — The average duration of thoracic aneurism U two years
aud a half (Loomia, Tracticul Medicine). Kecovery rarely occurs In
some cases the aftortton seems to remain stationary for many months.
Death may occur suddenly at any time; the prognosis as to diinition
is tlierefore extremely uncertain. It depends somewhat upon the posi-
tion of the aneurism^ the strucinres pressed upon, and the occupation,
temperament, habits, and general health of the individual. Death
nauolly occurs from niptnre of the sac, but may be due to asphyxia,
pDeumonia, gangrene, or cerebral embolism.
Tbeatmest. — A mixture composed of equal parts of tincture of
belladonna and chloroform liniment has been recommended for relief
of pain, hut when this is acute opiates will generally be required for
temporary relief. The persistent boring pjiin will ui^nally be grcjitly or
oompleteiy relieved after a day or two by potassium iodide given ia
doses of gr. x. to xx., three or four times a day. These methods of
2C6 CARDIAC ASJ) ARTERIAL DISEASES.
treatment hare been sucee8£fallj employed in a fev cases for the relief
or the cure of aneurisms.
TufncU's method, which in sereral cases has succeeded in at least
greatly relieving the patient, is a modification of Yalsalra's starvation
plan. It consists of perfect rest in the recumbent position with mod-
erate diet.
Ciuiselli's methml of galrano puncture first proposed in 1846 has
been successfully employed in a few coses 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 points 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 iipftrt. 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 qniet in
the recumbent position.
Another method consists of the use of large doses of potassinm
iodide. This treatment usually soon relieves the severe neuralgic pains,
and possesses the advantage of allowing the patient to move abont, though
it is more effective if the patient can be kept continaoualy in a recnm-
bent iKwition. The remedy should be given in doses of ten to thirty
grains three times a day. The larger dose is much the best. Cory:a
may be relieved by moderate doses of nnx 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 dyspntpa through spasm or paralysis of tie
vocal cords, tracheotomy may be necessary; but this operation can co
no good when the difficulty of breathing results from pressure on tbe
trachea.
COARCTATION OF THE AORTA.
Syiwnynu — Stenosis of the aorta.
Coarctation of the aorta is one of the very rare affections of the ci"-
culatory system. The constriction may be ring-like, as though a coid
had been tied about the artery; it may consist of a cicatricial band, par-
tially obstructing the calibre of the blood-vessel: or it maybedue toirrejr-
nlar 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
«nch cases usually no symptoms have been observed until about the age
SOLID MEDTASTJIfAL TVMOHS.
2flT
of puberty, when deficient development of the lover extremities, and es-
pecially of the sexual organs, has been the first indication of the condi-
tion.
Inspection reveals ingns of hypertrophy and more or less dilatation
of the heart; usually, dilatation of thenrt'li of the aurta,«f thesnbelatinn
arteries, and of tlio 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 pulsntiuii, and
somt^times by small nnenrismal enlargements of the intercostal arteries
Trhich may be sufficient to canse ercfsJon of the rilis.
A thrill can generally be detected by palpation over the large «rteriea.
The obstruction of the vessel renders the pulsation feeble in the branchee
of the abdominal aorta, and causes feebleness or absence of the pulse in
the tibial and popliteal arteries. Percussion gives no signs. On aueonl-
tation, u harsh, high-pitched, and usually intense systolic or postsystiiHc
murmur will bu heard over the aorta and larger blood-vesseh. This is
usually most intense close to the edge of the sternum in the second in-
tercostal space npon the right side. This murmur is propagated throngh
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 due to pressure, and by the want of an increased
area of dulness on percussion.
DiA(iNosi8. — The diagnosis of coarctation of the aorta rests mainly
upon the cnhirged and tortuous condition of the superficial arteries 'a
the upper portion of the body, and the feeble pulsation in the lower C'l-
tremitiefi, associated with an aortic systolic mnrmur.
TreaTHEKT. — No treatment can be reeonuueuded.
SOLID MEDIASTINAL TUMORS.
Excluding aneurisms, tumors within the cheet are nearly always m-**
lignant in character, and are therefore attended with grave constitutionO
aymptouiB; some arc of syphilitic and others of tubercular origin.
Stjiitohatologt. — A growth usually cttuscs pain of a persistent
character, sometimes lancinating, but not subject to the neuralgic par-
oxysms which attend an aneuriitni.
The principal «tgns are : turgescence of the Teins, cedema, dyspncea,
dysphagia, and other evidences of pressure on surronnding organs, with
dalnefls and loss of respiratory murmurs over the growth.
By inspection we commonly find persistent turgescence of the veins,
and cfidema of the neck and upper extremities in a more marked de-
gree than from an anenrism. A tumor is nearly always i:ccon'pj:nied
by- enlargement of the lymphatic glands in the neck rnd axillary ro-
S66
CARDIAC AND ARTERIAL DI8EA8KB.
gions. The contlition of these glands is an important point in the
differential diagtiiMis; for, if it ia due to malignant disease, they will
be adherent to tbe surrounding tissaes, but, if the conditione ure not
of malignant origin, tliey may nauully be moved freely beneath the in-
tegument. The symptoms and signs caused by pressure on the sur-
rounding organs are persistent, and they gradually inurcasc in severitv.
A malignuul tumor is not usually coutiued to the course of the aorta,
but is apt to extend u considerable distance beyond the borders of the
stornum. A solid tumor docs not ordinarily pulsiite, and, when it dues,
the pulsation is not ex|Hmsi1e, but is simpTy lifting. This impuliie is
caused by the pulsation of a large artery upon wbitdi the tumor rests.
On percussion, the sense of resistance is marked, and the area of duU.
ness is usually much larger than over an aneurism, because the malig«
nant disease gradually involves the adjacent lungs, instead of crowding
thorn before it.
By auscultation, no bruit can ho heard over a tumor, unless it pi
Dpon au artery, and then the murmur is distant and comparatively'
feeble.
Exeeptional.^Xn those unique casea where a tumor coexists witli a uuiea-
cent uneiirisni, Eonic iieriiliur )>henomeiia have been observed. The sense of rft>
SMtance to tliA pt'ru-iisAioii stroke over an aneurism may be great ; whertjas over
asolid tumor there may be only ftliffht reiiistance, and in the same posilioa w«
may detect an expansile pulsatiou, which »Uuu]d mituruUy be found over an
aneurism.
DiAoxosis. — 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.
Prognosis. — Sarcomata and carciuomata of the mediastinum ar©
commonly fatal within a twelvemonth. Syphilistic growths will often
Bnbside under jjroper remedies. Eiihirgement of the bronchial glands
is not infrequently followed by suppuration, and often eventually termi-
nates fatally.
Treatment. — No special treatment can be recommended excepting
that indicated by the constitutional dyscrasia.
Diseases of the Throat.
CHAPTEU XVI.
THE THROAT.
EXAMINATION OF THE FAUCES.
A cossiDERATioN of th© dtseasos of the chest is very properly asBoci-
•..ed with a study of the upper air pn^sagea, since diseases of the nose,
t iQcos, pharynx, or hirynx often cause symptoms which simulate tbo«e of
l>(t)inoiiary affections, lu some instances so slight a difliculty as elougu-
t'on uf the uvula will cituse the symptonit* nf hiryngitis, or even the pi^r-
Aitent cough, emaciation, and other syuiptonis of the later stages uf
pnthi»(is.
For the extimiuatiou of the fauces it is generally necessary to depress
the tongue. For this purpose n groat variety of tongue depressors hare
Tto M,— TVrcii** Tosion
Fin, S0. —BoswuKTS^ Toxaoa
[lEPBSMoa <?-3 site}.
been devised which will be found useful, but, if not at baud, a spoon-
hundle, lead-pencil or the forefinger will answer the purpose.
For ordinary use, ft spoon -liundlo is perhaps the best, as many pa-
tients object to an iusirumenC which is usetl promiscuously. Of the
difforont varieties of tongue depressors, for carrying iu the pocket those
which are jninti'd ure most convenient (Fig. 51). In office practice,
■oiue of the Inrger, stronger varieties are preferable (Figs. 50 nnd 53).
Some patients can so control the base of the tongue us to allow a view of
the throut without the uid of a depressor, but this is not the rule. A fair
Tiew may often be obtained in children while they axe crying or cough-
ing. If the child resists, a spoon-handle or other depressor may bo
27a
THE rUROAT.
passed well back upon the base of the tongue, so aa to induce retching,
vkicli vill afford ii 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-
vise we are unable to recognize quickly the siguB of diseuse. Upon
inspectiou of the healthy fauces, we lirst notice the soft palate with
the pendent uvula, whirh forms the back part of the roof of the
month. Kunning downward from either side of the soft palate will be
seen two folds of mucous memtrane, known as the anterior and poste-
rior pillars of the fauces, between which may be seen a glandular mass,
tenned the tonsil. Posteriorly we observe the posterior pharyngetil wall,
Tphich closely covers the bodies of the cervical verlcbrffi. Superiorly, our
field of Tisiou is obstructed by the palate; iuferiorly, by the base of the
tongue.
LARYNGOSCOPY.
In order to look beyond the lines of direct vision, we must use mir-
rors. Inspectioi* of the larynx with ihest; is called laryngoscopy, and _
the same method applied to the nasal pansages and nasopharynx is I
called rhinosnopy. The et^sentialt; for laryngosropy are, a throat mirror
and a gooil light. The cambination of a throat mirror and a reflector
for dii'ecting the light is rnllod a laryngoscope. A reflector and smaller
mirror used in exantiuing the nasopharynx is called a rhinoscope.
UuTORY. — The cretiit of ha\ing diBcovor^l (lie art of larynKOBoopy is iiNunlty
givea to Czeriimk, of festli, but many before liisiitiie li;ttJ ••X|wi-inieiit»'<l more or
levR Bui-oL'ssfiilly in illutiiiiialiiijf llie ]iii-ynx, Buzziiii in thn be^inniiif; of the
pn-scnlcvntiiiy, Beaiimlti in 1832. and Avery, of London, ta 1844 attempt«d to
illummate tlie lni-\'nx by-nifans v( iirtiRoiul light conducted Ihruiigh tubes ; but,
as »howo by Trou-ssetiu and bcili>c-<|, tlieso laittrunients crowded Uie tongue and
epiglottis bcture them, boos nearly »r quite to c]os« the oriflce of the larynx.
At most, tlioy ouuld ex|>0!u> only a small ptirtion of its pofiterior wall.
About a hundi-cd years previous to these efforts, Levret, of Parifi, probabtj
the first experimpnter in Oils direction, attempted to uee t)ie lurj-nx by meau of
a email throat nunror, (.imilar to that now in uee. St-nn, of Geneva, in 18S7;
Babbin;rlon. of Ltmdon, in 1829; Baumpft, of Lyons, in 1838; atul Linton, of Lon-
don, in 1840, employed similar inRtrumentn with equally nnsatisfocfory result*.
Wurden, in 1444, made exf)erimentM with a couple of prisms. Allot those in-
veslitrators failed iiioi-e or less completely, for tiie rcuw>a that they could not se-
cure suitable ilhuiniiatiun.
The first to demonstrate the larynx in the living' subject was Si^oor Uanuel
Oarcia. a teacher of vocal mu»ic >a London. Ho became quite expert in auto-
laryngoscopy. and also succeeiled in demonstrating the larynx in others.
Oarcia's uhservation^ \rere communicated to the Royal Society of London ia
1H&5. They attracted little attention at An^t, for the art was Ihou^ht to Ik* o( oo
practical value in the dia^no<u<( of di.Hease, because a thni-oiigh inspectioa waa
Bupposed 1o depend upon a peculiar education of the mufit^lett which would enabla
the patient to control the poi«ition and niovementa of hiM throat However,
Oarcia'a writiugs iaduced TQrck, of Vieooa, to experimeot witli similar mlrrotft
LAHYNaOHCoPY.
273
in the htHpitnl dunnf>'theftiimnier^r ld>^7 Altlioiigh TQroku-aK tjiirlyAuccessru]
in r)iefu> PXpei-imf'ntA, he llnally (lir>'w lusitle his mirrors as tho autumn oatne on,
bwuii-^ of Uie (htliciiUy in obtainitiK- sunlight. His experiments were not lost,
for Czeniiuk, o\ Feslh. wlio iiud l>e(>n visiting in Viennu during theKumiiipr. bor-
rowed tltfniirrursanttcontinuL'illheint'estigatiuns. Ht> uveix^iiiu lliv ililllciillies
wliidi liiid previiJimty preveoled a. clear view of ihe lurynx, Ijy ciupluyiDK ihe
reflector anil causing tlie ptitient to protnulo Hie tongue, ititlPitd uf iVprcssiiig
iU and by substituting arti(K-ial light Tor the ilirr^'t ruys of th(_< s.\in. Soon a
rivalry sprang up |)€twe«n Czermak and Ttirt-k as to the priority of their claims.
Their letters, which were publiRhed in the various iiiiHlicut journals, hpieod a
koowledfre i<f the new art throughout the mediml woiid.
Thkoat mikkors have been made in various fornix. Some are round,
others oval or lozenge-sbapc-d, and »tiil otliers <|UJidrilateral. For gen-
/ /
Of
i ^. e
no, en -TnitoAT UiR»>iur<tKt^B*KuoM-oFT. 1. a. Rand)*; 6, BtMn: c. cUrror. S. DUTemt
lof routiil nilrn'rv. S. n.h,e, Difrnrent T'lrait of throat mlrrort.
eiml use the round mirrors, varying in diameter from threo-eightha of an
inch to .an inch and a rjuartcr are preferable. Mirrors should be made
^-of clear and perfectly white glass. The qnality of the glass may be
ted by placing a white card liefore the mirror. If the glass is per-
fectly white, tho reflection will also bo white; if the glass is tinged with
color, it will give a corresponding shade to the reflected image of the
card, and would necefi^arlly similarly affect tho laryngeal image.
The glass and its setting should be thin, in order to economize space
in the throat.
Ihe glass should be set firmly in a metallic frame, which mast en-
as little ntt possible upon the anterior surface of the glass, so that
19 hirgest ponaible reflecting surface maybe secured. Some of these
mirrors are backed with amalgam, and others with silver-leaf. Silver-
274
THE r/fnoAT.
leaf renders a mirror more durable, ns it is less affeotefl by heat nnd
moisture. 1 have used mirrors bncked vith amalgam many times duily
for several months without xnjurJTig them, thoug)i one mar be ruined in
u week if healed loo much or kU in the water. The mirror should be*
firmly attached to a wire stem about four inches in length, at an angle
of not loss than one hundred and twenty degi-ocs. This stem may bo
fixed in a t>mall hsindle about three ini'hes h^ng, or the handle may be
removable, the stem when imscrted btdng 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 pahttine muscles, when the mirror is in position, in such a mannef
that the hirynx cannot be seen. •
An inflexible stem is always preferable, for the obliquity of the mif^
Tor can be euaily altered by elevating ur lowering the handle. If the
beginner attempla to alter the (ibliijuity of the mirror by bt-nding the
stem, he is likely to break the instrument iu his frequent attempts to
aecnre an angle which will give a diflFertMit view nf the larynx; iind it is
better for him to attribute want of success to lack of skill rather I ban to
a defoct in the mirror.
Illcmin'ation.— To obtain a perfect illumination of the hirynx. three
tilings are necessary; first, the eye should bu brought as nearly as pos-
sible into the centre of the beam of light used in theillumiuution; second,
the light shouli] be bright, especially if a small throat mirror is used,
for the smaller the mirror the fewer the mya viiich can be reflected
from it, ai]d 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 cost convergent rays into the larynx
cause nbove and below the focid point wliat are known as rircles of dis-
persion, in which the illumination for a short distance is nearly us bright
as at the focal ])oint. 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 pari of tlie mouth, and
in this position the mirror is about three inches from the lips; therefore
in men the glottis is about six inrhes within the lips, Imt in wonien about
five inches. As theeyeeannoi Ix* Ijrought nejirer 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
it wuni on the forehead.
Being myself hypermetropic, I find it moat convenient to have the
eye at legist eight inches from the [>:ttient's mouth: and therefore must
use a, rofleclor which will concentrate the rays of light ut a point four-
teen inches from itself.
I
lARYyeOSCOPY.
275
Persons with presbyopic eyea may obtain a good riew in the same
manner, deficient accommodation in the eye may be corrected by glasses.
Myopic eyes of less than oue-teuth will necessitate the ase of concave
glut-scs; but for eyes, myopic from one-tcntli to one*scvoDtccutb, glosses
will not bo needed, excepting to view tlic bifurcation of the trachea.
To exnmino the bifurcation of the tradiea. which is five or six inches
below the plane of the vocal cords, we must remember that the focal
point should be at iMSt sixteen or seventeen inches distant from the
reflector.
The larynx may be illaminatcd by a simple flame, or a jdune or con-
cave reflector with or without condensing lenses may be employed to
reflect the rays of light into the thrmil. lu iUurainutiug the larynx by
the direct rays of the sun, lenses are not used, and reflectors are not
absolntely neop^sjirv. When diffiised davlight is employed, reflectors ;ire
requircil to cum-entrate the rays. Though direct sunlight, or sometimes
diftuscd daylight, gives a beautiful illumination, artificial light will he
found in*disi)en8ftble for general use. Xutnral light cnnnot usually be
secured in the proper position ut the time we wish to use it.
JIluminatioH with Direct Artijicial Light. — When usingn simple flame
without a reflector, the lanij) must be placed directly in front of the
p.itieut's mouth, and shaded toward tlie eye of tlie ubi-erver. This will
give a good illumination tf the light u very bright, but with tlie ordi-
iniry lamp or gas-jet it is not satisfactory. This method may be im-
proved by using n condensing lens with a focal distance of six or seven
inches. The lens should Iw 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 tlic lens at the plane of the glottis. The obser-
ver's eye must then be brought nejir the edge of the lens,
JHuminatwn with f}fj\rt'tfd Artifiiia) Lii/fit.—Thc nbore-nnmed ap-
paratus nmy be supplementcil by« plane perforated reflector, which.placed
iu 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
with<mt a roiideiiser.
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 illnminntion.
and to have the fooni point fall upon the port to be examined — lnr}-ngol-
ogists generally reeort to a perforated rftnram rtflfi-inr. Such a mirror,
by collecting many rays otherwise lost, and concentrating them on the
point to Iw exiimiiiMl, intensifies the illumination, and the perforation
in its centre brings* the observer's eye into lino with the centre uf the
cone of light. Slany hiryngtdogists prefer to place the reflector alwve
the eye, but unless a very bright light ia employed this position will not
give a good illumination of the larjnx, and if a brilliant light is used It
is very trying to the eyes.
*:6
THE JHHOAT.
The reflectors rary in siz«, in focal diixance. ouid in the material of
which they are constmcted. Thow nsod in tarrngcwcopy are nsually
from three to four inches in diunecer, vith « focal diiitjuica ranging
from fire or £ix to foorteen or sixteen inches. They are made of either
glan or metal; the former are beet, ai thej do not l.ie<:ome dim br tnr-
niahing. For ordinary u»e, a reflector with u focal dt^tAnce of seven or
eight inehei will give better satisfaotion than one with a longer focuCf
ext^ept when panillel r»T8 of light, as those of the san or of diffii.-ei) da^:.
light are Xm be refletted. The rays coming from any urli6dal light are
necesBartly dirergent* and consequently cannot be brought to a focui in
the larynx by a reflector vith a focal distance of eleren inches, which
would concentrale only parallel rays at the proper poinL
With the ordinary position of the flame, aiid of the observer's eve, a
reflector of seTen inches focal distance will throw the radiant point upon
the glottis. The nidianl point may readily be moved toward and from
the eye by increasing or lessening the disUince of the flame from the
reflector, so that reflectors of varying focal distances may be emploved,
providing the light is siiflicieutly intense.
On acconnt of its simplicity, the formula TT ~ X "f" jT ^"** *•«»
genenilly adopted in determining the focal dij^tance 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 npon 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 disliuioe 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 iuchca,
and the proper distance of the imago of the flame, which, as already
explained, should fall upon the glottis, and will therefore be eleven
inobee from the reflector — Bve inches from the observer's eye to the
patient's mouth, and six inches from the pjitient's lips to his vocal corda
~-ire can readily ascertain the proper position of the flame by substitute
ing the known quautities in the fumiula thus: 4 =: — - -^ ■^■^, 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 And the fo&il distance of the reflector by tirtilicial light, we pro-
ceed in iL similar manner with the same formula. Placing the light ;it
a fixed point and the reflector iu front of it, we find the distances from
the flume to the reflector, and from the reflector to the imago of the
flame, by direct measurement with an ordinary taptr. These two known
quantities being then inserted in the formula in the phice of A and A',
the value of F can readily be obtained. The focal distance of a reflector
4
LAHvyaoiscopr.
nmy be eaeilv usrertHined with solar light by plneing it in the snnlight,
tbrowiiig tbe railiaiit point on some object, and meu^uring its distance
fi-om the C4?ntre of the reflector. The fociil distunco nntv b^ iiiaisurod
n itli dittiised light h_v reflecting the iniiige of some distant ubjtitt, as a
window^ ou Bonie jdune surface, and nieaaurlug the dietauce from tUie
imngo to the refleotor.
In usiug r^flectorji, it iu essential that the li^ht be so managed that
the radiant point will fall on the juirl to be ilUiminale I.
Stndpntt) of Uryngoscopy usually have great tlitllcnlty in obtaining
a uniform illumination. Sonietimt'a the parts will be brilliantly illumi-
nated; at other times with the same light and tin* ^:tnie laryngoiicope thft
larynx ie only seen in a deep shadow. This is gent'mlly due to the im-
proper position of the light. We must not forget that the larj-nx is
necessarily fromolcvcn to fourteen inches frt>m the eye, and that, with »
reflector of sex'ou or eight inches focal distance, if the Hnmc be placed
too neur the eye, the radiant point will fall a considerable distance be-
yond the glottis; or if too far from tlie eye. the radiant point will not
reach the glottis. We should always know the focal distaiK-e of our ro-
flector,and ascertain by the formula jnst explained the]>roperdigtanceut^
which to plac*^ the flanip, n*mi-mhoring that tho distanre of the radiant
point from the it-Hector will vary inversely its the latter is carried towai-d
or from the flame.
Practically, if we have a proper reflector of sctpti to eight inches
focal distance, it will not be necessary to measure accurately the di-i-
tancc of the flame. Placing tho light beside the patient, wo may sit in
front with tlie reflector, ten or eleven inches from the |witient'« mouth;
carry the liglit forward or Intckwurd until its perfect inverted image
falls on the piitient's Hps, this will be the projwr 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. Cxermak
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 pltysician happen to be myopic or hypermetropic, lenses may bo
fitted in this frame to correct the error in accommodation. Jointed arms
for holding tho reflector accompany many forms of illuminating nppa-
ratns. Those are inconvenient for, if the (>atient 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 modificjition of it, is the
most common, and, I think, the best dovice for holding the reflector.
It consists of a head band with a metallic or vulcanite plate in front to
frhich the reflector is attached by a ball-and-socket joint, which enables
one to flx 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 Iicudiiche; and second, tbe ball-nntl-socket joint
is so cuQstructuU ttiut, ufter it becomes a little woni, it is imposaiblo io
fix ihv reflector lirmlv. Schrotter's licaU Ixiud made of firm non-elastic
webbing, witli uusal rc^t, obviutcs these ditliculties.
Pu. M.— ticniunTBH'a Huo Baxd wira N^ut. Ucm.
Whatever ihe menus employed for holding tho reflector, it must be
borne in mind that the flnme mnet hare a certain definite relntion to the
relleclor, depending on llie focal ilistunec of tho latter iind its diciUnt-p
from the glottis, so that the image cjf the i1:inie will full upon the vocal
uurds.
\
\
Tta. Si.— KRusxan's Iu.cicoi«Toa.
a, Lma ; b, rpfletrtor.
Fio. OA.— XnMrtsa HAomrnK** RACR-JinvEiierr DrLL'*-vn
CoXDEKm. For g»» or UKaiKlrnwut divtrtc %bL
In phice of throwing the radiant point on the glottis, some physi.
cianfl prefer to illuminate the parts to be examined with the bright diao
of light which may be obtained in the circle of dispersion above or
below the radiant point.
SeTcnil instrnments hare been devieed for the purpose of rendering
the light in thia disc more intense.
LAJii'yGoscopy
27!»
One of the simplest of these is Krishubor's illnmiimtor (Fig. 55). It
«onsifiU of a reflector and a contex lens, which may bo fustened by tho
clamp to an ordiuary lamp.
This rtpfmnitus will often giTC very satiafnctory results.
Miicki-nzie'ii buUVeyo coiidenflcr ia used for the same pnrjiose. It
con^JHts of :i ruck-iiioveiueiil gas fixtaro ivith u metallic chimney, which
^tSKti bo jidiusted to the ordinary gns-hnrner (Fig. 5t!). The chimney h;is
an orifice on one side for the condensing lens, and the liittcr is p)nr*'d
At a fixed point in front of tho flame, 30 that the rays of light on leaving
m
m
<--i /^
it will be nearly parallol. This illuminator may be brought directly in
front of the patient's mouth for direct iUuniiniition, but it is geuerally
used with a reflector of from eleven to fourteen inches focal distance.
Fraenkers illuminator is somewhat similar in construction as regards
the condensing lens, but ig so arranged that the rays of light on leaving
the leoB may be made either divergent, parallel, or convergent, according
to tho size and focal distance of the reflector which is employed.
In accordance with my flU|c:ge«tion!t a »imi)ur condenser has been con-
•trttctefl, which limy bt; used with Iln? orxiinary Around ^niA-buroer or Ohi*.
man fittHl<!nt*3 latii|i {Fig. T)'). In (his I'OndonM'r the l^ita, whirh hiu a TikmI
diAtunce of tliree mkI one-lmlf inchi^N. \% set about itvo iuchos Trom thi> (Iiiiiir,
«o llittt the raj's of light are dtrer^at on leaving it, and are thus adapted
THE THROAT.
for » reflector with a focul distance of 9eveQ or eight inciies. If it is desired to
obtain 4 hrijfht cin-le of di-spersioa for illumination, or to use a reflector with a
longer fix-aJ di«tanc(>, the cap in which the letu i« Ael can tie dmwn out so thai
the ray5 will bt> Ir-as diTcrgent.
Tbt&t.'ondeuser 18 comparatively iaexpensive, and |>ooe8Maall the advantages
of the last two de»cribed, us wirll a» thuse of Tobold's lUuiuiuator. without lbs
imperfeclioas of the latter. With tlii^ condenser and Frueukel'a, eitlier the
radiant (>oint or Ilia vxkW of dt^iperMoa may he u»h1 (or illummatiug the glottis.
ToboU's iUuminator. a coaibiuaiiou of leuses dei'ised by ToboM, is
in common use. Weil bus showu tUut the apparatua is improred lir n*-
znoving one or two of its leitseis. These lenses merely cause a large
circle of dispersioiif which, though brilliant vben thrown on an external
object, is, in point of fact, lese intense than the image of the flame,
Tobold's apparatus has a combination of three lenses, two of whii-h, each
baving a focal distance of about three mches, are placed closely together, and m>
near the llame thul they cotltrct divergent rays as Ihey leave the lamp, and con-
centrate ibem to a focus about six inches iu front of the second leo». The thinl
len», fartliest from the dame, haa a focal distance of about five incboit. It is
placed four inches in front of the second lens, about two inches within the point
at which the rays of lij^ht are concentrated by the latter, so that the rayti of ht^ht
falling on it are converjjent. The convcrKenl rays, by passing' throug^h the third
lens, are rendered still more convergent, and are brought to a focus about Uiree
inchcH in front of tlie apparatu-i, where the in3u^e of the dame is perfect. The
refit^lor is Uxed about four mchen in front of tlie apparatus, or one inch beyond
the radiant |H>int of Uie last leas. Here the rayjt, havmg crossed, are so widely
diverKent. that a reflector of one and a Imlf inches focal distance would be re-
quired to concenti-ate them upon tl»e glottis. The reflector used has a focal dis-
tance varying, in difTerenl instrument examined, from live to nine iin.-hes. There-
fore the ravH mu^t al»o leave tho reflector widely diver^nt, ho lliat most of
them Will Im> loHt. Hence, we see that the larg« bundle of ra>> collected by the
first letiH. which mig'ht theu have been entirely utilized, is first subjecied to tha
XtxfA incident to refraction, and then !ai':ge]y thrown nn'ay. We must admit
that a (tufficinnt number of rays are still retained to give a good illumination,
though less intense than when only one lens is employed.
No advantage can bo derived from such a combination, except where
cheap lenses of a moderate couvexit; are placed together to secure &
short focal distance. A single lens of sufficiently high power to ac-
complish the some result would bo comparatively eipenairc. Tobold
has also devised a smaller iuslruiuent known us the pocket illuminator,
tbe construction of which is stmiliir to that of the one just described.
The imuge of tbe flume may be eu mitgnlficd by n single- lens, »5 found
in the condensers already mentioned, that it is as large as can possibly
be reflected from any throat mirror.
lu using comlensing lenses, any one of three methods may be adopted:
tlie flame may he placed at the focal point of tbe lens; it iiiuv be placed
beyond the focal point; it may be placed nearer to tbe lens than its foont
point.
With tbe flume at the focal point, tbe raye which atwnys leave the
I
I
I
I
light in a divergent direction arc refniciod, bo as to loavc the Ions in a
pamlle) direction, and they must thcu bo managed in tUt' suute manner
as the parallel niya of sunlight or diffused daylight, lu this instance.
a reflector of a diameter the «ame la that of tlic lens should he em-
ployed, baring a focul distance of from eleven to fourteen inches.
Thia will bring the image uf the flame upon the glottis, providing tho
eye is from" five to eight inches from the month.
When the flame is pUced beyond the focal distance of the lens, its
divergent rays, after paesing through the lens, become convergent. Here
the reflector may be smaller tliau the lens, but It must have a focal dis-
tance of more than eleven inches; otherwise the rays will bo brought to
B focus too soon.
When the flame is placed nearer the lens than iUt focal distance, the
rays, after pa^^ing tltroiigh, are still divergent, and. in order that none
be lost, they must be received on a refle<'tor larger ihitn the lene, which
niDst have a focal distance of not more than eight inches, the same focal
{tistanco as that required when a flame is u^ed without a condensing
lens. This is by far the best methutl for practical purposes, us it gives
an illumination equally as good as the other methods, and does not ne-
cessitate the possession of a numher of reflectors.
Some form of condenser is desirable for office use, but I hare always
found a simple concave reflector of large size and short focal distance
snfiicient for ptirposes of diagnosis, and ordinitrily for operatioua within
the larynx. Such a reflector may be nsed with an ordinary gas-jet or
with any Ump, and may be sufficient, even if one is obliged to rely on
caudles. For general use it will certainly bo found more satisfactory
than a cumbersome illuminating apparatus.
When performing operatious in tlie larynx, it is desirable to have as
large a field illurainatcd as (wssible. This may be attained by means of
the bnll's-eye condenser with the ordinary flame, or with a brighter light
aud a rvfloctor M'ith a long fucul distance, so that the circle of dispersiuu
can be utilized in place uf the radiant jioint.
Several laryngoscopes, illuminated by electric light, have been in-
Tented, hut they are not usuidlr fo satisfat-tory as the simple reflector
and Argand burner or fierman student 'k lamp.
A bright electric light, if properly arranged, would perhaps be the
beat for Uiryngoscopy. and, next to ii, the oxyhydrogen light. The
former, however, cannot always be obtained, and the latter, besides
being difficult to manage, requires a grout deal of apparatus, and is
consequently expensive. A good Arg:ind gas-burner or a German stu-
dent's lamp with a bull's-eye condenser is all that is necessary for
illumination, even during oponitions. I bavci sometimes obtained brill-
iant illnminntioii even with a common kerosene lamp, having a cir('nl:ir
wick like that shown in Fig. 55. For purposes of dingnosis, any ordi-
nary lamp, freshly trimmed, and with a clean chiwuey, wiU generally bo
•oflLdaiL Aa mggmud far J. Sofia CaiMB;, Kv» «r Ant imiTIh lied
togvcbcor, >ad plutd m tnai of tW Wvl af s HpuB wed w * tttAcc
tar, nmf be mtmdt to uuwtr tbe pofpoo if % knp enwot te obCAised.
t>iJXa*eti ilmTltght, vbcn pnipertr ma^tgei^, pret « baiotifal illami-
tmtiao of Ijw brjax. Arttfcid U^ Mae or knt diacufari tha im^e,
mwDg tint DomsJ hrjnx to qtpear xeDsviik or icd, vbenu diffiued
dftjlight ihovB ihe parts in tbeir nmnl ealan. Unfurti^iucelT the
hltcr » KMon sofficieiitlT br^lit- Oa b fangbt dar, il li^fat cm b«
admitted throogfa a aaaU opeotag inta a darkraed rmmd, en &£ to fmU
opon the reOertor, it vill give a good iUsainatioa. If it is impcMnfale
to sdmit the light throagfa a saall apertare, a good Tie* but saiDetisiea
be obutue^t Nj pl^in^ the patient at the fortfaer side of tb« roaair op-
posite a tingle window left DDCorered, with his back to the Eight. This
podUofi will giro a moch better view than when the patioit u placed
near the vindow.
Direct sunlight may be emj^ored, viih the patient facing the vin-
dow, in sttch a ixuition that the rar^ foil npon the thruat mirror held
the phiirrnx. A wrioni hindninre to fhia method is that the light
not often be obtained in a »aitable position. BeAeeted eunlight
more fretjoenllj be emplojeU with the avl of a plane reSeetor, or of otti
with a long focal distance, bat it is onlf in coroparatiTelj rare instmces
that we have n proper exjKKure auJ finil the $un at the desirvi altitude.
HeliofTtAts have been construttt-d for reflecting the eunlight in a
given direction. They may be arranged by a eystem of clockwork to
mninuiin the beam of hght at a giren point throngbont the day. This
■pptiratua if very eipeiieive, and not to be recommended.
An ordinary toilet mirror may be so placed pa to receive a beam of
lunlighl. nnd dire«-t it horizontally in any desired direction; bat this i
not often patisfiu-tory for cynscctitivc work. For the reasons natnedr
are iisnally com]>ellc<l to ose artificial light,
Loryngnscopy iihnnld bo practise*! with both natural and artificial
light, to give fumiliarity with the appeomnce of the parts under both
forma of ilhiniination. The mme Iar>'ux will have different shade*
when vi<fwe4l by different lights; wliat api>earfi cougeeted when viewed
by nrtiflcinl light, may seem of normal color by daylight.
For 11m pur[>u»e of magoifyiog the ima^e of tlio lan'nx, Wertheim recom-
msnded concave llirunt mirrors, and TQrck Bopge-sted a small tcl(f<icup«. soma
lnipravemi*nu id whidi were made i\v VuUulini ; but these have all bwn found
praHK-ally uw'lesH.
The laryngoscope which I prefer consists of a perforated reflector
f*)ur inches in diameter (Fig. hS), willi it focal distance of eight inches,
allachi'd to Schnitter's hetui Ijand. with nasfll rest, by means of a bail-
nnd-Aooket joint; with three round throat mirrors, three-eighths, seven*
<^ghth8, and nine-eighths of an inch in diameter re*!pectively, the small-
LARVySOSCOPT.
^83
est for children, and one ovnl mirror three-fonrtha of an inch in diamo-
ter, for use in oAseB of onLirgcd lAnsils. As before stated, thoso throat
mirrors should tio btieke<:3 v.'\i\\ $i)Ter*lcaf und firmly fastened to an in-
flexibk' stem, which nmy be i»eriMiiueulIy fasteued to the handhr or not,
ns 18 most conTenient. The reflector need not he mure ihiin ttireo and
one-half inches in diameter, but tho l.-irger instrument will reflect a
greiiter nnmber of rnys, and thnH give a somewhat brigliter illumination.
The fonr-inch reflector possesses the additional advantage, when worn
before one eye. of shading the other from the light. The only objeetion
] have found to it iii that the uttnc-hnieuL fur the ba]l*aiid-Bocket joint
is in some instruments placed too far from the perforation, cuu^iug dilfi-
/
Fki. SK— LuvMOtOOFlC lUn.BirToN. kiui AtlAt'ltiiK-fil for holilfu^ Imh tnoorrvct d^^rcan* mc-
comniudntloii. Tb* ball for tMiU-RiMt'«>H'krt Joint lOioulil >>; (lUivl Aix'unUir 1^ iv^Xtn friini
ctiaint of rt-flcotor.
culty in bringing tho perforation grinarely before the eye. This objeo-
tion eiiould alwnys be remedied by the nianufactarer.
For an ilUiminating appai-atue, we may use an Argand gas-burner aU
tached to a rack-moTenient fixture, similar to the one shown (Fig. 5ii),
or a Germun student's lamp, which may be eiipplcmented by a condenser
<Fig. 57).
^f^lni/^uffl/^'ul of tfif Lanfuffim-ofMi. — After familiarizing onrselves
■with the laryngoscope and the rules for its use, before attempting laryn-
goscopy on a living subject, it is veil to practise for some limo on %
dummy, or on a larynx which has been removed from the body and
attached to a standard. If one of these ctinnot be obtained, wu may
easily make a model by boring a couple of holea in a block of wooil —
one about two inches in diameter to represent the month, and tho
other about an inch iu diameter, intersecting the first at an angle of
eighty degrees, to represent the larvTJX. By praeiising on it we may
fumilurizc oarselves with the management of the light, reflector, and
throat mirror, and may educate our hands to steadiness.
llaring' learned to control the hands so that the mirror will not
tremble, and to reflect the niys of light accunitely to the objective |>oint,
ve may begin to practise u[K>n the living subject. A noric-e at first
will find it uf great advantage to practise upon a jmtient who has baen
trained and can undergo the manipulations of an anskilled hnnd with-
OQt retching; subsequently he should practise upon healthy indirid*
uals fur some time, in order to become so familiar with the normal
appearance of the larynx that any deviations from it will l>e at once
recugnized.
For the most favorable laryngoscopic examination the patient
ibonid be seated in an erect position with the head thrown slightly
r»t. BB.— I'MVTtm or Hkao oivmo thk Bbvt Vikw or LAXTur. as aaoms n
SVAIX CTT AT T*»
back. The physician shonid be seated in front on the same or on a
slightly higher level, and as close as pcysaible, with one knee on either
side of the patient's knees, which are brought together.
It is often neoessarr to make the exaniination with the patient slig-htly
propped up in bod. unit tlic ph^'Bucian sittiiiff as best be may beside him ; or with
the patient fitaiiditigr, as when a library drop-light is used, which cannot btt
brought low enoiigli to illuminate the throat when the patient is itiltlog.
The most suitable scat 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, wliieh will compel the jMitieiit to sit erect. For
the physician a small stool, which can be raised or lowered to any de-
aired level, is most convenient.
LARvyuoscoi^r.
385
The patient should be seated beside or just in front of the luble
ffliicli holda the iiistrumeuU, with a cuspidor beside him, and n gltus of
water close at band. If direct sunlight ta employed, the [Miiieut should
be placfd near the window, facing the light, which, coming in over the
physicuiu's shoulders, falls directly upuu the jiharyngeai mirror. With
reOected suulight, the positions of patient and examiner as regards the
window are reversed. When artiHoial tight is employed, the examining-
room should be shaded. Tbo light should be placed on a levid witti the
eyes of tho patient, and slightly behind him, so that it will not shine
on his fuce^ 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 [latient, ur far from his head,
at one side, the angle at wluch the rays fall upon the reflector will bo
so grcAt that a good illumination will be inipoeaible. The patient's
^■•
l:?^:
M
/^'
no. <P.— IVwiTion or Hbad mvnto a Pt>oR Vot or LAiintz, ut mtowv ix rmc BUtx CVF IT
Tnt LOT fBiiowirE>.
head should be inclined backward (Fig. 50), so that the edge of the
npper 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 himp is on the patient's right, the reflector should be placed
in front of the examiners left eye, or I'lce versa. The throat mirror
may be held in either hand, the patient's tongue being held by the other
or by the patient himself. Right-handed persons should educate the
left hand to tho tusk lis soon as possible; for when other instrnmenta
are to be used, the right hand will be required for them. £ven in
diagnostic manipulations ambidextcnty is very desirable, fur by hold-
ing the mirror flrr>l with one hand and then with the other, uuy false
impressions of as)'mmetry may be corrected.
286
THE THHOAT.
lu making a laryngOBCOpic cxarainntion, everything being in rea^li-
ne88, the physiciim tukes his i>06ition in front of thu patieuCj and iixcs
the reflector in its plucc; his eye is now brought within about ten inches
of the ]mtient'8 lipn, upon which the light is directed. If tht? himp has
been placed at th© proper dit^tiince, a perfect inverted image of the
flnmc will be geen nn tlie patieiifa lips; otherwise the light shouh^ be
moved backward or lorwurd iiutit this result u ubtoiucd. Tlio puLieut
/.
;
^atfttiiitf
\\
J
7'yi
Vwjy
Via, U.— TBI I^itvmimcorK- HiRflon ix PostnoK 9nat to Oi«« 8io« iCt/mai'ii
is then directed to protrude his lungut-, which the physioinn grasps mid
holds between his tluunb and fore-finger, which huve Ihwu previously
enveloped in a soft napkin. The eye of the examiner is then brougltt
about four inches nearer, and the light from the reflector is so directotl
tluit the brightest point falls on the base of the uvula, where it must be
retainetj. The throat mirror, having been wfirmed for a moment over
the lamp and its teinf»eraturc tested on the cheek or tuick of the hand, ia
carried into position in the throat, and, by a slight, ^tendy movement ot
the mirror, the image of the hirynx is brought into view (Fig. Gl).
lARryooacopr.
287
The first (liffionlty which the beginner experiences is to direct the
light into the month, and th« second U to keep it there. Thtae diflicui-
ties mny be readily ovt'icomt* by practice, aud sboiilil always be mastered
ou 11 dummy or some other object before nu attempt is muUe to vMunine
a patient.
The pntient should protrude tl)e tongue oa far a^ po^irible by the
muscles of the tongue itself, and i( niii^t be held gently by the ph^vsioian
without un attempt to draw it farther out, for such an attempt would
cause pnin and contraetinn of its muscles.
A soft cloth is necessary in holding the tongne, not only for neatness,
but because if it be gnisped simply witli the tingers it will elip uwar.
In holding the tongue, the 6ngcr which is beneath it shonM be held
slightly higher than the edge of the lower teetii, or the teeth may be
oovert'd bv H napkin to avoid injury to the fr^viium.
Whenever bolli uf iht' phyeirian'H hands art- lu b« occupied with in-
fftrumcnts. the tongu« may be held liy thp patient; sometimes this is a
nscful aid in overcoming the iiKliridnal's nervousness.
Tlie throat mirror employed must correspond to the size of the
fauces. The one most genemlly useful for adults is Beven-eighths of un
inch in diameter: but mirrors one and ouc-futirth inches in diameter,
or even somewhat larger, may often bo employed. The larger the
mirror, the better the illumination.
The mirror should be warmed so that the moiBtnro of the breath
may not condense upon it. When first placed over the flame, a thJn lilm
will be seen to spread orer Its surface, which disappears as soon as the
ebss becomes warm. It is then of a proper ton)]>erature for use, bnt
should always be tested on the cheek or back of the baud.
Insleiul of warming tiie niirrur, its nu-fure may be covered witli a M>lutian of
j^lyetTJiie and water l<> |>iw<>nt comleatiatlon of moisture ; this floes not leave
Ro liaoii a reUectiii}.' surfuce. and. as a ri'itult. the image will be less dniliuct.
Otiier devices have been &ii(:g't?3teil (or preventing comleosailOD of the breath oQ'
the niirror. but they are of uo practical viilue.
The mirror is less irritating to the fancea when warm, and it will re-
tain the heat as long as it ought to be kept in the throat. It i>boutd he
held like a penholder between the thumb and tingers, with the baud
bent slightly backward u])on the wrist. It should be {Missed bonzoutally
iut^i the moutli, with the reHocting surface downward, and Mirried
promptly midway between the tongue and the roof of the mouth. Uick
to the uvuln, which is caught upon it and curried upward and backward,
until the rim of the mirror almost touches the posterior wall of tha
pharynx. If the uvula hauga too low to be easily caught on the back
of the mirror, it may be elevated by causing the patient to take a deep
inspinition or to phonalc the syltuble a/i ur efi. If the throat will
tolerate it, the mirror may be rested aguiust the posterior wall of the
pharynx.
j^KiSLtlT
&i Cj- i -a»
mt.fut ^ fumc ^rrr^-ff^ jj^t^li i i*- /■■■^ ^ Zi
■;f ^•■j^ri'**- ; ^;_ •► !Uip?- r- _
-*>-r *^ .^c j"rr*r-r, tut- arrrr*- xn- »- <£ics!r tmm
Jr.*— K V aov'Sif h*#- -joati^c TEC"
V " f .^w a -,^«»«rUit ■•'ni*- Tat- ictt * _
vh^?r A h^ iirroE '•• -cesiF ^uoi^E' Tea; :c » -iRtf
TrH 'bir trrmr x:rrnr Ji yrna«. hk «dL i^ihil kshb it ^es
■^^j^i" -i^^r */ -ft^ ^^ •€ "tli^ IIKeifc BBC IE "IK i^^XE. ^ W^ ^V
'-■,^rf»- !■,*■ «;:.-r*i.r «r jil"'^Z!l«»t -grrsa-^ •£ TBS K^TESnm^ 'TW
-e,'^r-'.^ -T.'x '' il** iiili-.'**. »"r".I rji "'il:. Ill ■•-.w>-^%~\ _, jji. -,, iTTTm'-nii.-:»
» r^i -,-»--■.;<—*..'.- '■■">. T\^ ".ir"-Tr ill- aj^Jai?- 1 :: ''iiirL vxa. A si.i-
■f>^ _/-^/ '..^ ::-'<':nf'.f.c I.—- .mi.i:7 >*•: t-jt^ ?• ii.: i ;r m. miua^ jm^
OBSTACLES TO LAJtYNOOHCOPT.
289
The mirror should not be kept in the thro:it more lhnn twenty or
thirty secoiulii, but Iho exiiDiiimtion umy be coutiiiiied by reinlroduf iiig
it fiifvcrtLl timet!.
Whenever the sligliteat nulieiition of retching oacnrs, the mirror
liimt be instantly witliJmwn, but. after \\ few moments, linother tridi
Uuiy bo m.ide. which the pjitient will iignnlty tolenito a« well as the first.
When inserting tlie mirror, its reflecting surface should not touch
the tonn:tte, nor its back rub against the palate. The former accident
-clouds the reflecting surface, ^and either is likely to eauae retching or
An attempt to swallow, which will prerent the examination.
OBSTACLES TO LABYNUOSCOPY.
The obstacles fretpioDtly encountered in laryngoscopy can nsnaHy bo
overcome by a little Ijiot and patience, at lenst at a second sitting. \Vo
abould 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 iuepectcrl with a single introduction ot the mirror.
The jiriiu'ipal obstacles to be overcome are: an elongated uvula, en-
Jnrged tonsils, irritjible fauces, a short frwniim. iirebing upward of the
back of the tongue, and a pendent epiglottis. In two r<ases. one an
actor, and the other an elocutionist, T have fonnil difficulty in inspecting
the larynx apparently on account of hypertrophy of the lingual muscles,
vhich greatly restricted the space between the tongue and the posterior
vail of the pliarynx.
Ax ELONGATED UVULA, hanging bolow tho mirror, appears ns though
curled over the lower edge jind resting upon the reflecting surface. Thla
is rery confusing and prevents a view of the parts below.
To obviate this diflU-ulty in ordinary I'ases, it is only neceesary to nse
a large mirror and to be cjireful in plaring it against the nvnla. Mir*
rors have been devised with a little pocket in the back for catohing the
arnla, bnt 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 theiio are inadequate, tt should be amputated and the ex-
amination made at a subsequent sitting.
On account of irritable FArCE-' some patients cannot hear 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 fnlly impressed
with the necessity of the examination, and urged to restrain himself
from retching; the mirror ehnuld then be introduced during a deep
inspiration or as the patient aays cA or aA, which elevates the uvula,
and, by thus preventing the necessity for pressure against the palate^
secure* Tnuch greater tolerance of the instrument.
•9
S^ TUB THHOAT.
With uervuus patients it is often best^ for the Kake of firat guining
their coufideiice, to introduce the mirror once or twice so iti jutt to
touch the palftte, and then wiclidruw it at once without nttcnipting to
sec thu larvux. Ice may be mucked for tift«en or tveiity uii»uie8. to
produce some degree of temporary local oufesthesia. If the^e devices
fail, tlie most feiiaible method for overcoming the disposition lu retching
is tin application a few times of a small amount of u ten-|M.M'-cent solu-
tion of cocaine, by spray.
Many persons, in whom the pharynx is scnsitiro, will tolerate an
exauiimition at a second or third sitting, in whom bitrdly a glimjiae coulii
be obtained at the tiret. lu »uch cages it is a good plun to have tlm
patient educate the throat to bear instruments, by introducing a ^pooii-
liandle against the uvula before a mirror eevenil limes daily during thiv
ixtterim.
Id cases of n-ntahnity of tbe fauces, some lar>'nirolo?t!ttM ivrommend titilU-
tJOD of the palnte with a prube or a penholder Uefore atluiupting to introdutv
til* mirror, m order thut Ihe parts inuy bc-come ucTustoiued to iiiaiiipulAtum.
, Various other devtceH hitve been reconimeDded fur uvenroitun;; Uit* tteusilivcaiiaa
u painting llie fuuees with diloroforni uoil luoiphiiii*, laluiliition of a f«w
rhiffsof cbloroform. and the internal iifte of larg^ dowrs of pulusKiiini bramidif ;
but none of these meusiims are very salisfactory. Ordinurlly we will sucoeeil
best simply by |»ativii(:«* and care in introducing and luddiiiLr the luitror. supple-
mented, when necessary, by the use of ice or (x>cainp. Tbe faii<-eft arv more
Irritiibin when tbi; btoiiiacb is disordered and dunii>c dii^vHtiun tlnta ut other
times: then^fore it i^ be«t, whenever tbe throat is )t<*iisilive, to make the oxanii-
naUou l>eforu eating or not until thre« or four hours-afterward.
A ttHOKT yRiUKim is one of tbe minor obstacles. If it proves verr
troublesome, it may be cut with a jmir of bUinl-poiiite<l scissors.
AitcHt.vi) OP THE TOSGI'E Gccurs in some patients just us the mir-
ror is being carried between the t**eth, the posterior part of the tongtip
arching upward, so as to touch the soft paUite, iiiid tbua preventing tlie
passage of the mirror into the fauces; or ruuiainiug here to intercept
the rays of light after the mirror is in position. This ditticulty is best
overcome by cautioning the patient not to strain and by care nut tn
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 mirrorncarly horizontally against ihc p;tlalr.
and rctlecting the light upon it from below upward. In some caseii. trie
patient, by watching the movements of his tongue in a hand mirror,
may be able to keep its base depressed. Other patients will need li
jiructise before a mirror at home for several days before control of tlie
organ can bo obtained. Tongue depressors seem indicated in ihcsecaso».
but are of little value.
Greatly enlarged tonsils may prevent the introduction of anj
mirror into the throat; in such cs^es the only remedy is excision. Wliea
l_
OBSTACLES TO LARVSOONCOPT.
S91
thev are only moderately enlarged, it will gnmetimes be impossiMe to
introduce the ordinary mirror without touching them l>oth, ttnd perhupit
ciiu«iiijr rptrhinjr; but in many caries, if the mirror is carried promptly
between iin<l iH-hinil tlie toneiU, the throat will rumaiu quiet, even
though both sides have l>een touched. In other canes it is l>e«l to use an
otbI mirror, ,.hioh may be pn*«scfl into tlie fancea without touching the
tonsils.
A LAROB OR FF.KI>EN'T RPinLOTTlA \s Sometimes an insurnionnlable
^b«tftcle to laryngoscopy. When the glosso-epiglotlidean li>:anjenl> are
rekuced, or when the epiglottis is swollen, it falls downward, so that its
Tree edge mnv roet against the pharyngeal wall, leaving little if any
«pace for the passage of light. In some of these ai^-ea we can obtain a
view of the larynx by causing the pjitient to sound the letter 0 in a
high key or to utter a high falsetto note. A vocal sound, as alt ur
sh made during inHpiritiun, will liave ti !<iiiiilar effet:^t. Hy a laugh
or a cough the epigluMis may be thrown upward with :i sudden- jerk. In
other instances it is only necessary for the patient to drawn a deep
breath in order to raise the epiglottis siitticiently to give a view beneath
it Frequently by passing the mirror lower into ilie pharynic. and more
perpendicuhiriy than usual, the inferior surface of the epiglottis and
other portions of the larynx may be seen.
Various instruments have been devisetl
for lifting the epi;;lottis. The lH*st nf these
is known as \'uUuliiii's staff, a ^tont whale-
bone or metallic rod. bent neiirly to » right
.ingle about an inch from the end. with its
terminal extremity turned slightly backward.
It may be passed behind the lip uf the epi-
glottiij, so as to lift and draw it fcrwui-d.
Occasionally when operations are to be
performed, or for simple inspection, s<»nie
special instnimeiit may be necessary to hold
the lip of the epiglottis forward. For this
purpose Brnns' pincette has been recom-
mended. Instruments of this kind, how-
«Ter, usually cause too much irritation to be
tolerated, and asimpte bent staff or strong probe will be found prefernblc.
It occasionally happens that only the posterior part of the larnix can
be M«D, and the vocal cords canuot be brought into Tiew. Id such in-
\ 7J
Flo M — IxTRA-OLornc Lumr>
ooacupr Kuiall niH«aK' tulrmr
In pci>ak>D lu Utr. fromtrft <>f Um
tnu.-lHwl cantiln
293 THS THROAT,
■tanceB the moTements of the arytenoid cartilages maybe seen snffi*
oiently to enable us to judge of the mobility of the cords; bat 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.
INPRA-GLOTTIO LARTN008C0PT.
It is sometimes desirable to inspect the larynx from below, which
may be done, after tracheotomy, through a fenestra in the cannla, by
the aid of a small metallic mirror (Fig. 63).
Fia. M.— Rklativx IVjnint>jii» or Lartkx ^m m Iiuot iv trs L^mrKatmoopto MouMm
(OOBCIH).
Flo. tt.— NouuL Linrxx in Rnrnunon. kvuuhisd. Pan* nacg«nit«)] lo Ptmder them mnre
eooiliicuoua. 1,1. UnRUftlMirtAoeof eplglotUa:2.9,lUT»sulMn1kc*Qf cp(ftloUi«: SJiMteiilRdcrrM
flf c|4gloui» ; 4. 4. |iliarTafo«pigloUlc fofals: t>. &. •rr-eplKlBtttc fulda; 0^ outhiun of rplclurnH : 7,
gli»ii>eplgln«tic UguHMtt ; ft, 8. mloptilK' : 9, V, pytiffrnti mduw^ : 10. V), foKtrrtar ptiaryvf^al wait
•0«lfDimK«lntocBBO|)tu^s: 1 1. InlM'-U'rieooii] lovtsurv ; 12. 1i£,canilagc«cirSttntnnni : I3,iitt«r-
knrt«on44l loM : 14. 14. cartllwi^ of Vi'tiftb«n-K : IB. )&■ rentrkulAr baa^bi : 10. 10. tocbI corda : 17. IT,
nntriclM: if*. 18. postertor vocal proc«MM : lf>,thjrroM eartflo^t: a)Lcri«o-tfarn>tdfiiembnu)« i SI,
crimlil cM-tilnffs ; a, SS, Xf, rlufc* of tnchek ; Za, Sl^ S3, S8. Intcrqwow b«t<reeii rtags ot tnu4m
(Oobmf.
below close to the lower edge of the mirror. The sides of Uib larynx
are not reverscil in the image.
An ininge of the whole larynx can seldom be obtained at a single
glance; but by i^light rotation of the mirror, with elevation and depre^-
sion of the handle, so ag to alter the plane uf ihe reflecting surfnee, the
different parts may be brought into view. The vocal L-ords, because ot
S94
THE THHOST.
their white appearance and frequent respiratoTV movements, natnrally
attract the most attention, and when onco seen can hardly be forgotten;
but the epiglottis comes first into view.
The norual larvnx is «hown in a somewhat exaggerated form
(Fig. 65) in order that the parts may be more clearly identified.
TiiE EPIGLOTTIS IS tt leaf-Iikc valve, which covers the upper opening
of the hiryux and closes it during deghiiition.
The base of the epiglottis — in reality the apex of the cartilage —
la connected with the thyroid cartilage at its receding angle by a long
narrow band, known as the thyro-cpiglottic ligament; a small band, tho
hyo-epiglotlic ligament, connects it with the posterior surface of iho
hyoid bouu. The free extremity is broad and rounded. Tlie liuguul or
upper surface of this cartilage usually curves forward, its concavity
toward the base uf the tongue. Its covering of mucous nieinbrune fornin
a median and two hiterul folds, known as the glosso-eplgloltic folds.
The central one of these is also called the frsnum of the epiglottis, of
the glosso-epiglottic ligament as it contains a ligamentous band. The
lateral folds contain no tlbrons tissue tiud are frequently iibsent. 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 iiry-epiglottic folds.
It varies greatly in size and furtn in different iudividnuls (Figs. ^6 to
71). It may be long and thin, ur short and thick; it may tie 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 tlio jews-hurp
form (Fig. 70), or it may be asymmotrieal. It may cover the whola
larynx, or it may be nearly invisible. Sometimes only the upper or ou-
lerior 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 agiiin considerable [lortions of both the anterior and
llie posterion surfaces nuty be seen at tlie same time.
With respiration, the lip of the epiglottis rises and falls slightly.
With phonation it is generally thrown upward, and in deglutition it ia
carried downward to the posterior border of the larynx.
The whole epigiottis is seldoii* vi«iblu 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 bo seen near the base of the epiglot-
tis, known as its eushioi}, j)ad. or protuberance (Fig. fiK),
The color of this organ varies in different piirts. The upper surface
is of a pinkish hue, and frequently blood-vessels may be seen crossing
it. The lip looks like a yellow cariiluj^e. as it really is, covered with
mucous membrane. The cushion generally uppeurs of a much brighter
red color than other portions of the epiglottis. When the whole of the
laryngeal surface can be seen, it often has a uniform bright-red color.
I
Ttam. U to T).— KuRMAL I.XKV}fX,
WHD Vkmrnjuaw*-
Fltl. M.— |>ITVl]KK-IUIAfKD liTTKII-AMmXOin FoUt. PROIUTIOK.
Flo. f7.--L^rpt>-o or Arvtbnoid Cahtu-aocm tx PaoNATios, wmi OArtra or Tocai. Omuw.
Fio flM.-4:aiiHio)t iir »ioix>rrt« VmBUC : xo Qapixi) up Vocal Coumi in PaoKATum
tZiBlunft).
Fm. (KL— Poivtkd F.rtt.iAmt»; Ventkiolks DuTtXtrr; IXunxATKiw.
no- iQ.— ' .Tirir»iiARp" on OnKriA-tJEB Kpiaumra-
Fn. n. — PKMAtJ: LamTNK IM Rm-IHATHIM iCOUKX).
Tlie fettialv burox mny h«ri; ttie form tii-jvn la anr at th« prveodl&K llffur««,
some plastic eultsUnce (Fig. 65). They vary greatly in depth and in width
in difTorent indiviihmls, iind in rarious positions of tUv fpiglottia in the
wme individual. Tlieso siniises eliould tilways be exnmincd up they
frequently give Indgeniont to portiona of food which aro u sourct! of irri-
CfliioDi and Ihey iiri' sometimes the seat of ulcers.
»9
200
TBE THROAT,
Thk akytksoid (.'ARTiL.\nE.s — ao imini'd on account of their ajtftar-
t>i)t rewniblaiice iluriiig jitioiuition to Uie iios« uf u {liicher— ujipeur Lhh
roath the free edge fif Ihe epigloltis. Thev are tuu in niitulttr, unt
opon each side. They are located at the back of tho Liryui, re^tinK
upon the \ip{>er border of the cricoid nirtilagc. EiicOi of these i^artilAge?
is somevhiit pyniinidal. The apex, which is slightly pointed and rnrred
uj)wiird and inward, io surmounted by a smuH conioid nodule, which has
been nanied the comiculuni laryngti! or cartilage of Sautorini.
Trr I'Airrii.AitK.^ \*v Santuhim. which urc Ui<uully about the siza
of n millet seeii. are most prominent when the glottis is cl-jsed, aii in
phoujtion. The niiicotis membrane iniinediately covering their .ipii'e&
IB of n lighter hue than ttiat in other parts of the larynx, but the light
color is usually surroundeu by a zone of deeper re<l.
The CAttTiLAtiKs OF WnisuEur, are just external to the cartiluges of
Santuriiii, in the fold of mucous membrane which extends on either side
to the cNlge uf the epiglottis, prominences known also as the cuneiform
cartilages.
These cartilages rury considerably tn form in different individuals.
They are usually round, but are occasionnlly triangular, the iipioes being
direi ted downward. Sometimes tliey are hardly vis^ible, bnt they are gen-
erally quite distinct and fully as largo aa the cartilages of SantorinL
These, like the coruieula, are of a lighter color than the folds which
contain thcni, but they are usually surrounded by a zone of munous
membrane redder tlum the general surface.
lu a few instances a small nodule, due to a third cartilage, i^ ^e^u
between the rartiluges <tf Wrislierg and ihe cartilages of Santorini on
each side. The cartilages of Wriiilwrg and those of Saalorini are some-
times termed the supra-arytonoid cartihiges.
The ARYTB-VO-EriOI-OTTIDEAX FuLDS or thc AliT-EPlOWmC POLbS
constitute the lateral and jtart of the posterior bonier uf the snperior
opening of the larynx. They cunaist of folds of mucous membrane, one
on each Kide, which extend like bows from the arytenoid cartdages up-
ward and forwanl to tho sides of the epiglottis. They are usually from
one-twelfth to one-eighth of an inch in thickness, but are occasionally thin
nnd shar]). In color they closely resemble tho gums, and are somewhat
Jigliler than the zones about the bases of the snjint-arytenoid cartilages.
The I'YRAMIUAL, PYKIFORM, OR LARYNno-I'HAKYXGEAL &INUSES OTC
found extemid to the folds jnst named, and between them and tho wings
of the thyroid cartilage. The broad end of each sinus is directed for-
wanl, and Itti apex iKickward. It Is bounded internally by the cjnad-
rangular membrane, the upper border of which is formed bythoary-
epiglottic fold, anteriorly by tho wing of the thyroid cartilnge, and
laterally by the wall of the phar}-n\. Like the valemta?, these sinuses
often give lodgement to foreign bodies, and are frequently the seat o£
ttlcenitions-
THE LARYXX.
297
Tns rBKTRICULAS BAXDS, kiionrn nUn iia the sniierior or fiilac vooal
cmrds, the regulators of the gluttiis, or the sit|H>rior ligaments of the
larynx, are thick folds of hiucduh nieinbmne which ittretch soroga tht^
larynx in an antero-poeterior direction, about half an inch bMnw its
superior opening^ and a isbort ilistince above the true vocil t'ord?. 'I'iipy
arc frequently very prominent, standing out in thick welt« from the
sides of the larynx. In other instances, they can hardly be distin-
gnisfaed from the surrounding tissues. They are of a deeper red color
tli:in the tissnes above them, but their inferior or inner honler« gen-
erally appear pale in the laryngoseopic image, on acconnt of being illn-
niin.ited nioro perfectly than the siirronnding parts. Just beneath the
anterior ends of the false vocal cords and above the true cords may fre-
qnently be seen a fossa, about the size of u pin's head which has been
K^^
V ni—Vinr or Lkpt Sidc or LiRryi rrPitcx>. a. Left vocal cord : t>. povtcrlor ponioa ot
v«F«itriclc* ; e. Ml vnntrk-iiliir ttanil ; it, |HMlrrior K'.irfACi- of «|alelMete: e, border of ar}r-«|j|gluUlc
foM ; /. Wt cortila^ trf WrtBUrru ; y, nglil v^irtilBtfa <if Wri»l<rg ; A. li^ht voc«l foixl.
named by Mackenzie the fossa innominatn. This oommuniuates with
the laryngeal sinuses upon either side.
The vestriclks of the uarym are fousd immediately beneath
the ventricular bands. These consist on either side uf an obloug fossa,
which is the opening to a nij He mr of mucous membrane, known as the
a:iL'irnUis laryngis. They are bounded above by the false vocal conls;
below, by the true vocal cords; and externally, by the thyro-arytenoid
ninst^les.
Tho ventricles are seldom seen, and, when visible, usnally appear
merely as dark lines; but occasionally they are patulous, with a width of
nearly ono-eigbth of an inch.
TuK SACCCLUS LARYXOis exteuds upward and outward in a conical
form beneath tlie ventricular band. The mucous membmue 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 mcntbrane, and this membrane by
muscular tissue, which, according to Hilton, compresses the sacculusand
discharges its secretion upon the vocal cords.
The vocal cords, known also as the inferior or true vocal cords, are
the moBt important objects to be seen ou iuapectiou of the larynx.
Thpy (ippeiir tis two pearly white bands 8trotche<1, one along eacli side of
tho iaryiix from ha nritorior to its posterior purl.
In tiie iiclult they vury from fivo-t-ighlJis of an inch to one inch in
length, anil are usually about ono-cightit of au inch in breiidth; thev on
somt>timea perfectly white In women, but in men thoy are usually ut %
yellowish white hue. They consist of tibrous tmndB covered bv a thin
layer of closely adherent mncous membnirie, being attached anteriorly
to a depression between the ol* of the thyroid eiu-tilngc, posteriorly to
E.ht' anterior angles at the bnae of the arytenoid cartilages.
During- rej^pimtion the corda alternately upproaol) each other and
recede, lejiviiig b*-tween them a triangular opening for the paFsagp of air.
Tho cords and the space between them form what is known as tho t/ht^
tiK. The free edges conatitn'o the lips of the glottis^ and the chink or
Kie. Tl.— NoBiut. LfcftTMX or Womam is FuKMAnux or Rkao Toxu tOosBiO.
Assure between them is called the rima glottidis. The front of thft"
rima is formed by the anterior commissure of the vocal cords, its sides bj
the cords themselves, and lu batie by the arytenoid cartilages and th«
inierarytenoid fold. In the adult, this fisKiirc varies in length from
seven to ten lines in women, and from ten to thirteen in men. At ita
widest part it ordinarily meatiiire^ from three to six lines, but on deep
inspiration it may measure us 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 extrentities remain close together, thus forminir
a triiingnlar opening. On expiration they approach more nearly together,
and in phonntion their two borders are more or less closely approximuled
but there ia usually a narrow tissure between them throughout their en-
tire length. In women, and oocasionally iu men, during the production
of hejid tones, the vocal proeesscB are pressed firmly together, so that the
fissure is left only betw(>eik the anterior parts of the cords.
From a careful photographic study of the larynx daring the prodno
tion of the singing voine, Thomas R. French (Tnui suctions of Anicricm
Idryngnlugical Association, 1>*8S) concludes that the female voice has
three and the male voice two registers; the transition from one to the
Dftxt higher being usnally marked by backward movement of the epi-
kMi
mm^
THB LAHY^jr.
299
glottis, change iii the shape uf the glottis, iliortetnng of the uordSj and
uu apparent iucretue in their tension. Protrusion of tho ton^e doea
not mat«riaUy affect the Uir^iigoBcopic uppearunoe.
The oonis are Bonieliiiie« lent^h«aed in men on chan>;inK to a higher register.
The i-HocEftsus vocales or vo«il processes sire Hotuutinies seen aa
four 3-cllowLsh spot«, two anteriorly and two posteriorly, whcro the vocal
cords iiruuttaclicd to thu cartilages, but the anterior processes arc not
often vitiiblc. Usually, wheu we speak of the viK-al processes, simply the
anterior angles of t]ie arytenoid cartilages are referred to. Curl Seller
has tlf^criU'd narrow fusiform cartilages", fouiul along the edge of tht,
vocal c(trd» in women. Thpse are un\y rudimunlary in men.
The iNTER-ARYTEKoin KOU> or posterior ^ommissuro is a hand of
mucous membrane whicli extends between the arytenoid lyirtiliigcs. Th»
prominence of this fold depends upon the position of the c-jirtilages.
When the glottis is open, it may measure six or eight millimetres iii
length; but when the coi-ds are approximated, it is folded upon itself str
that it can hardly be socu.
The cricoid cartilaor may ui<ually bo seen a short distance belov
Uie vocjil conis, separated from their anterior extremities by the lower
]iortion of the thyruid rurtilage and by the crico-thyroid membrane.
This cartilnge is of a lighter hue than the nembraiiuus tissue above or
below it, and is similar in color to the rings of the traeheji.
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 arc separated from each
other by the intervening mcmbnuious tissue, which is of a darkur color.
As we carry the inspection farther down the tnichea, the cartilages
Appear narrower and narrower until their outlines are Hnally losL
The nuieous membrane lining the trachea is generally paler than that
covering tliu surface of the lurynx.
Considerable variety In the shape and movements of different parttt
of the larynx may occur within the limits of health. This is cepecially
the case with the epiglottis; and variations in the appearance of the ary>
tenoid cartilnges and of the commissures, and slight alterations in other
parte of the hirj'nx may occasionally be found, as illustrated in Fig?. 66
to 71. The epiglottis muy possess any of the various forms already
spoken of. The sup ra-ary tenoid cartilages vary considerably In their
size and form, as already mentioned. The position of the arytenoids
varies; constantly with respiration and phonation, and may he quite dif-
ferent in healthy individuals (Figs. fiC to Tl).
In disease of the larynx, changes in its form and movements consti-
tut* the principal signs. There may be hypertrophy or swelling of its
various parts, with more or less loss of movement, or ulceration may
ANTEHIOR RiiI2iOliiJOVY.
301
RHINOSCOPY.
Khinoscopy or exnmination of the nasal cftvitips is termod anterior or
posterior acconiing to the position of the parts inspected.
ANTERIOR RHINOSCOPT.
Anterior rhinoscopy or the initpection of tlie snterifr nares is per-
formed vith the aid of die laryngoscopic reflector and itna^al specnhim.
Various instrumental have hcen made for the purpose. A simple hivalve
cnlura, snch as shown in Fig. 7C> is most satisfactory for pnrposoe of
diagnosis; but when operations arc to be performed, instruments that
will retain their positiuu when placed in the nostrils are preferred by
some laryngolugislei (Figs. 7? and 78). No special Uirectionsare needed for
anterior rhinoscopy, excepting tliai, in order to view the back jwrt
j of the niiaal c'lvities from the front, a (condenser, and ii reflector an de-
^scribed with the laryngoscope, are very desimble, and it is absolutely
o=
Pia. 77.— Jaittu* Bmua. VtMtu Smnrbcii <H vlxp't.
necessary that the light be properly focnssed according to the principles
laid down in speaking of condensing lenses. No obstacles will be found
to the examiniUionr excepting in unrnly children, unless there be some
deformity or swelling of flie turbinated bodiee. The Intier is eummou,
bat may usunllv be quickly reduced by a (fmull amount of a spray of
<N>caine. The nares are usually about one-eighih of an inch in width and
from an inch to two inches in height. The inferior turbinated body is
«een occupying about two-thirds ul the outer wall; and the middle tur-
binated, much smaller, is seen at the upper part of the cavity occupying
ubout one-t{uarl(T of the outer wall, and usually approiiching to within
iruiu oue-iwelfth tu one-Hixtceutli of iin inch of the geptum.
Thtt superior turbinated body cuunut be seen. The whole cavity ig
303
Ti^^ ^'ffiOAT.
coTered with gmootb macoafi '"^"■^''•w, awTnallrof about the nme
color aa thm corerine the gti«i»*» *>"! often, ander I«as perfect illu.
mination, iipi)earing ilijehtly coOgm^ The normal relatioiu of the
pitrU. iibout an innh hncit of the ntatriU, are shown In the acoonipdnr-
ing cut from the photograph of a frozen section prepurtd for me br C.
fl. Stowell.of Wafehiugton. D. C. The »oft tuques are somevhat sbmnk-
en, :i£ alwaya found in the cadaver.
In aboat twu-thirdFt of all eases thfr^* U some diitparitv in sise in the
two cavitifM, dne to dcllvution or to oatgrovthi from the bonr or cuti-
'g?
*l
Ful. rg— C»ni utntKm or Read, ukhiivo rtum axrvrnt «Antw*Kt»i4-& naUmU •»•}. gbow-
)*)«: €t. a. mfaUk turUnatHl Iwflhw, h. t,. InTrrfor mrtMafttcd hnllea. r. r,c «thmnii| cHk; a.\t. uttfm
• >r HIjrhtnon- ; r. r. nrinu : / «e|«uin : ff, hard |«U«tf
'aginoui sepinm. Usually the turbinated bodies of one side are some-
vhat swollen^ so that it i» exceptional to find the nasiil cskvities exactly
ulike.
posTFRioR Rnrxosropv.
Posterior rhinojiropy, or inspection of the rauU of the pharynx and
jKisterior nurwt, ii* prartiaed with instrumenta :Bimiliir to those used in
the inspection of the larj-nx, and in much the same manner, excepting
thut a eni:illor mirror is necessary, and its reflecting sur^co is turned
upward instead of downward.
A mirror from half to five^ighths of an inch in diameter is usually
employed, and it is generally best to have a flexible stem, which may he
reatlilv 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
»8 the laryngeiil mirrors, or at an angle between these two; bnt this i^ a
matter of little importance, as tho obliquity of the mirror may be easily
dianoM'i \ty niising or lowering the handle. Special throat-mirrors have
POSTEHIOH HIilNOSCOPY.
303
bQ constroctetl for rhinoscopy (Fig. 80), but ihuy arc not 8it|»erior
to those alreo^ly de>8cribed. A ioDguo depressor will coniiuunly be
needed in rliiiiogcupy, and vunoim forint< of bluut liook^ and ntlior
istniments m;i_v be uw»d for holding the uvula; these latter jire rarely
Iployefl and are seldom if ever of uee except during opemtions.
In rhinoscopy, the patient should sit ereot, Hiid the hen*i nnif^t n^t be
thrown buckw»rd, but nmy be slightly inclined forward. The phYsicinn
should cake a position lui for laryitgot!i^py, or on a slightly hi);her level,
and tho light eliuuld be placed ti^ fur inspection of the larynx, except
Lg
>. 80.— riuKXKKL*s RHtKOBTupit. Ttip M«l« ot Uw mllTDr <a) ou b* elu&ff^ tt wiU hf morVOK
itw alblliiR roil ml b
t it should be on a level with the patient's mouth instead of hib eyes.
The patii'iit's tongue ssIkhiM not be {irotruded, btit niUbl be left in the
floor of the uiouth, where it will gencrnlly need to be held by a tongue
ipressor, thougli some [>alietit» cau control it better without an instru-
nt.
The rliinoscope in general use i» a number one or number two
laryngeal mirror, the stem of which is bent to conform it to the Jloor of
the mouth (Fig. 81). It is to he warmed and introduced with the same
care as in laryngoscopy, wttli the retleeting surface upward. It should
be carried Ixick to the posterior phuryngeul Wfdl, though it is better
to avoid touching it. The surface of the mirror will then be at uu
angle of abutit thirty degrees to a horizontal plane. The stem may be
rested on the dorf^nm uf the tongue, hut rare muet be taken not to touch
the base of this organ. I'he handle shuuJd 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 unilu and
304
TUB THROAT.
t)ieu oil the other, to give a view of difTerent parts. In somo caeca a
Urger mirror may be usetl if it is hold completely below the uvula.
When the mirror is in position, if nnly the posterior wall of tho
pharynx is seen, in order to expose the posterior nares, the handle must
be still farther depressed, or tho mirror mni»t be withdrawn and beni
more nearly to a right angle with the stem. If at first only the nvtila
iind posterior surface of the palate are exposed, the handle must be ele-
Tat«d to obtain a view of the posterior nares or vault of the pharynx,
fy^
L
.X"
Tn. n.— Fourmr von RamoKorT, •■ovtxn >uo Ctrve ni Stkh or Mibiuml (TUshtlr «l»rad
The mirror may be roLitcd slightly to obtain an image of the lateral
walls of the pharynx or of the orifices of the Eustachian lubes.
OBSTACtXS TO POSTERIOR RHINOSCOPY.
Some of the obstacles to rhinoscopy are the same'as those to kryn-
goecupy, and demand ttimilar treatment. Thus, the uvula may he elon-
gated and the fiiQcett iiulv be irritable.
The principal difflouhies met in the examination of the posterior
nares are: irrittxbility of the tongue causing the patient to retch when-
ever nn »ttompt is made to depress it with the spatula; an elongated or
sensitive uvula; irritability of the fauecs; too close approximation of
the uvula and palate to the puHterior pharyngeal wall.
Irritarilitv op the rosoL'E will :;umetimes prevent the uee of a
toiigiie depressor, hut it may generally he employed if the ])hy«iciaa is
careful not to allow it to slip too tar back on the base of the urg»n. In
many ca«es ii is not neuesmry to depress the tongue with any instru-
ment, if patients are instructed to allow it to remain passive in the floor
OBSTACLES TO POSTERIOR RnTNOSCOPT.
305
of the motilh. A Iianil mirror, in which tho p»ttont can see his tongue-,
vril) sometimes :ii(l him muteriHily in contrnHing it. In other oases tlio
tongno may lie bold ns in hiryngoseopy.
Somo ono of these methods will Tiearly nlwiiya overcome this diflR-
ciilty; but if they should ull fail, the {Mitient must practise ut home be-
fore u mirror until a sputnla cim be tolerated, or until the lougue can be
J:«'d wiiliout one.
Instruments have been eonstnioted which combine a tongue depressor
and the thront mirror; but they are not neces&iry, for. whenuvcr the
phyaician dcsiivs to use hotli hands, the care of the sp:ittihi amy be in-
trusted to the ]Tqitient. Instruments of this kind are objectionable, aa
the depressor necessarily greatly restricts the movements (if the mirror.
An ELONGATED UVULA, SO relaxed us to become an obstacle to ilio
n^e of the rhinoscopic mirror, may be contracted by astringents. It
the imila is too long to be niamiged in this manner, it should be excised.
Various instrninents have been devised for niieing the uvula tiiid
driving it forward, but they are of very little service, as they usually
cause so much irritation that they cuuuot be borne.
Irritability of the PAUfES can be overcome iu many instincea
by allowing the ])alicnt to 8uck liits of ice for ten ur fifteen minutes. In
other cjises there muiit be prolonged practice by the patient ;it home in
holding the tongue, and in touching the palate and pharyngeal widl
irith a spoon-h::nd1e.
In obstinate cases a solution of cocaine may be used us in laryngos-
copy.
Closure of the post-palatixe space, by contraction of the pala-
tine muscles, often occur;* the mumcnt a patient opens hi8-raoutb,:iud it
eomotimes continues in spite of our best directed efforts to ovenrome it.
Thi^ is the most common difticnlty with which we hnvo to contend in
illuminiiting the vault of the pharynx and the posterior iiares.
Sometimes this difficulty may be overcome by cautioning the patient
to allow the fauces to remain passive when the month is opened, ur by
directing him to Rimply 0]>eii the mouth wide without attempting to
show the throiit. Then, by introducing tho mirror carefnlly so as not to
touch any jiart of the fauces, and removing and reintrodnriiig it several
limeit if necessary witbonl attempting to obtain a view behind the palate,
the patient's confidence may be secured and the exflmination completed.
If the patient can be taught to breathe quietly through the nose
during the examination, the palate will hang loosely so fl« to cause no
trouble.
Sometimes a view may be secured by directing the patient to sound
H or ng. Frequently a glimpse may be had if tho patient will atiem])t
to exjiire through the nose.
Various palate or uvula hooks have been constructed for the purpose
of overcoming the difficult}'; bat, as has been well stated, the time spent
30
TBE THROAT.
in Lew-hing the putient to tolerate them is ueuallv more than ie neooe*
eary to educate the throat to maintain a position which will require ao
instrument. Timt.', {uitient^, and fre<|nent practice by the patient at
Fir. eu. -RiTmm Palatc RmuoroK cM *'>•*)
home must he the main dependence for auccesefiil examination in these
cases.
When operations are to bo performed, the palate may be draim for-
^^
Fl». HL— Poicbek'b &ELr-axr.ktsaeQ Utula a»b Falatk KcnucroK (Hilae.)
ward by the palate retractor {Fig. 82), 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 naros.
Jio. S4.— PalaTx hzTRjtCZoa. !>« ku«j.
brought out at the mouth, and tied over the Hp nrd very coDrenieut for
this purpose ; or the palate may be held by means of a broad, strong
palate retractor. The palate retractor onliuarily gold (Fig. 84) is only
Fio. 6&— Rbiwokopi vitb Uvna Bou«R.
hro-eighths or three-eighths of an inch in width, and is therefore too
small for this purpose. Combinations of mirrors and uvula holders havd
boon constructed, but they do not give general satisfaction.
iVhT OP THE PHARTXX AND POSTERIOR N'AKAL CAVITIES.
On Account of the small size of the mirror which we are generally
iliged to use, ntu\ the limited 8[Hice through whieli tho rays of light
can be reflected, it is im[H]ssible t<i libtain u com pie e imuge of the posterior
region with the mirror iu uny single poailiou, but by slowly turning it
from side to side, elevating or depret<sing the hiuidio, and introducing
the mirror tirat on one side of the uvula uiid then the other, part after
part c!in be brought into view.
The natural condition of these parts should be thoroughly studied
from diiigmms or models, before an 5ttempt is made to inspect them in
the living subject, and the stndf nt should make hiraeolf perfectly famil*
iar with the description of different parts. When the mirror is first
carried into the throat, we usually see ia it tlio imago of the upper sur-
rio. W— HemoaroPtr Ihaak. 1. Vomer or feeptuiti : n.a. fm ii|ini i rriiiiiiil|WijtiM . l,3,Mrp«.
nor meanu: 4. 4. tntddl« roeavu»:&.nv superior tiirblitnu^^l b<Mly:(t,A. mldiileturUiict«dbodj ;?.7, ia-
fanur lurbtlMtHd liudj' : H. B, pbArynffeol firtllnr ol Ktwtui-huiD hitie : II. 9, U|<fNfr purlliia nf fmsBi of
RuMiuuueUer : n. tl. glaixlular tlmuH at th«> cuwrlor i>onbiuof tliATmullof tbe pbATjux : K, pos-
lerfctr wutmix of veluui imUoU iLVjIwu),
face of the palate, or of the posterior surface of the uvula, or of the pos-
terior Willi of the phiiryn.T. If either of the first two is brought into
view, we then elevati^ the handle of the mirror, or if the lost is soon we
depress it, and thus bring into the field of vision the parts just above the
soft palate. We then search fr>r the septum nariuui, which is to be
takeu as a starting point for further inspeotiou.
Having found Ihn sRptum, we truce it throughout its entire vertical
length from the narrow lower extremity, where it joins the palate, to its
upj»er broad base which arches outward on either side at the top of the
,|K>8tcrior nares. On either side of the septum the irregular outer border
the posterior ot>ening of the nasal cavity should be traced from above
'downward past the projecting turbinated bodies to the orifice of the
Eusturhiau tube, and finally to the jialale and lateral walls of the
pharynx. The middle turbinated body is the most prominent object at
the outer pnrt of the nasal opening ; but it seems overlapped at its
lower part by the inferior turbinated body.
External to the middk turbinated body, und just abore that portion
aud uulward toward the vault and the posterior wuUs of tlii? ptmrynx.
This groove is knomi as the fossa of Bosenml'I^ller or the KsrEsscs
PIlARYNUEt.
The choax^ or posterior openings of the nares are seen jn front of
the rcbro-iiasal space. Tliey are of o\'al form and ufiually ulmui oiie-hulf
an iucli wide Ijy three-quarters of au inch in heigjit U»rrij«on Allen
(Tranmctions of the Aniericiin Larnignlogiciil AHsocintion, 1888) has
ghown that they are not infrequently of inieqinil sixe, without deviation
of the septum, the left being iisually the smaller.
The sm:nioH H'RBiXATEn uodies are located at the upper part of
the nasal fossae aud cannot be distinctly seen. They have the appear-
5
ttrx. I'crten.jr wall i.r upti^r imrt .<f piinrjrnx
(LiMcltkaj. t, I. Pli?r>'f<'<^») pn>(.-«Ba : 3. «ti.-tioii
Um IUUbI fiMue ; 4. i, iihoryupfal urUI*.-e <<t tlie
EuMaoliMD uibp : 9, oiilln' of tlic huraa pharyu
fMi ; 0. 0, rwnsu!* jiliMryiigrii!! <tiiMU ot KtiMtl-
inucU<*r'i: 7. mrvt1iitifi>MftrommI hy Cli>^ iul>>tiukl
•ulMt«acet<f llutiuualpiinionor till* |>li«rjriix.
Fra. i'- - [\i.!.\-i-)tAL Bobs*. Aowto-poMo-
rtor «^:iMO (L-J»dil»>. l. Section of bMlUr
prticpM vf Uie Dudptta) luine ; t. Ixvljr of qibv-
notJ : 3, |iluih«ry irlNn>I: 4, ntWnold ■uImuoc*
tit tbamult'if ttu*phiiryyx, brliliHl wbidttotMB
a. tba itlutrrnirt^l him*.
anoe 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 si'PERiOB, middle, akd inferuir meatus are the spaces
2ound between the turbinated bodies aud the external wall of the naeiil
cavity. The superior meatus, wliioh is the largeaf, appears as ii large
shadow at the upper i>Hrt of the fossa, just below the superior turbinateil
body. The middle meatus is seen as a dark opening near the middle
part of the fossa, external lo the middle turbinmed body. The inferior
meatus, if seeu ut all. >;eueriilly appears simply as u dark line.
The yAOLt of the pharynx U known also as the fornix pharyngis.
3^0 THE THROAT.
and u lometimes fpoken of u the tonsilla phairngea. It is that por-'
ticm of the pbarrngeal wall which begins at the posterior nasal orific««
and extends backward along the badlar process of the occipital bone,
and tiien downward to be lost in the posterior pbarrngeal wall.
In the perepectire riew, which we obtain of this part br rhinoscopy,
it appears shorter than natunL The mncons monbrane is of a light
red color, stodded with minnte whitish follicles, and broken on its rar-
&ces into irregnlar, more or leas longitudinal fissures and ridges, which
gire it mnch the appearance of the sor&ce of the foncial tonsil. This
appearance of the sarfiice is caosed bj glandular tisrae which has re>
ceiTed the name of toxsilla phabyxgea. Near the middle, at the
lower part of this glandular tissue, is an opening about the sise of a pin's
head, which leads np into a small cut de «ar. known aa the bursa
phabtxgea. The posterior surface of the uTula, palate, and pillars of
the fauces mar be seen below the nasal fossae. The palate appears in the
rblD'r^copic image as a fleshy ledge running at right angles with the
septum.
Si/Hontfmit, — KrytLemjitou8 or cutarrlml sure throat, cynanche pharyn-
geii, Hnd others.
An ticute inflaminntion may nffect the mucous membrane of tho
palate, pharynx, or toMsils, or all combine*!. Acute sore throiit is fouud
ftDiODg people of all classes and occurs at all ages, bni most frequently in
youug adults or children. It is said to bo more common in those who
liave Buffered from syphilis or who huve been mercuriulized, and among
those who fulluw sedentary occupations. It is most often observed dur-
ing the changeable weather of spring or autumn.
AsATouic-AL ASi> Patholuuio.vl CHARACTERISTICS. — There is at
first simple active hypertemia of tho 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 occusionally the uvula and
posterior pillars of the fauces are edematous. The superficial blood-
vessels are frequently distended, and soon the muaculnr ami ghindnlar
tissues become involved, and the setTetJons, primarily arrested, jire iiguiu
established, but changed both in quantity and quality. In some oases the
inflammation may terminate in suppnration.
Ktiologt. — Acute sore throat is commonly caused by exposure to
colds or draughts, eBpe<;ially 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 superbcat-
«d atmosphere, and then going out into llie cold. Among tho occasional
causes are extension of inflammation from tiurroundtng tissuea^ the iu>
liulution of poisonous gnscs, the abuse of tobitcco, the inhalation of steam,
the taking into the mouth of irritant poisons or of hot fluids, the im-
piction in the fHUCcs of foreign bodies, and possibly the excessive use of
spices. Over-use of the voice in poorly ventilated rooms or in tho open
air, especially at night, nniy be an exciting cause. Among the [irmlis-
posing factors arf^ the syphilitic, rhenmittii', and scrofulous diatheses,
Symptomatolooy.— In mild cases the patient at first snffers simply
from malaise, but soon experiences more or less headache and pain
in the neck, back, and limbs. Jn severe easts the pain and constitu-
tional syniptomij are marked. Karly there is irritation or a sense of
itching in the throat, with pricking pain. A few hours later nain be-
comes severe, especially as the patient attempts to swallow.
20
sa
DISEASES OF THE FAUCES.
When ths inflammation is in the upper iw4rt of the pharrnXf tlw pain
often radiates toward the ears, and there is more or leu deuluett, Jae lo
exteniiiuD along the Eustachian tubes. If the iufliuuniiition is stthe
inferior portion of the pharrux, ihe patient suffers from morementi of
the larrnx, which is uliio eensitirc on pressure. In eevere esses the skin
ii hot, the tenipeniture ruiigiiig at alwnt IDS" F. Indeed, the oonftita-
tional sjinptonie are out of nil nrupurtitm to the amount of inBanuuaUuii
in the throat. The jmlse ranges from W> to 120 or even 140, attHirdiii^
to the extent uf inflammation and the susceptibilities of the indiTJdtiAl,
all the symptoms being more marked in children tlian in adnlts. The
Totce often hus a nasil tv:ing, due to swelling of the it:iI»Te and nmla
and topreiijture on the pluiryngeal and palatine mn^'les brtheinflunniii*
tory deposit. There is no hoarseness. Cough does not n«imllydistartith«
patient, unleiu the uvula be<'onies nuu;h e1ongat«<1. There is, howetw,
«n annoying tendency to hawk and clear the throat of the secretion^
throughont a conaidorable portion of the disease. At flrst there is bnt
little expectoration ; later the secreiions are more abundant, thick uid
tenacious, and hard to expectorate; finally they become mnco<panileiit
The tongue is nearly always furred, the breath is feverish and oflentire,
the bowels arc constipateil, and the urine is high colored. Ujtott eiuB-
ination of the throat, the mucous membrune «*iU he found of a bright
red color, which may be limiteil to patches or diffnsed over the whole
earfuce. The superficial blood-vessels are often, though not always en-
larged; the nrula is usually congested and Bwollen, and occasionally tli»
same condition extends to the posterior pillars of the fauces. The £oft
palate may also be considerably swollen, its edges having an oedematoas
appearance. Whenever oedema occurs, the mucous membrane is some-
what translucent and of a lighter red color. The infliunmutiou may
extend orer the j>alate, tonsils, and pharyngeal wall, and sometimes the
swelling of the mnoons membranes causes large longitudiiud welts back
of tlie posterior pillars. Occasionally, in severe cases, the parts are al-
most livid. The cerric-al glands arc very apt to be slightly enlarged.
Di.\(ixo?is, — Acute sore throat is to be distinguished from scarlatiiu*
acute tonsillitis, and rheumatic sore throat The constitutional symp-
toms in 9tarltttiiui are more marked than in acute sore throat, and usu-
ally after a few hours a cliaracteristic rash appears upon the skin-
There is at first con^^estion in ncntr toHKiIhlit and pain similar to thut in
acute sore throat, but shortly the glands swell sufficiently to distinguish
it from the disease under consideration. Again in acute tonsillitis the
iutlammation is apt lo lie confimnl mostly to one side for the first two
or three days. The pain is greater in anth rkruwalir mtn throat
«od the congestion usually, thongh not invariably, Ie*« than in simple
\U !*orp thmat, an<l there is nearly always a rlipiimatic diathesis
history of previous attacks, which aid in esublishing the dUg-
ACUTE HOUE TlfJiOAT.
313
pRonxosis. — Acute Hore LUroat runs its couree in from seven to ten
duya. ituil it; not tlaugeroufi to life; but often tliore remains » tendency
to frequent recurrence of the uttncks. In verj* rare cu*t« it has proved
tiaX by extension to the larynx.
Treatmkxt. — Patients subject to acute sure throat should be espe-
cially cautious about exposure; they should so clothe themselves aa not
lo r(>el sudden change's of tCimjierature; they should not sit in diiinp or
averhe;tted rooms, and, in a word, should iivoid all the known causes of
the iifTet'iion. The cold sponge bath is of uniloubted etKcucy in prcvcui-
ing the taking^ of colds. I direct patients to sponge the trunk vn<x a day
with cold wnter as it comes from the hyilrant, either morning or evening
as best auitn thctr convenience or inolimition. Fur the ru^igLd, the morn-
ing epougo bath is, aa a rule, better, but for others I adrii^e sponging at
night in a M-arm room. The bath t-liuulJ be taken quickly, and thu crkin
nibbed vigorously witli a co;trse towel to establish reaelioii. Full doFes
of quinine will sometimes abort an attack of acute sore throat. For this
purpose, from six to ten gniins should be given In a single dojjp. act^ord-
ing to the pconliuritios of the individu;d. Early iu the attuck. ice sucked
t-'ontinuously or applied about the neck in a rubber bag will frequently
uburt the inflummation. If the disease is not checked by these means.
J advise small doses of opium, aconite, or belhulonna. admini.Blered as
Xoliowf: the tincture of opium, one njinini every ten to thirty minnlvs
ut fir»t, and less fre(pu-Titty as the patient experiences relief front the
throat symptoms; or the tincture of aeonite, one minim every Hftecn to
thirty minutes for three or fonr hours until perspimtion is eittablished,
vheu tlie tliroat symptoms are generally relieved; subsequently once In
one or two hours iiocording to the fever; tincture of belladonna is given
in similar doses with benefit iu certain cases. I often rely upou potaa-
sium bromide alone, or with small doses of opium when the latter is
■well borne. Tho bromide is given in doses of ten or Bfteen gruins every
three or four hours, according to the amount of pain. As the dieensc often
occurs in persons of a rheumatic diathosi)^, uml since it is tiumetimes im-
passible to determine whether or not the rheunmtic 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 uf opium, or of belladonna gr. i. to ij.; or rarlmlicacid
gr. ij. in four drachms eaeh of glycerin and water, will often br found
very soothing. If there be constipation, it is desirable to give a saline
cathartic. Some physicians favor a mcreurial purge at first, especially
iu patients with engorgement of the portal system. It should be given iu
B single dose — for example, calomel gr. v.. with sotlium bicnrboiuto gr.
■»,— and followed after six or eiglit hours by a ajiline laxative. In nearly
all afTet^tions of tho throat, potassium chlorate is commonly administered;
it i» not certain that it has very much influence on these diseases: but
ERYfilPELATOra SOKE THROAT.
315
F grene, characterizeil by a durk pnltacfous apjieumuce of the tuucnns
I membrane and an odur peculiar to gangrenous ti&sue.
Etiolokv. — This variety of sore throat is pr(Kluced by the same con-
ditions that canse errsipelaa of the face or of other portions of the skin,
and is sopposed to result from infection by a specific microorganism
tlie streptot'ocoua erysipelatosus. The a£Fection is more frei^neiit during
epidemics of erysipelas.
SYMFTi)X.iT()i.uin. — In most cases the patient is attacked by facial
eryeiitelas, nrhieli continues tvo or three days before the throat becomes
involred. In rare inBtancei!, the inflammation starts in tlie fanvos. I*rc-
eeding its development, the patient usually snfTers from malaise for throe
or four days. Constitutional symptoms are more marked in erysipelas
of the throat than in simpio facial erysipeks.
Fever ranging from lul° to 104" B', sometimes occurs before conges-
tion is observed either of the throat or ekiu. Often there is nausea, and
pain at the epigastrium. The patient complains of dryness or a t>ting-
ing pain in the tlirout with stiffness of the jaws, so that there is dillivnlty
in opening the mouth. Usually there is swelling of the snbninxJllHry
and cervical giauds. Deglutition becomes exceedingly ]>ainful, luid is
sometimes dithcult on account of pure«i3 of the muscles. When the
muscles of the palate alone are iuvolved, food will be partially regurgi-
tated through the nose.
DiAONusis. — Upon examination of the throat, in the erythematous
variety, the mucous membrane covering the palate, tonsiU, and pharynx
has n shining snrface and bright red color, or in severe cases displays a
deep livid hue. In cases marked by phlyctipnulre or gangrene, the njipear-
anee of the eruption or the color and odor of the dead tissue would sug-
gest the charai'ter of llie attention; in those where the throat is attat^ked
first, the speedy occurrence of an eruption upon the skin will clear up
the diagnosis. Utinally the skin i^ tintt attacked, so that when the
throat symptoms appear, the nature of the disettse is at once suspevled.
I pRoososis,— The affection may run its course to cither recovery or
death in two or three days, but in the majority of cases it lasts eight or
ten days. Cue-haU of ibe patients die, and in those who recover resulu-
tion is slow. In fatal cases, the disease may extend to the larynx, caus-
ing suffocation, or the patient may succumb to blood {wisoning or ex-
haustion, with or without the formation of abscesses. In gangrenoag
cases, death is almost certain.
THEATMEST. — lu a disease so often fatal, the treatment cannot be
very sat itt factory, but anything which offers hope should be tried. An
applicaiiou of a sixty grain solution of silver nitrate very eitrly in the
attick h:is seemed to cut it sliort in some coses. Constant sucking of
ice luis been found beneficial in moderating the severity of the inflam-
matiun. and is to he recotunieinled, at least during the first few hours of
the disease. As the patient suffers much from pain and restlessnisi^
310
DISEASES OF THE FAUCES.
opiftteshltoul'l bo administere*! in (^iifTicictit finnntityto giro relief, un]
there is an idiosytinmsy to the <'ontr:iry. Bet^tanee of tlio teTidenoy of
the disease to death bv exhaustion, gtiroii1aii>« and tonics are iiulic-ateU.
Quinine should be given in doaes of two or three gmiiis, avei-uging about
fi praiu for each huiir of tht- day and night. TUt' tincture uf ehlnride of
irou hag seemed the best iiiternul romedy for cry»i|ichis of the skin, and
is therefore recoinmendei) in erysipehttuus inniimm:ition of tlie thro t.
It should he given in dones of ten or tifu-en minims iihont every two
hours, dihited euffioiently to enable the pittii-nt to take it without pain;
glycerin and Fynip of ginger best cover its taste. In cases whore ap-
plieatioufi of cold do not check the infhttnmatiou.Maekenzii'rei-onrnieiids
H'tirni funieuttitions and inbahitious of Hteani, or steum imprt-gnatud with
soothing remedies, nnudynes, or carbolic acid and glycerin. Hot ap-
plicatione ehuuld not bu made, howuver, until we have become cronvinctHl
that the inflaainiation cannot hv itbortcd. Frequent gargling with a
one per rent solution of cjirbolic acid \» itometimes beneficial. If much
(edema of the thro:'.t occurs, scarification should Ive ptiictitied to relievo
the tension of the tissues; and if the disease extends lu the birynx.
UB it frequently does, tracheotomy mnst be performed. Unfortunately,
however, tho operation is usually futile in this affection. In gungrenous
cases, antiseptic washes of carbolic acid gr. vi. ad ; i., potassium per-
manganate gr. v. to x. ad 3 i. or listerine 3 >>■ ad z >• should hu frequently
used;, and we should urge the jiatieut to take freely of alcuhuliu slimn-
lants and liquid food.
RHEUMATIC SORK THROAT.
ACITE RHELMATIC SOBE THEOAT.
Uheumatlesore thront may be considereil aa of two varieties, the acute
and the chronic. The acute affprtion is often attended by marked cou-
Btitutional symptoms and severe pain, and is efipeeially frequent in pa-
tients of a rhoumatio diathesis.
Anatomical and P.vtholocical Characteristics. — The throat ia
more or less red and swollen, but usually much less so than in simple
scute sore throat, and seldom sufficiently to account for the severe pain.
ErinuiOY. — The disojise is produced by the same causes which set up
rheumatic inflammation in other parts.
Stjiptomatoixwy. — There is almost always a rheumatic diathesii^
the patient being subject to frequent attacks of muscular rheumatism,
or having suffered at some time from the articular affection.
An attack comes ou suddenly and is announced by severe pain in
tho throat, which is soon followed by constitutional symptoms. Tlieee
usnally 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.
ACUr£ IIUEVMATIC SORE THROAT.
317
Iw^k, or extremities. Occasionully the disease pusses 00* with acute urtic-
ulur rlieuiimtism. Tlio pain is so peculiar thut [Hiticnts who have once
hai3 tlie [li»uit{40 will iisiiully rccoguize it immetlintely fi'om the chnnicter
of this i^yTn|)ti)iii. It is very severe upon lUteiiipts nt swulluwiu^ even
ft;lWn* Sudden shifting uf tlie patu from the throiit to the ninscicB
oi the neck or back, .ilKiut the «eitoin3 day, is tmo of the notnhle feature*
of iho diseaae. Tlie tempeniture is raised two or tiiree dcgives iiud the
pnlae is correspondingly quickened. U[Hm exumioiiig tlie fauces, we
find more or lesa redneaa imd swtlling, which may be uniforni hut often
consists simply of red stripeft running longitudinally Whind the posterior
pillars of the fauces npon each side, wliile other portions of tin* tliroat.
are but very slightly congested; yet the p:Ltient suffers intensely.
DiA'iNosis.— Thp disease is not likely to l>e confouniled with nny
oiher excepting simple lU-nle jtorr tlirunt. The distinguishing featureti
are: the peculiar piiiii. the history of former attacks, the suddenness with
vhirh the attack comes on, and the shifting of the p:iin after thirty-stx
or forty lj<»urs to sumo uther portion of the body. TIiltu is generally
much less of redtiej^a and swelling thuu in simple sore throat.
pROOSosis. — The atfection usually terminates In from two to four
djys. There is very little danger so far as life is concerned. F know
of only one reported fatal case; in that, the diseiise extended to the
larynx.
TttEATMEN'T. — Prophylaxis is of first importance in this affection.
Patients subject to it sliould wear citlier silk or woollen underdothing
the year round, and should be citreful to keep the feet dry and warm,
and i^^ avoid all undue e.xpO!<ure. £arly, an effort should be ni:idu to
abort the attack by means of salicylates, alkalies, ur guaiacuin. .Siniir.m
salicylate may be given in the manner recommended for acute sure throafe,
or salicylic acid iu capsules or solution, iu dosca of five or ten gmins
Bvery one or two hours. After a few dosea, the patient usually breaks
out in a profuse pera]>iratiou, and the pain subsides. When this occurs,
the dose should bo reduced one-half, and continued in that fpiantity for
Ato or six doses, when it should be further decrejisetl or substituted by
the alkalies. When this remedy is administercil in capsules, the patient
should always tako freely of water with each dose, to avoid irritation ot
the stomach. Potassium acetnto iu doses of twenty to thirty gnuns, or
ammoniated tincture of guaiacum in doses of one drachm may be given
every fourtli hour, or troches of guaJai^um maybe taken every two hours.
On account of the severe pain, nnod_\Ties may be required; of these^
opiates are most efficient, bnt the peculiarities of many patients render
this drug obnoxious, and therefore potassium bromide, phenucetine or
nntipynne or similar substances are often preferable. Applications to
the throat of warm fomentatious or poultices often iiave a bencticial
effect.
318
DISEASES OF THE FAUCES,
CnROKIO lUIEl'UATIC bOKE TUBOAT.
SynonifTA. — Chronic rheumntic laryngitis.
Chronic rheumtitic Rore throat is u. pninful affection varving niQch in
severity from time to time and alteiidod by only slight physical c)iangi-s
ill the jMirtfl involved. Though it usually affc-eis the hiriitix, and there-
fore luui been deacribed as rhc-nmatie kryugitis, yet in ntatiy cases it tn-
Tolvea only th** ftmcea, the hyoid bono, or ponaibly the tmcbea, without
implicating the hirvnx; therefore the term chronic rheumatic sore
throiit is preferable. It i« t'omi>arattvely frequent, and has probably n*
ifited from time immemoriid.
I huve been utmble to find any descni>tion oi it prior to that which I gnvcsl
the Ninth International Meilical Congress, hrlil at Washington, D. C, in IWT.
The affection occurs mainly in the spring and fall, but may also b»
obflorTod during the winter, and there are occaeional cases in which it
continues through the summer months. Thougii aETccting all claoM
with the Hamc impartiality as rlieumatism of other parts, it is more fre-
riuent in nien than in women, and all the eases I huve tseen hare been in
adults from twenty to sixty years of age.
Akatowical and Pathological CHAnACTKitiRTics. — No verj
marked charucteristics appear, although there \a usually slight conges-
tion, ctrimmscribed in chiiructer. but chaugeable.
ErioLurtY. — The disease is due to the same causes as muscular or
articular rheumatism.
Symptomatolooy.— Chronic rheumatic sore throat comes on insidi-
ously ill many cases, in others suddenly. Commonly the patient will
have been compliiiiiing for mouths when heapplie-s to the laryngologirt
for relief. Most of the eases I have seen have previously consulted *«-
end physicians and huve received almost as many difTerent diagnoses,
but all have feared either tuberculosis, sj'philis, or cjint-er, most of Ihciu
having a filed dread of the latter affection. The general health is not
imiKiiretl. The patient complains simply of a localized paiu, commonly
referred to the comu of the hyoid boue; I have observed it moat fre-
quently on the right side. Kext in frequency, pain is folt iu tbe-H
larynx, as a rule upou one aide only. Occasionally, however, it is in
the trachcA or tonsils, and sotuetimes 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 jihonation or deglutition, but often it
completely disapjiears while ilie patient is eating. In any case it is lia-
ble to shift it« position from time to time, but it may persist for weeb
in one pUee. Sometimes the person will complain of sensations of
fnlneea or swelling or of dryness, itching, burniug, or an indescribable
sensation of discomfort instead of an actual pain. ITsiiidly the voice is
not affected, yet it is common for these patients to comphiin of £atigu«
speakiuga^ijortliuu). There is no fevcr.andnoquickeningof iha
[
CHRONIC KUEViiATIC SORE 7'HROAT.
Sl»
pulse except from alarm. Usually there is do cough, hut in Bomo cases^
especially where the larynx is involved, an anni>ying, hacking cough ia
a prominent symptom. The digeetivy organs may act pi-rfectly, but
ordinarily the tongue is more or less covered with a whitish or yellow-
ish whit« coating, and, although tho appetite is usually good> the patient
is often troubled with flatus and eructations of gas from the stomach.
Upon laryngoscopic examination, wo may find congestion, contined
.generally to a small spot in the region of the pain, and sometimes slight
swelling. This condition, liowever, is liable to diminish, disappear, or
change to other localities after a few days, and there is nothing char-
acteristic in the appeamnuc of the parts.
Diagnosis. — The affeetiou is apt to be mistaken for neuralgia, for
enlarged glauds or euhirged veins at the base of the tongue, for chronic
follicular tonsillitis, gloesitis, or pharyngitis, for gouty syphilitic or
tubercular sore throat, for tobacco sure throat, or for caucer. The
essential points in the diaguosisare the uucomfortable seusatioos of paiu,
which change usually with changes in the weather, the existence of the
rheumatic diathesis, and the al^gence of auy distinct physical signs.
Chronic rheumatic sore throat is to be diagnosticated from varioosi'
veins, enlarges! glauds at tho 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 conrse of
the disease, and by the reswUs of treatment. By inspection, we may
at otice ascertain whc-ther the veins or glands at the base of the tongae
are enlarged, but unfortunately we cannot tell whether enlargement of
the glands or a varicose condition of the reins 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 glnnds at Uie bnse 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 diaguosis of rheumatic sore throiit. The signs upon inspection in.
chronic follicular ionitillitis, ffiosaiHn, uud pharynptis are characteristic,
and when they are fouud we may tistmlly take it for granted that tlie
8>lDpton)B of which the patient ronipNiins are <hie to these iliscasea.
We might possibly be mistaken in rase« of this sort, but, if &*>, a fiiilnro
to relieve the symptoms by curing these conditiouB would soon clear
up the diagnosis. Sometimes the diagnosis is extremely difficult; but in
the majority of cases, having intiuired carefully into tho history and ex-
cluded the affectiona here mentioned, we may come to an accurate con-
clnsion. (Jouttf nffections of the throat as shown by S. Solis LVihuu
(paper read at first Pan-.\nu licati (.'migress) oau.se painful symptoms
similar to the rheuumtic aficctiou. They may be distinguished from the
320
DrSSASBS OF THE FAVCSa.
Utt«r by the anteco<lont liiatory and Iiy the presence of gouty noUule*
and enlargement of the joints. The ulTet^liou may l>e distinguitilied
from *.tfphi!ia by the history and hy the phyHital signs. In rhe eurly
period of syphilis, and in the itewitidury and tertiary stages, there are
Ufiually fharaoterialin physical sigiiiS which are not fimnd in chronic
rlieiiiiiatic sore throat. Coses of syphilitic! gore throat oocnr, however,
in whirh the signs are not chamcteriatic. bnt in these I have never
known the patient to romphiin f\i the persistent pain or discomfort
which chiimcterixes the rheumatic affection, and I have seen no reason
for ooufonniling the two diseases.
Wo niny disting^tish this sore throat from fubereuh«ii by the absence
of confititiitionai symptoms in the rheumatic affection, and their great
prominence in the tubercular disease; the rchitively moderate pain or
discomfort and t)ie alH<euce of ulceraitun in the former and In the latter
the ifvere pniu, with suiierficial ulcenition, whit'li may e.\tend over a
considerable part of tho painful regiof, or occiisianidly deep ulcenition.
Chronic rht'umalinaore throiit may bcdiittinguished from tfihatra xors
ihroof by the history, and the absence of phn/t/e^ whicli appe.ir very much
as if the surface had been brushed over with silver nitrate; these arc
common in tol>acca sore throat, though in some cases we find no physi-
cal signs. With tobacco sore throat the patient cnnimonly cumphiinsof a
burning sensation in the part, usuully relieved soon after the tobacco ia
discontinued. If we find the jHttient a habitual user of tobacco, if stop-
ping its nso relieves his discomfort, and if there are no symptoms of
rheuniatisyi in other jmrts of the body, there will bo no difficulty in
differentiating tiie disorders.
It is often difficult to distinguish rhenmatic sore throat from neural-
f/ia. The presence of slight congestion or swelling is of considerable
value in the diagnosis, for in neunilgia there arc no local signs. In most
cases of rheumatic sore throat, pressure increases the pain, while in neu<
ralgia it does nut incrcjise but may relieve it. In rheumatic sore tlimat,
changes of the weather from fair or clear to cloudy and damp almost
always aggravate the symptoms, while in neuralgia they have but little
effccl. In neuralgia the pain is commonly worse in the latter part of
the day. when the patient is fatigutd; in rheumatic sore throat it is apt
to be worse in iho morning, and is not particularly increased by faiigue,
The physical signs dii^tinguish enaa-r. In most cases of cancer that I
have seen, there have been in the eitrly stage more or le?s iniluration,
with gra<lually increasing, irregular swelling, and finally deep ul(.'er»tion.
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
8ymj)lom, and the physical changes are not marked.
Pitotixosis. — We may expect the cases to continue for several months,
or even for years. There is no danger so far as life is concerned.
aOHE THROAT OF Si/AILFOS.
•sn
Trkatment.— In the trentment, our first nttention should be directed
to prophylaxis. With this in view, thepitticnt must be v,o]\ clothed mid
boused, mill protected from undue ox posti re. Khennintic pjitlents should
■wear either woollen or silk next the body both night iind day thmughniit
the yeur — light in summer and heavy in winter. They should be care-
ful ilmtull the excretory organs perform their functions properly. They
ehoulti eat sjuiringly of albuminouti siibfiLiiuces and live largely on vege-
tables and fruit; tho vegetable Hcids are often advantageous, but, what-
ever is eaten, it is especially imponanl that digestion Ix) perfect, so thi'';
the formation of ptomaines shall be reduced to a minimum. Korthe locU
treatment, sedative orslimnlunt applications may be made, with almost
ct|ual chances of relief. Appliculious of the tincture of acoujte tu tho
j)ainfulsi)ut fuur or Cv« times a day, of morphine in solution or in powder
will sometimes give consideriible relief. I Ji::vo frequently observed much
benefit from tb« application of such stiniiilanls as xino sulphate or
chloride and copper >iulphate, in solution; but I have derived most ben-
efit from a solution of morphine gr. iv., carbolic acid and tannic acid iSL
gr, XXX., in glycerin and water uu3 iv. It is applied by spray, and ia
frequently given to tho patient in one-half this strength to be used at
home. In some cases swabbing the surface with strung titiclure of
iodine or a iiixly-graiu solutiou of silver nitrate luis proved beneficial.
These liittf-r applications apjmrently act much the gjime as blisters over
rheumatic joints. The most important part of treatment is the internal
metlication. Here salol, soi^lium salicylate, potassium iodide, guaiacum,
Phytolacca, and the oil of guulthorium, one or all may be used at differ-
ent times with bouelit; sodium salioylute may be given iu doses of seven
to ten grains, the oil of guultheria in doses of fifteen minims, the am-
mouiated tiucture of guaiacum iu doses of a teaspoonful udministfired in
milk three or four times a d:iy. Tlio resin of guaiac in lozenges fre-
<iuenily repeated is of considerable vulue. 1 have observed most benefit
from the extract of phytolncca and salol combined, M gr. iij. to iv., with
an occusionul laxalive; but somclimes they have been used conjointly
with jwUutfium iodide, or with potajjsium bromide for its sedative effects,
I occasionally give the salol in doses of ten grains. Tinctures of bryonia
And of cimicifuga aro said to bo valuable remedies in rheumntism, I
ha\'e used them both, with apparently slight benefit in some instnnoeSj
bnttbe obstinate cjises have done better under phytolitcoa and salol with
occHsional use of the other remedies already suggested
SORK THROAT OP SMALL-POX.
Sore throat of small-pox isoharacterizei] by an eruption similar to that
which occurs upon the skin. In many cases it appeiirs before the cntn-
neous eniption, in others not until the third or sixth day of the original
31
J>iliEAfiES OF TUE FAUCSS,
duoue. The extent of tbe eniption will varj according to the aeveritj
of the Tariola.
JkSiTOMiCAL iND Pathological CHABACTERisrirs. — Tbe mncoaa
JMnbrsue is *irolleii, nud the iiecuU&r pustules are foaniJ,but wtthotit
the contr»etv<], depressed centre that is seen ajwu tbe skin, becau^ the
eoTenng launot become drj. The ulcention of the«e pDstulee fre-
qoentlr extends entirely throagh the mncons membrane to the muscolar
ttsrae. which is more or less inrolred in tbe inflammatorj actioit. It is
probablj on thie account that patients experience socb severe pain in
d^lntnion.
DiAG^osifi.— Tbe diagno«i« reeU upon that of the con»titutionit]
pEOGS^osis.— The tbrout affection per se is not dangerons; in serious
cue* of Tariota there are liable to be grave complications in the throat.
Treathent. — LocalU, weak astringents and soothing garglea ara
rMoromendad.
SORE THROAT OF MEASLES.
u
An eruption in the throat is present in nearly erery case of measlea
msoneof the first indications of the disease, but it gouerally disappears in
m fev days. It is usually a simple catarrhal iufiammation of the macous
ntembmne, which may extend from the nostrils to the ultimate bronchial
tabes. In comparatively nirt" wises there is a diphtheritic deposit.
SYJilTOSiATouMn'. — On examination of the fancea, often one or two
dftyi before the disease becomes well marked, several small rod points
•re noticed on the palate, pillars of the fanoes, or the jihnryngeal watt.
At the lime the eruption appears upon the akin, we nearly always find
iDDch congestion of the tljroat. In diphtheritic cases there is a fibrin-
ous deposit npon the surface. In some instances the inflammation
extends deeply into the ti&sues, and abscesses result. Many cases of
meules are attended by hoarseness due to biryngitis, which sonietimes
becomes a serious complication, particularly where there is a fibrinous
deposit. The inflammation and pain often extend to the ears.
DiAOXosis. — The diagnosis will depend upon the cntaneons emptioD
and the other symptoms distinguishing measles from other diseases.
pROGKosis.— So far as the throat is concerned, we expect the ea-
tiirrhal infiammiition to last seven or eight days in the majority of cufcs
and tu terminate iu resolution. Where fibrinous deposit occurs, the
prognosis i^ 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 inflHnimation to the lungs.
Tbeatuent. — The treatment for acute sore throat is appropriate,
but often no trwitnient is necessary except tliat which may be indicated
fur the const itutiuuul disease.
SOJiE THROAT OF SCARLET FEVEH.
3%3
SORE THROAT OP SCARLET FEVER.
Sore throat of scnrlet fever is characterize<l by congestion of the
pftlate anil f»iices. wbicli occuri> early iu the attack and is presiMit in
nearly every ca£e, even iu tm>se where the cutancoue eruption ie absent
or Blight.
Anatomical axd Pathological Chabacteristicb. — In 8ome in-
fltances the congestion is flight, in others tlie parts are of a deep red or
hrid hue, iiiid in anginose cases th^re is nuich swelling, and the puiatc,
piiarynx, and tonsils are all involved in the inflammation and the o-dema
If the process is intense, the swelling may cause almost complete closure
uf the throat. The inflamniation lrer)Uontly extends to tin- submucoas
liasucs, resulting in extensive suppuration, and nut infrequently abst^esaes
o<;cur in ttlher portions of the body. In a large number of f!i»es the in-
ifamnrntion extends alotig the Eustachian tube to the middle ear, not
infrequently resulting in |>ermanent deafness. In some cases there is
tliphtlieritic deposit, but it has not been tletermined wJiether this is a
|>eculiar phase of the scarlatina or whether it is an associfition of the
tvo diseases.
Stmptomatologt, — The attack is usually ushered iu by vomiting
and fever, and the patient complains of more or less stilTnesa of the jaws
and acliing pain in the throat, which in scarlatina angiuosa may be very
severe. The tonsils and mut^ous menihrarie are swollen, and the glands
at the angles of the jaws are often considerably enljirgod. In many cascfi,
in ibe beginning of the attack, the temperature rises to 105'' F., and oc-
(sasiounlly even to lOG'. It usually continues high sevei-ul days, and is
iiot apt to disappear before the ninth or tenth day. In severe cases,
Kith much swelling, respiration may be seriously obstructed. The
iongne at first has a peculiar strawberry like appearance, due to promi-
itenco of the red papillse. which are surrounded by a white coating, but
Jater it is red and glazed. The breath is offensive, particularly in diph-
'-heritic eases, and in scarlatina anginosa. Disturbance of the stomach,
'Ufficulty in deglutition, and loss of appetite are among the common symp-
'oma. The degree of redness and swelling varies much. In simple
oises there is a bright scarlet uppearaucc of the throat, sometimes ap-
proaching a livid hue, and there may be very little swelling, but in the
anginose variety the mucona membrane iind tonsils are so much swollen
OS nearly to close the fauces. In many cases, during the first or second
day u thin pseudo-membi-anous deposit occurs npon the inflamed tissues,
and in some this becomes thicker and darker in color and tinully acqnirea
the appearance of the membrane in <l iplitheriu. Occaeionally in the
beginning the symptoms and signs are those of tonsillitis only.
PiA«NORls. — The disease is tn be distinguished from acute sore
throAt, from tonsillitis, and from diphtheria. The eKseniial poinltt in
the diagnosis are the history and characteristic ernption of sftirlet fever.
9U
PISEASSS OF THE FAVCSS.
The nppetimncos aro much the same in acut« $ore thrttni as in scar-
Utiua (luring the first two or ihreo dftys, but the constitutional synap-
toins arc iiRiinlly lighter niid the siibsetjuent history different.
There is apt to he more swelling in (uitHt'l/i/ix. whioh is often con*
6ned to one side, aud there is no cutaneous eruption excepting in rare
instaaces.
A tliiiik false membrane occurs early in dipfi/heria, while the temperii-
ture is ooinjmnitivcly l»tw (101" to 102'' F.). and other constitutional eynip-
toms are not severe; in sourlatinu there is high fever at first, with little,
if any, fibrinous depasll: and Ihirk p?eud<)-niembra,ne, if developed at
all, does not often ot cur until lato in the disease.
PKOGXOSIS. — In niihl cases the lliroat symptoms usnally disappear in
fruro six to ten days, but in scarhiiina anginosa or in malignant cases the
throat may not he involved until iheeigblh or ninth day, hut then extvri-
sivv swelling takes phiee in thcconree of a few hours, and in a short time
extensive pseudo- membranous deposits may occur. In simple eases there
is no danger so far us the throat is concerned; twenty-five pt-r cent of
the HUginose eases die, and of diphtheritia cjtaes fifty i)er eent aro fat::i.
Tkeatmest, — Emollient iipplieations and antiseptic gargles or spniys
are nsually recommended. Solutions of earbolio arid gr. v. to viij. nd
Z i. of glycerin and water, weak solutions of potassium permang:inato
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 feri-ugt-
noas and bitterti>nies will be found beneficial. If there is much dejires-
siun. alcoholic stimulants are indicated, and i^honld be given freely.
Potassium chlorate has been recommended highly in the treatment of
the throat alTecliou of smirlatina, in quantities prnpoi-t innate to the nge
of the patient: for an adult, gr. xl. to Ix. daily in divided doses. It
should be proniptly disoontiuued if it causes irritation of the kidneys.
SIMPLE MEMHILXNOrs SORK THROAT.
S^ttauyniit. — Herpetic sore throat, aphthous sore throat.
This is a form of sore throat characterized hy the occurrence of 8i
blisters and her|ietic patches in the fauces and on the pharynx, which, after
a short time, nipture, and the surface becomes covc^re<I withan inflnmma-
torii" deposit or false membrane similnr to the mombnine in tliphtheria,
though less dense and much more friable. The affection occurs niojit fre-
quently iu damp climates and iu 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 o)iserve<l oftenetit
among those who are naturally delicate. It occurs fre'pientty duriiig
epidemics of diphtheria, and is occasionnlly rssocinted with tnbercnlosia
or syphilis.
Anatomical .\sv P.vtholooicii Cn.iRACTF.niSTica.— In thelK-gin-
SIMPLE MEMBRAHOUS SORE THHOAT.
3SS
ning nf th« Attack ibere are foand aertnH snull distended follicfoe*
abaat the size of a pin> head, with mom or leas reddening and lamefae-
tian of the sviToandiug mueous memKnine. Thi-se luajr ocear sinflr or
in (Mtches^and may lermiiuite io one of tUive mtva: drsl. by n«4>rpth>n,
in which cue thej muT diappear ia two or three dar$ and the uinrous
membraue may be left in a beoltby condition: second, ther mar buret
and small deep ulcen may remain, which mar either heal rapidly in
twentr-fonr to forty-^ight hours, or may become corered with membra*
nous deposit; third, several of these ulcers may coalesce, forming a large
patch whic'i becomes covered orer with false uienibruiie. I have fre-
quently seen, in the beginning of snch an attack. (Mitches five to ten mil-
limeLrvs in dtumeter, covered with this false mfmbrane. which to nil
appearances, were nut preceded by the email inflamed follicles.
£tiui^oy. — The disease is attribated to exposure and to certain
miasmatic influences not well understood. In occasional cafws occurring
at the meuftirual jieriod it is attributed to aterinedisturbunces. Certain
epidemic influences appear to favor the diseaee» for it is more frequent
whcu diphtheria is prevalent.
SYMiToiiATOLooT.^The attack usnally comes on with a slight chill,
followed by fever and attended by sevi-re jiaiii in the throat. For Iho
firftt day or two the patient eompluius only of the »yni[itnn]« of siniple
acute sore throut. V^ually there is first a sensation of dryness^and after
a short time a tievere burning or gnmrting juitt), which, so far as vp can
judge from the patient's description, is more intense than that of .iny
other acP.te affection of the throat. Thi-( pain !<ametinies nidiates townrtl
the ears, and is sai<I to extend occasionally to tlie ita^^al cavities, and in
rare instances to the larynx. Xearly always we find a herpeiic eruption
upon the lips tit some time during the course of the disojise. The fever
is occasionally very high for a few dayi<; in other instinct^ there is bnt
very little elevation of temperature. The pulse is acceleratetl; the tongue
is usually flaltby, indented nt (he edges by the trpth iind covered with a
thick, whitu fur; there is great ditticnity in swallowing, because of tho
pain, which, however, varies with the location of the diseased follicles
or patches. Upon inspecting the parts, we find sinull inflamed follicles
or pustulcii, often not mure than twu or three in number, ou the paJtite,
fauces, or the side of the mouth; or in place of these small ulcers, or
nicer? covered with false menibniue; sometimes the pustules and ulcers
ar« found together, becauso the inllanifd fullicles come iml in succe«sive
groups for four or five days. Often early in tlio attack there is general
redness of the parts with localized pntohes of deeper congestion, M-hich
may appcjir Ix-fore the pustules are developed. In the uinjority of cases,
the most pronounced physical sign will be the presence of one or more
pafclirs, round or oval in form, usnally from five to ten millimeirea
in diameter bnt sonietiines a little larger, und covered by a thin yi-IIow-
ish white fali<e rnenibnine which can be readily removed with a t^wab
336
VJSEA8£:i OF THE FAVCSS.
nf cotton. These aro found on the aide of the tongue* fauces, or inner
surface of the cheeks, and somecimes even upon the lips. Under this
iitembranc wu may find iin iiTitaie<l and easily bleeding surfHce. In
sonio instances, ua removing it we find the niueoiis niembnint.* benenlh
iu a perfectly hejiUhy condition. Oecusiouiilly early in the uttHck there
it a thin uicmbrano spread over the tonsiU, iviLh very little t^roeion.
Daring the ntt«ck fiilae niemhrono will sometimes form npon sores in
other parts of the body. Utfimlly the diaejtse is more pronounced upon
one side only, but it may t^preiid over both sides and the pharynx, aU
Ibongh it seldom or never extends forward upon the hard palate. The
tnenibntne is not apt to be continuous like that of diphtheria, but occuiii
in scattered patches.
DiAOXosis. — The disease is liable to be mistaken for diphtheria only.
Late in the nttack it may sometimes be distinguished from dipbtheriii by
the slight constitutional tiymptoms; though often there is high fever la
the beginning of the attack. In simple membninous sore throaty herpta
appears upon the li]>8 during the firgi three or four days; not so iu diph-
theria. The membniue, in mi-nibrunuue) sore throat, is superficial uiid
thin, about one millimetre iu thickness, and it may be easily detached,
leaving beneath simply an exeoriated, congested, or sometimt'S heulihy
surfiiee. In diphtheria the meuibraue iii tliree or four millimetres in
thickneea, is detached with difficulty if at nil. seeming to extend into the
originul tissues luid he a jwirt of them, and leaves an irregular and deejdy
ulcerated surface. Menibninous sore throat is owasionally followed bv
IMiralysis, leading one to question the accuracy of the diagnosia. In
ionie cuses the symptoms uud signs are clearly those of niembranoua sore
throiit, but after a few days diphtheria becomes iniplunted upon it. giving
all the clmracleristics of the latter disi-ase. Some authors believe thes/»
affections identical, but the weight of authority is against this view.
Pkooxosis.— The disease may bo expected to terminate in recovery
in from eight to ten days; there is sometimes, however, a teudencv Uj
recurrence. We may assure the friends that there is no danger froiw
the disease alone, but it is well to warn them of the possibility that diph-
theria nuiy iMWonie implunted u(k)» it. •
TKEATMr.NT. — In the treatment of the disease a medium dose of
magnesium sulphate or citrate is desirable early. This may be followed
by qninine and anodynes to relieve pain. Arsenious acid in small doses
h-18 l»eon highly recommended. 1 have given potassium bromide inter-
nally. for its anodyne effects, with benefit, and it is recommended in
Bolotion as an inhulatiou from u steam atomizer. The vapor nf mm-
jmund tincture of tienzoin, 3 i. ad O i. of hot water, is nlao reoommpnded
as an inhnlatlon. Weak antiseptic gttrgles of pota&sium permanganate,
carbolic acid, listerinc, or Dobell's solution are useful to clear the throat
of the mucus. Charles K. Sajous recommends that the false membmno
)y •! and the exposed surface touched every throe hours with a
SIMPLE MEMBRANOUS SORE THROAT. 327
ten grain solutiou of potassium permanganate (Diseases of the Nose
and Throat, 1885). I have derived most bene^t 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 XTX.
DISEASES OF TUE FAVOEH.—C'onUHved.
DIPHTHERIA.
^yHOrtymj*.— Diphtheritis, uugina diphtbcritiea, anginu membriiuoeo.
Diphtherui is a specific contugiotis diBOJisc, chiiraotorizeil by pro-
nounced cwtistitutiunitl ^yiiiptuuiti uiid iutlumnmtioii uf liie 1111100118 mum-
bnine of tho futires ami upprr uir patwugcs, wilJi exudutiuu of iij(!ui]i-
niatory lymph, nliit^h rupidly l}L'ci>mcs formed into t&W^ inenibninc. It
hits long bwt-n rfto^nizwl by the bei*t uiitboritJM af out' of ilip z-yniotic
fever*. Kuny English authorities^ with wlioiii I lun fully iti accord, lonk
upon thiti us H cDustttutiuUiiI Ui:ifiise with load munifebttitiuns, biil nmnr
coiitineiitul iiuthors iiiitl some American writers regard It tis a priiiiury
loot iifTec'tioit with sccundiiry eougtilutiuniil niiinifi-8tiitioii3. The ds.---
e:ise occurs spomdiciilly. ftnlcnuciLlly ur t'pidi-niimlly. and iippuars to
have uo geogruphiciil limitutions, but U must frequent iu teuipemte
climates. It is mn.<t common in cold, damp weather and during the
spring or fall montlui. but is o fie 11 sieeii in winter, iitid not infrequently
durinjz warm weather. lA^unox Browne states that thoee who have
enlarged tonsils are e.-ipecially recopliu' of tliecontuKiuni (Diseaws of t!ie
'i'hroat, -M 3d.). The yreat majority of cusi's iire n'j^erved in <'hildren
under six yenrs. but adults are not e\empt. The d iseiisc is not often
obtjcnod twice in the same individual.
Anatomical ANi>.pATHoi,ocirAL Characteristics. — In the begin-
ning of diphtheria there is congesiiun of the mucous membrane of the
ftuiws, nsu:dly uniform, but occasionally in patches. Tins may gradually
o\tcud tu tho entire mucous membrane of the tliroat, and it is soon fol-
lowed by tho cjiudation of inQammutory lymph, whicli in most instiuices
proceeds withiu a few hours tu the formation of false membmne. Thi>
deposit originates generally in one placuand gradually exlends tu the enr-
rounding tii^sues. but it may ronimencc in several spots at the samp time.
It is usually first found upon one or both tonsils, from whicli it grad-
ually cxicuds, according to the sevority of the disease, to tho palate,
phnryux. naso-pharyux, and other portions of the air pasisage. Ri^relv.
It is found lining llie a'sojihagus and other jHirt^* of the alimentary canal.
Wounds upon the skin are li:tble to become covered by the same pro-
cess. Extension of the disease to the air [lassages gives rise to dipb-
tfauritic croup, or pulmonary collajHse, Blood clots iu the ventri4;les of
DSPUTHEHIS.
:w»
the licftTt or large arteries are not infreqnently fnunil in poet-mortcm
ex:iininutiou5. Enlarged lyniphntic glmuis are common, occasioually aup-
purating^iiud in the umjurity of cases the kiilncy^ jvru congC'st4.Hl or uctu-
ally inflamed. Various twittcriu have been found in the di]>htheritic
nienthniue. hut nioi^t or all of these inhabit the mneoufl membrane of the
niotitl) of lie:ilthy individuals.
Etioloov. — The disease is generally conceded to be contagioue. and
may be eomnumicnted from man to the lower animals and f(M rcr^rt ; it
is believed by most piiysicians to be due to a specific micro-orgiuitsm.
The researches of T. M. I'rudden {Amirkan Jour?tut of MeiUcal Srienres,
April smd May, 1880) pointed to a Btreptocoecus us the probable e:mse
of diphtheria^ hut the resulto of hia later iuveiitigiitions harmonize with
those of moiit bacteriologists^ who now attribute the. disease to the
Khdw-fji^iffler bacillus. This i« a microscopic rod nhout the length of
the tuberi'le hiH'illus, but twire ics tliirkueas. It is usually more or less
bent-, with rounded ends, one or both of whicli may be thickened, giving
the club or dumb-bell a])|>ejir.ince; it is immobile and contains no spores.
These buc-illi do not readily absorb the common aniline stains, but are
easily colored by a solution of Lofflcr'a methyliii-bluc, the coloration often
being ino^t intunsc at the extremities. Aceording to Annunil ItiitTer
{/ii ilinh MefJiaiJ Jtturnat, July 2*Jtli, 1800), these bacilli are foun<i most
abundantly in tlie superficial jmrtions of the false membrane, and ne;krly
all experiments go to prove that they do not nsually enter the lym-
phuiics or blood vessels; therefore, of itself the bacillus is innocuous,
but it produL-L's a virulent ptomaine which is readily absorbed and which
may cjiusc the constitutional symptoms of the disca^se. Numerous clin-
ical observations and experiments, however, have demonstrates) with an
c^fpial degree uf certainty that psemlo-inembranotis iiiftiuuination is often
j)roduced independent of the Klebs-Luftler bacillus, as, for example,
that re«ulting from surgical operations in the throat; or from injury
inflicted, boiling water, steam, cantliarides^ chlorine, and ammonia; or
the exudative inflammations supposed to be of niicrohic origin, fre-
quently observed iu scarlet fever and measles. This hitter variety of
inflammation is termed by Smith and AVarner [Amivitl of the f'tiitrr-
mtl .Ucilintl Srifiiccfi, 1891) pseudo-diphtheria, and, a^ stated by them,
cm only be distinguished from true diphtheria due to the Klebs-
L&fller bacillus by the fact that it is not followed by paralysis and is
not attended by a peculiar form of albuminuria nnassociated with
dropsy or unemie i>oisoniug. The necessity for assnming that there are
two varieties of diphtheria, one produced by the Klebis-LolHer bacillus,
the other by other bacteria, seems to justify the etjitement, that the
identity of the specific mtcro-orgauism, believed to eause the disease, is
as yet uncertain. Itoux and Yersin {J/i'nion Meduale^ Paris; Annual
of Ihe Universal Medical :^ience»y I8i>'i) report that iu the secretions
from the moutlis of tifty healthy children, living in a village near the
sap
DJSEASHa OF THE FATCSS.
<!Out, where (li|)I)theriii(f-ui!uukiiuwu, they found ir, 53 {Krceut a bucilhia
morphologieally i<leutical with the ordinary Klebs-Loffler boeillns and
behaving in ciiIturL'a exactly like the latter, cxtei>tiug in the nuail)er of
its colonii?8. This tliey iK-lifve to be the KIcbs-Luffler bacillus in a uon-
virnlent condition.
There can l>e tio doubt that primary simple inflammation favors the
production of diphtheria, but it iii doubtful whether it is ever iu itself
capable of pro<lucing the disease. Infection may occur from another
patient or from articles contaminated by him. Commonly it« origin is
referred to the use of certain drinking water or milk or the inhaU-
tion of emanations from suffers, or from dump, nnhealthy collars or
deoiying refuw. The must L-ommon jiredisposing cause, I believe, is lb»
«HH)8ure of young children to the chilly utmoapbers of oar honges Vn
the spring and fall months or during the warmer portions of winter,
Tvhen Ares are not considered necessary by adults.
Symptomatoloot. — After a period of incnbation varying from one
to eight days, the disease usually commences in young children with well-
marked constitutiomd symptoms, such as hcudachc, drowsinvsii, more or
less fever, thirst, vomiting or diarrhiBa. and stiffness of the nock at the
angle of the jaw, with more or less Boreness of the throat. In older
children and adults, the invasion is more gradual. In from twelve to
thirty-six hnnrs from the first symptoms, the false membrane can
usually bo detected in the tliroat, and in some cases it is depositee!
in considerable quantities before the porsou 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 paiu, cspcciully upon deglutition. Ex-
ceptionally an erythematous eruption makes its aj>j)eanince on the skin
during the first few huiira of tho affection. The pulse is rapid, small,
uud feeble, and as the disease progi'csscs it may be intermitlcm,
Finally, it grows exceedingly feeble aud slower than normal as deatii
fTOMi exhaustion approaches. The temperature nBUiilly rises to 101** nr
102'' F. during the tjrst houra of the uttacrk, but with the deposit of
false xnembmne it generally falls and may even become subnormal.
After two to four days it may again rise, iudicjitiug in favorable cuse^
enppnmtion and sepiinition of the faUe membraue, or in others an ex-
tension of the disease to the larynx, lungs, kidneys, or other parte. In
the later stages of the disease, sudden full to the subnormal point is a
serious symptom indicative of fiiiling strength. The voice is often
a]tere<1, weak, aud hoarse, even before the lar)Tix is affected, but when
fidso membrane has exteuded to the glottis hoarseness becomes more
pronounced or the voice may be entirely lost. With involvement of the
larynx, dyspncpa 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
con gb, and with the spasms of the glottis all the symptoms of suffoca-
DIPHTHERIA.
331
tion appear; the fulsc membmne niiiy be loosened, aud fragincnU of
coiiBidcrablc size uro often oxpfctoruteil. Sometimes complete castii
of the trachea or broiu-bi are thrown off in tliU way. When the disease
extends to the niisu-pluiryn.\ and iiustrils, there 1^ ul>»trucli(>n uf the
nose and a fetid, sauious discharge, frtiquently aeconi|uni«d iu p-ave
[<raM8 by epistjaie. Tlie tongue is coated with thi^'k, yellowish fnr, and
the breath \m\a a pm.'iiliar odor most cliaracteristic of the diseiise. In
malignant cases tliis odor is so prononnced us to ]teruieato the entire
apartment. The tpngiie is coiited from the tirst, and in unfavorable
eased it bpeonies harsli nnd dry iind covered with a thick, dark eu:tt.
The appetite is poor and in severe ciscs may be entirely lost; nausea anA
YuniiLiug lire not infrequent, particularly wheu the kidneys are in-
Yolvotl. Swelling ol" the cervical glands occurs in most severe c.ises,
l«8peeially at the angles of the jaw; the submaxillary iind parotiil glnncf^
nre sometimes involved. The throat is at firat deeply congested, but.
Boon tho false membrane is deposited, primarily upon one or both,
tonsils. In tho beginning, this membrnneis white in color, bnt it soon
becomes ycUowisii, and with the advance of the disease grayish, brownish,
Ar even almost black. It has the apj>earance of involving the mueouA
membrane and being slightly elevated above the surface. If the men:*
farane ia exfoliated or forcibly removed, an ulcerated, graoulur, and
bleeding surface remaini!, which is again soon covered with false
membrane. This membnine is firmly adherent to the aarface, and can-
not be removed by brnshitig with a swab of cottoTi, as can the mucus
which collects in other forms of sore throat. With the laryngoscope, false
membnine may be discovered in the unso-pharynxor 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 tho
f^aviclee, but especially at the lower part of the sternum. As the glottis
1 becomes more and more obstructetl, the skin is pallid and bathed in
cold perspiration, tho lips,, ears, and extremities appear blue; the \wu
tient grows resitloss, throwing himself from side to side of tho bed
every few moments, and with the paroxysms of dyspnoja he throws his
arms about and clutches at his throat in tho vain effort to obtain more
air. As the dlbease progresses, the signs of carbonic acid poisoning
ire 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 catwrrhal,
or rheumatic pharyngitis; tonsillitis simple or follicular; erysipelas,
scarlatina, und other constitutional diseases, or with simple membranous
)re throat. The easential points in the diagnosis are tho history, the
rapid progress of the case, the appearance of firmly adherent whitish or
yellowish giay membrane in the throat, and the condition of the urine.
In catarrhtrl or rhenmntit^ phartjrigiiis the temperature is higher,
Itte pain is greater, and there is no formation of false membrane.
33%
DISK.USEtf OF THE FAUCES.
Id fir If iti If etas of ihe ihrotti tlie eruption is developud more slowlv, aud
the liiatory is cntirt-I)- ditli-reut. Srarhttiim is developed luuro rupidlv,
the Iciupentture risi's uiirly to KCi" or 105° V. and remains so for several
days; in diphtheria it seldom ritum higher than KU* or 103"^^ F. in the
hogiiiniiig. Ill 3o:irliilina, after u short time a charactoristii- rash ap-
[KMirs upon llie skiii ; itie upjK-urauce of tlie throat is not greatly different,
iu the ounimonc^eiiiuiit, tlioiigh the congestion is geuerally more uuifoi
than in diphtliL'ria, and iu nnix)mplioated cases there is no false mem-
brane.
In iotisillitis the temperature is much liij(licr, the disease comes un
more r(ipi<]lr, there is more pain in the throat, and neunlly there is
difticnlty In ojjening the mouth whirh doe« not occur in diphtheria, lo
simple touifillitis there is more sn-elling, but no deposit of inflammatory
lymph. The liistory of foIHeuhtr tonsiltitia is essetitinlly that of tho
Rimple form, hut numerous yellowish point)* or Ri>ote appear n]K}n the
tonriilt) at tlie (iririres of the lacuiue. Tliew^ however, ditrpr from the
upiwaranrc of diphtheritic membrane, in that they are more numerous,
emaller, are not elevnte^l above the surface of the raucous niembniuet
an< conHtiH) to the tonsil in the mujority of cawd, and never found upon
the palate.
SiutftU membrnnous $ore throaty if seen lit the beginning of the
attack when the vesieica ftrst appear, is not very likely to bo miiitakca
fur diphtheria; hut if tlie patient doe^ not imme under obtH*rvation until
tti'o or thret) days later, the diiigno^is may he ditticnlt or even imjtogfliblCf
especially if diphtheria is prevalent at the same time. In mo?t (•:««.'« of
membntnons sore throat the patient complains of much more jtain and
the ful(« membrane is more easily detached and ii> much tliiuner than iu
diphtheria. Ju some cases a herfietic erudition iu the throat aud on the
lips reveals the true nature of the di^'ase.
In jthiefivivnous or ert/sipffofoii.t tore thntnl the patient suffers moi
pain, the temperature is higher, and the tifwue--! are very o-dematous and*
lirld, the inraeion and course of the disease ar&dilTerent, and diphther-
itic memhtnnr is alisent.
^KVHiNl>sl^. — The prognosis is always grave, for uo mutter how mild
the case in its rommenremenl, it is im[M»i!i(ibIt> to predict what the com-
plications tnay K; twfore it has run itii cour^'; aud alth(>ugh the largo '
majority of rai»M recover, it is never safe to make a favorable prognusu
without warning tlie friends of possible danger. In fatal rases death
oceasiitnally occurs within twenty-four hours after the first appearance
of Ui« disease, and in the majority the fatal terniiuAtloQ is within fire
day's; but in some the struggle for life continues five or six weeks l>e*
fore the {utient succumlw. Iu favomble cast's convale«*cence is nni&lly
Miabliithed aliont the end of the third week, but especially where com-
plicatioos have existtxl. the duraflou may be much longer. As a rule,
the youngs the |iatient Ih^ greater Ihr danger. Among the $ymplnm»
and sigos indicative of gravity arr deposita nf merabrane in the vm^
MPHTHElilA.
333
plmrjuXf or iiit«fitincs; extreme pain in the eurg or throat, purpuric
spots oil the »kiii, epistiixj^, and other hemorrhages, persistent iinorcxia,
vomiting, iliarrhci'a, unil gTippreanion of the iirino. Asthenia, a typhoid
condition, or uigne of heart faihire are often prernrsors of death. When
the larynx is Involved, it is probable that witbunt Rurgiral interference
the mnrtulity readies ninety-five per cent, and with it abont sixty per
cent. Patients not infrc«inently die snddenly of heart failoro, and nfteu
tlie pulse becomes weak and intermittent on the slightest efifort, and
clearly pointi? to the necessity of relieving the heart from all undue ex-
ertion in order to save the patient's Hfo.
As the Wise progroaaes toward recovery, tho appetite returns, the tom-
per.-turo diniinisbos, ditlitMilty with respiration disappears, and articula-
tlonagiiin is normal; liowever, the difiirnlty in jtwallowingoften becomes
greater, from exposure of ulcenited "surfaces which cause moro puin on
deglutition, or from puresid of tliis deglutitory muscles. Not infrequently
pnriiiytic symjitoms follow the attack closely, about tho end of the third
week, but, except in cases where tho respiratory or circulatory ceutrea are
involved, ifcuver)' usually occurs, though it may bo delayed for several
weeks or even months. Owing to danger from the Hetfuels, especially
heart fnilurc, we ran never fully relieve the anxiety of friends until our
patient has been well for about thrco weeks.
Tke,\,tment. — There are few diaoases in which the methods of treat-
ment recommeuded are more numerous, a f:ict which is explained by the
inutility uf a great majority uf the means adopted. Ko much depcuda
upon the nature of the epidemic, the condition of thcjmtiont when 6rstat-
iucked, and his t;urroundingi<, tliut it is very ditKcull lo arrive iit accurate
4!onclu(tinna regarding the effects of remedies. During the earlier por-
tion of many epidemics ii large proportion of those attacked die, and
therefore whatever remedies have been used seem to be fruitless ; wliereas
in the liilter part of the siuiiy epidemic :; brgo majority of the cases
recover, no matter what treatment is employed, and the remedies in use
at the time get iliTredit. Many jihysjcians have favorite prcscrijjtions,
ou wliich they place great rtfliance until called upon U) treat serious
fcasee; then, unfortunately, all methods often fail and the physician
comes to believe that little can be accomplished by treatment The
tncthods to bo adopted are: first, prophylactic; second, dietetic; third,
local; fourth, interual or general; fifth, upenitire.
ProphijUuis is of prime importiince in relation to diphtheria. The
noet useful measuresconsistof thorough ventilation and proper drainage,
pure water supply, proper clothing, and proper heating of jiving apartf
mentR, and as far ns possible protection especially of children, fnirn the
contagium. It must be romemliered that sometimes the specific poison
may be carried from one to another by domestic animals, or in the rloth-
ing, or about the person of one who has been visiting tho sick or at-
tending funcraU. As the disease ie generally prevalent during the cool
n34
DISEASES OF THE FAUCES.
and ilamper portions of the ;ear, wbeii clie ueed of fires is iiot appreci-
ated by adults, it is of special importance that childreu be cared Tor
at this tiuie, thut they have projier clothing, and that a anitable
tcinpc-niiuro of tlie liousc be laaiutaiiied. It hus ap[H:ured to luu
thai during the spring and fall months children arc much riiorv
liable to cfitch cold and consequently lo have diphtheria, in the hause
with u temperature of iibout 06^ to 08" F. thun when the temjicruture is
even colder. An effort should be inutle lo muinUiin the tempuraCDru uf
the hou(!e as neiirly as pos^^lble at TO' F.. iind children should not bo
allowed to run ubout in their night clothing nioniiiig and evening or to
stand about while dressing with the teinp<>nitiiro at fromSo*^ to G5° F., as
it is liable to be. They need to bo carefully protected ut night from
exposure due to kicking off the bedding. If the disease hsa made Us
pppeHrance in ii household, other children of the faintly must be pre-
vented from iill intercourse with the patient, and tiie sick one should be
given an airy, comfortable room, which may be frev]y veulilaled without
exposing the patient to dniughts. Dniiicl K. Brower, of Chicago, advo-
cates an excellent method of vpntilation during nn nttat^k of this dis-
ewe, consisting of changing the pntient two or three times a day from.
one room lo another, the vncnted room being thoroughly ventilated in
the interim. It is u useful precaution to hang over the door of the sick*
room sheets kept moistened with carbolic acid to prevent contamination
of the iiir of the houso during the necessary opening of the door. The
temperature of the sick room should be kept at from 70*^ to 75" F., and in
«U e-ases an abundant sup]>U' of fresh air provided. All utensils or
clothing used in the room idionld he diHtnfectod or destroyed, and finally
tbo room should he thoroughly rumigntcil before it is again u«ed.
Orancher, of Pflris {Rentp fV Hyrfipnr ft de PnUre ttnnitmre, Pecember,
1890; AnnuulVnivtrisal Mftiictd S(\(uceK,is\\'i), expresses the opinion that
in nearly fdl instances diphtheria is propagatod by infected clothing or
furniture, lie states that in » diphtheritic ward in Paris, among 1,741
iidmitted were 153 that did not have diphtheria at the time, yet none of
lliem contracted it. The means of prophylaxis employed in this ward
••■ere: a metallic screen about the bed; disinfection of articles tised by
tu*; patient by boiling in ahciu a six per cent solution of sodium carbon-
ate; disinfection of the bedding and clothing by heat, and of the walls
and fnmitnre by washing with a solution of mercnry bichloride. At-
iciidunts and doctors wear blouses that are disinfected by heat daily and
wjtsh themselves in a bichloride solution or in a five per cent solation of
carbolic acid.
Ice taken frequently in the mouth tends to relieve thirst and redui>e
consrostifm. When children will not take this, Ixunox Krnwne (Disejwes.
of tlic Throat, ^d wl.) recommends the use of frozen milk or froxen
beef t«a. Of nutritious drinks, ntilk is the mnet important;, beef ti>A
and the various broths may be given in aildition when the child will
I
DIS'llTltJiHtA.
335
take them, and these may be supplemented by rice water or barley water;
tbe latter is sometimes taken more readily if flavored with leoiou jnice.
As MKin as tbe appetite l)ecomea impaired, tbeae liquid nntrimjtf* must
be given at regular intervals, and in aa great a quantity ae the patient
can be induced to take. To a child ton years of age us much as haU a
pint of milk or its equivalent shniild if possible Iw given, every third
honr 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 freqnent drinks or gurgles acidulated with citric
acid. On the Siiuie principle, pineapple juice liod lately been liighly reo-
ummended, particularly by the luity. M'heu patients cannot lake food,
or when it will not be retained by the stoiiiuch, nuci-itive enematji become
j)eoo8s:iry; in tbitf case the various pre|mrutiona of peptonized meat ore
exceedingly useful.
Alcoholic stimulation is of great importance, and is usually recom-
mended early in the attack, but I donbt its value at this time. The form
in which it is administered is of little importance, so long a£ it ia accept-
fcBl)Ie to the iMitient; whisky or brandy is most commonly used, but
children will generally take much mure readily alcohol diluted with two
|)arts of syruj) of tolu, given iu as much water iis desired.
The early continued application of cold externally is often of the
itest service; for this purpose the throat nuiy be tilted with a coil of
ibber or metallic tubing through which a cnrrent of ice water is kept
constantly passing, or the ice bag may be used. When the ktter is em-
ployed, the ice should be broken into small pieces and changed about
once an hour; the bag should nut be more thuu half tilled, so that it
may bo &4.-curately applied to the surface. When the false membrane
begins to separate, hot applications have seemed more beuefioial than
cold, and occusionnlly, even in the early part of the attack, the patient so
Beriously objects to tbe 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 borne.
7'opiof Treat men f. — A variety of substances have been used with the
hope of removing the false membrane. Tbe simplest uf these is steam,
applied either with the croup tent or the steam atomizer. This may be im-
Ipregnated with the time honored Hmc water, or with various other sub-
atances according to the fancy of tbe physician. There can be no doubt
that lime water is capable of dissolving the false membrane when the
rtter is immersed in it for a snfflcient length of time, but probably it
laa very little intliienec upon the nicmbnine in the throat. Liquor
pota88a,onc part to four of water, may be used with equally good results.
Mackenzie (Ditteases of the Tliroat and Xose) highly recommended
lactic acid applied freely with a brush or pledget of lint. He did not
state, but left us to infer that it was applied iu full streugth. Ho
33(1
DISEAHEKt OF THE FAVCS8.
oJassed it aa among the niu^t reliable mlveiite of diphthcriTJc meiubrane,
Lennox Brownu recouiniouda li Milutiuu of lactic acid to be applied every
two or tbrcti himra by the miriw in from one to six parta of water, and
to be used pure oiict or twice » day by the surgeon. Trypsin, papain,
fiiid resurcia haveall been recommended f(>rtl)eirt!np]N>sL*d solvent effects.
Tannic acid, alum, and sulphur have beiiiiided in the form of powder by
ni:i:iy phygic-iaiis, but are of doiihtful utility. Various local anti^eptio
sppliwitinns are UBefnl when they can be made without too niocb objec-
tinu by the patient; but I believotV.at nhntever is used ebon Id l>e so uiild
aa t(» cause but little paiu, otiierwisf it is apt to do more harm than good.
Of these, mercury bichloride, rarliolic acid, potiisttinm permangauaCc,
jMwliuui cidorate, glyuerole of bonis, nhlnral, and the tincture of iron are
moat efficieul. The fir«t i^used in the proportion of 1 to 4,000 of water,
fir even «b strong as 1 to l.OtN), but this is too strong for ordinary
Tiw. Carbolic acid is nsed in tlie strength of from one to five per
cent; the latter is especially reconnnended by Oertel (Ziemssen's C^FC^l>•
pa'dia, English trannlation. \'(d. 11.). Potassium pprniangaiuite may be
used in the strength of gr. v. ad \ i., the liquor soda» clilorata.' four
drtichms to ten ounces, or potJis^ium chlorate a saturated solntioD.
H-gli ITeniming. of Kindiolton, Englind, advocmtes the synip of
rhb.ral. gr. xxv. tii\ 7i., applied every nne or two hour^. Suiplmrons
acid properly <ltlnteti is also lieneficial. Hydrogen peroxide has l>ecn
highly rertuumemied ;ih a sjjray either in its full strength (Marohand's)
aa obtained from the dri'ggist, or diluted acconling to the degree ot
amarting i)rodured. l*nro alcohol is used by some as agarglc or spray,
with apparent advantage. Tincture of myrrh has also been extolled a& a
locid application. Tincture af the chloride of iron may be used either
in the form of a spn*y or by rnoAns of u swab.
G. V. UIack,of Jacksonville, III. (/>?«/«/ /y^We/r, March 15th, 1889, p.
128), has shown that the officinal cinnamon water, although harmless to
thepatieut, is one of the most efUcacious antiseptics; and Koaxand Yersin
{Anmtln de (ft/ufvohgic d iVOft^tclru^vt^, September, 1889; Paris)
have demonstrated that the toxicity of cultures of diphtheritic bacilli
is greatly diminished by the addition of carbolic acid, borax, or bortc
acid; I have, therefore, been iiiduct'd to try as a local iii)pIication a siit-
nrated solution of boric acid in cinnamon water. This is neither pain-
ful, unpleasant, nor dangerous, and has seemed to me more efffoiont
than other locfll remedies which \ have empli>yed. 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 frcptenlly and in corn]>ani-
lively large doses as recommended below, lias all of llie local influence
that is usually necessary, and obviates the necessity of sprays or gargles.
When the diphtheritic process extends to the nose, the nares shoald be
I
I
DWHTMEHIA,
337
lahed throe or four times daily with a &atnnitcd solution of boric ncid
some mild alkuiiue wush, which shouiil always he used wiirm. The
washing may often he accomplished by an titomizcr. Wliencver it is
Uecesaary to employ a syringe, the pnlienl should be placed f:icc down-
ward 80 that the fluid will not run into the thruut iiiid cituse MtraugUng.
After the washing, a powder consisling of iodol, sugar of mil k, and pa-
pain— equal parts, may be freely blown into the nose.
hiternai Treatment. — Physicians generally are agreed that the treat-
ment of diphtheria should be tjuppurtiug and stimubiting from the he-
ginning. With this in view,iron,quinine,8trychiiine, and alcoholic stim-
ulants have been employed for genenitions, and they still hold the firet
place with a majority of the profession. No internal remedy has seemed
to be more effective than tincture of the chloride of iron given in fre-
quent and comparatively large doaes, amounting to about one minim of
the medicine for each year of the child's age admiuistered every one or
two hours, according to the severity of the case. I Dsually combine it
with a Bmall quantity of glycerin and sufficient syrup of toln to make
one drachm, and direct the patient to take it without dilntion, provid-
ing it does not caune smarting. As the throat becomes more sensitive,
the remedy is diluted sufficieutly to avoid much discomfort. To pre-
vent any irritntion uf the stuuuich, it is well for the patient to take a
drink of water before the medicine is given, and aa 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 nnx
vomica in some form, iitrychuiue may be given, but ihc tincture of
nux vomicji has seemed to me more effectual, and it should be given
in compnmtively hirge doses, sometimes as much as half a miuim for
each year of the child's age, being required every one or two hours.
Within t}ie paist few years mercury bichloride has been largely used in
the treatment of this disease with apimrcnt success, and other prepara-
tions of mercury are recommended by variona authors. Pilocjirpine is
advised by Oertel, who believes that it hastens separation of the mem-
brane but its depressing effect upon the lieart is a serious objection to its
use. Among other remedies which have received the sanction of good
authority arc eubebs, copaiba, potassium chlorate, the sulpho-cjirbolates,
sodium and potassium sulphites, salicylic acid, the salicylates, and ])nla8-
tium, sodium iind 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 calcuhite<l to re-
move the membrane or to prevent spasm of the muscles Jiave been rcc-
omroended. For this purpose emetics are chiefly employed; among
33H
DISEASES OF THE FAUCES.
thoae in common use are alam, ipecarnanha, tartar emetic, zinc snlphatep
copper sulphate, npomorphine, and turpeth minoml. Of tliese, ipccaon-
cnlia and uliim are the simplest and safen, though the tnrpeth mineral
IB largely employed, and copper gulphato is highly reeomn.ended by gooil
ftatboritii-a. These, however, should only be employed early in the nttuelc.
I fnlly indorse the ancient belief that in this condition mercnrials have
coDBiderahle j>ower in preventing the deposit of memhnine, snd remov-
ing thtit which hns already been formed. I prefer the mild rhlorideof
mercury, administered in doses of about half a grain for esich year of the
child's age, every one or two houre until it acts upon the bowels. The
frequency of the dose is then gnulaaUy diminished^ and, as soon aa
dyspntpa has been relieved, the drug is withdrawn. It is surprising
how slight its effecta are upon the bowels iti this condition; a child
two years of age will frequently take twenty t<i forty grains of calomel
without serious disturbance of the bowels. 1 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
aigUM of approiiching sutToration. At this time operative measures
should not he delayed. The openition to be preferred depetids 8ume-
whut upon the age of the child and its surroundings. Other things
being eqnal, in children under five years of age, 1 decidedly prefer in-
tubation by O'Dwyer's method. In olderchildren, intubation is not quite
Its satisfactory as tracheotomy, still it has been found useful in many
cases, particularly where the graver operation will not bo j>ermitted;
therefore I would advise that it be tried first; it doee not preclude th6
sub^queut perforinartcc of tracheotomy. These operations are described
under the treatment of membranous croup.
I
I
I
CHAPTER XX.
DISEASES OF TIIK FAUCES.— Cbn«nM«rf.
ACUTE FOLLICULAR PHARYNGITIS.
Acute folliculnr pharyngitis is an acute iuflammation of the follicles
in the iiiuc'oiia ineinbrunc of thu pliaryiix, oc(!tirring most frequently in
cold and damp climates, and iu young or middle-agftd people. Thos©
Baffering from ii riieiimati:! diathesia are peculiarly prone to it.
Anatomical and Pathological Characteristics.— As a result
of the infiammtttion, the mncous follicles bccorao cloaed and finally dis-
tended by their altered secretions, in some eases the distention becom-
ing 80 great that the folliclo i& ruptured and a small ulcer results.
Etiology. — The most frequent cansea are: exposure to inclemency
of thti weather; the abuse of tobacco; and excej^Rive use of the voice in
badly ventilated rooms or out of doors, especially in the night air. The
inhiUattou of irritating particles of dust or of smoke is an occasional
CI use.
SYMrroMATOLOGY. — Mild coses begin with malaise, which mny last
for a few day«. the patient eouiplaintng in the mean time of some little
fever and more or less diatromfort in the throat. Early in the attack, the
patient uaually experiences drynesH, smarting, or pricking sensjitione. hi
severe cases pain and swelling are excessive and the constitutional syinp-
toms very pronounced, the fever ruuuiug up several degrees. There es
often a slight hacking cough, with expectoration of a small amount of
glairy, tenacious mucus. Hoarseness is present in most inst'inces, due
to extension of the inflammation to the larynx. TTpon examination of
the throat, the mncous membrane is found coiigeste<i: and in patches,
corresponding to tlie 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. Soiue are ronud, others oval, and,
all more or less elevated above the eui-face. Some with yellowish sum-
mits look like pustules. xVt other points where rupture of the futlicles
and escape of their contents has occurred, small nlcers are visible, and
remain for a few days. Where the contents of a follicle are retained for
a number of days, they become somewhat cheeay.
DuoN'OSis. — 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 lees elevated above the sur-
face, accompanied by pustules or small ulcers.
DISBA8E8 OF THE FAUCES,
PRonxosis. — The diBeou uinall.T terminates in resolntion within s
few days. In most caws, hovever, there is a tendency to recnirence, and
thf iittacTt may be repeated many times. I hare seen one patient who
hatt hod an uttaek every three or fonr weeks during the lact two years.
Noorly always there is some disease of the tuual passages or o( the naso-
pharynx associated with this predisposition to acute follicular pharyn-
gitis.
K Trkathekt. — In cases where the portal circulation is alnggiEh, the
H^auDimistration of salines and an occasional mercurial cathartic will work
much benefit. In lien of mercurials, the mineral acids, especially hydro-
chloric, will be found useful as hepatic stimulants. Many of these patients
^ire troubled with poor digestion, which may be best relieved by the
^nso of bitter tonica. Qnininu is useful, more especially in uUra-malariul
districts, but under ordinary conditions! have found hydrastine muriate
and extract of nnx vomica more efncient; but whuterer 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. iix. to en. ad i i. It should be made
rith an absorbent-cotton swab or largo brush, satarated with the solu-
hut not so wet that drops fall from it. The tongue should be de-
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 applied only to the pharynx; they Caste badly
and cause prolonged smarting if used in strength sufficient to be of
value. For these reasons I seldom employ this remedy, and I have an
impression that it is of no more therapeutic vutue than leas disagreeable
agents. In these cases the astringent and sedative spray containing
morphine, carbolic acid and tannic acid (Form. 93) has not been disa[>-
poiutiug. In obstinate caaea some authors recommend the actual
cautery, in the form of a amall wire with a little bulbous end, which is
heated and touched to the inflamed fullicles. This results in a more
acute inflammation for a short timu, followed by thorough resolution.
The gulTano-cantery is much more easily applied than the actual cautery,
I and is to br^ recommended when needed. In cauterizing, not more tban
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 acutu cases.
CHHONIC POLLICCLAR PHARYNGITIS.
Sifnonyim. — Granular sore throat, clergyman's sore throat, chronio
'pharyngitis, sometimes knoirn as hospital sore throat.
disease is u chroiJc infiAmroatiou of the pbarynf;eAl mucous
the brunt of which is expended upon the follicles. It is
4
4
CBROmC FOIUCULAR PHARYS01TI8.
341
p.t<*r'^*€rK^ by hypertrophy of the mucons membrane and irregular
plastic exudatlou upon it, occurring in patches, especially about the fol-
licles. It is most murlccd in damp und chilly climatoE, occurs moat
often ia those of deiiotte constitution, und id perhaps the most frequent
of all chronic ufFectious of the fauces or throat. Three varieties of the
disease have beeu described: the liyper trophic, the moat common; the
atrophic, not very frequent; and the exudrtive, which is rare. Lennox
Browne does not recognize an exudative form, but I hare seen several
well marked costis.
Anatomical axd Pathological Characteristics. — In the hyper-
troplii*; variety the mucous membrane of the pharynx is studded with
swollen follicles varying from two or three to ton 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 sprface. Those cf
A yellowish red color sometimes apjiear 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 piilars, where they often form long
red welts. One or more of tlie superficial veins are usually enlarged^
sometimes to a diameter of one or two millimetres, and they occasioualiy
seem to terminate iu the enlarged follit-Ies. Where the infl.immatiou
has existed for a long time, it finally results in more or leea atrophy.
Some of the enlarged follicles may remain, but the mucous tnembrrne
between them looks thin and whitisth and sometimes seems to bo covered
with muco-pus; an appearance due to the atrophied wbiiuued tissue
shining through the secretions. In tlie hypertrophic form, the bulk of
the enlarged follicles Ims beeu 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
teen in chronic foUiculur tonsillitis, due to cheesy accretiona from these
diseased glands, mingled with viscid mueus.
Etiologv.^ — The disease may be tmused by the constant inhidation
ftf vitiated atmosphere, by frequent exposures to cold or dump, und by the
tise of tobacco — particularly, there is reason to believe, by excewtive smok-
jTig. Occasionally it seems to have been caused by the inhalation oi
acrid fumes, as for example, those to which tinsmiths are exposed. Over-
use of the voice, particularly iu 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 digestivo
disturbances, with which it is frequently associated. The most cuiiLmou
cause is obstruction of the nasal passages by swelling of the turbinated
bodies, polypi, and deflection or exostosis ( f the septum. As .1 result of such
obstruction, normal nasal respinition gives pl«ce to mouth-breathing,
which by rarefaotior nf air in the na.nc>-pharynx with each inspiratioUf
finally causes cougestiou of the throi-t, and if prolonged terminates ia
DISEASES OF THE FAUCES.
disease of its mucoue membrane. That the affectiou is hereditary in
some instances there cau be no doubt. It is claimeil that the arthritic,
rbeumatiL-, and scrofulous diathei>es favor tlie [irodiicti<i]i of this disease.
The frequent recurrence of licute attacks u apjNirt'ntly tlie cause in some
iufilances. Chronic follicular pharyngitis is sometimes found following
one of the eruptive diseases. It is favored by chruuie alcoholism, and
expoRuVe to prolonged dry hunt is a not very umiummou cause. Mental
dejiression, portal congestion, and torpor of the liver may be put down
as among the rare causes.
SYMijToMATOMHi Y. — Usnnlly there is at Brst passive congestion, which
may run into the chronic condition of inflammation without greatly at-
tmctiug the patient's attcniicin. The first complaint is liable to be of
slight discomfort in the throat, whicli may bciv feeling of simple dryness,
ursome peculiar sensation, or may amount to actual pain. Patients usually
B|>eak of drynesti or pricking sensjiliuns in the fauces, sometimca of a
hair, or lump, or burning pain, which may bo continuous or only occur
at periods during tiic day. IVorniunccd instances uf this character are
mortT prone to occur in the exiid.iTivo variety of the disease. Partial
deafness sometimes occnrs, and it may even become complete. This is
due to an extension of the induniniutury process into and along tlio
Kustachian lubes. The giving way of the voice is usually, however, the
first thing which admonishes the patient to seek medical advice. When
the voice Ih lined mure or less cuntinuouslv for half or three-quarters of
an hour, the person Iwcomes fatigued, and ilio piinnciation is likely to
fail. AlthoUL'h hoarseness is not a constiint feature, yet nearly all pa-
tients are troubled with it to a greater or less extent npan slight expo-
sure or free use of the voice. Short of hoareencBs. the expression of the
voice will be found feeble or mufHeJ, and the singing voice is generally
lost. A few patients may even suffer from complete aphonia as a result
of the extension i>( the disease to the larynx. AH the symptoms are
variiible, and are apt to change in the same patient; they are gener-
ally intensifieri during the cold and changeable seasons, while an im-
provement occnrs in the summer. In nearly all cases, careful investi-
gation will lead to the discovery that there is ond respiration. Many
{^Mitieuts, who aRirm that they breathe perfectly, will be found to breathe
with the mouth u|KML,jmrticulurly during the latter portion of the night.
The conjttitutinnal effects of follicular pharyngitis depend upon the im-
peded nas.'d 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 snnptoms of this
affection, and is duo 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 pelletn are
expectorated early in the day, more especially when the disease has ejt-
tended to the larynx. In some cases there is muco>puruleut expectora-
tion, and tMxasiunally the spatnm is etreakeil with blood ; this, however^
CHROiriC FOUJCVULR PTrAUYyoiTia,
343
is of DO consequence in the diaguoBis or prognosig, though it is often
alarming to the jmttent. In nmny v:A!f»& the BecretioiiH whicli furm in
the naso-pharynx and nose gradually find their way downward and bnck-
Trard into the pharynx, or even into the larynx, and may be Bt»en adher-
ing to the posterior pharyngeal wall aa thick, dry or moist scabs, or they
may hang in stringy masses from the edge of the palate. There will
usually be found a oousiderablo amoant of mucus iu the naso-pharynx,
and some adhering to the mueoas membnino of the larynx, where it may
cause cough. Commonly there in a coated tongue, togetlier with otlier
evidences of digestive derangement. Where pain is experienced, it may
te during the act of sw.illowing, but in some cases thi/ !> iifort may
be relieved by deglutition, and not reap-
pear uutil an hour or so after eating.
Liquids are e.-tsily swriUnwed by some p«-
tientij, but solids L-uuse pain; with others
the opposite \» true; while to still others
neither will c:iuse any discomfort. Upon
examination of the throat, the enrfoce
(Kig. SO) will be found congested and swol-
ien in pak-hes, the blood vessels in many
cases enlarged, and the follicles of abnor-
mal devclopiMfiit. About the latter there
is usually a narrow zone of congestion. At
the base of the tongue diseased follicles
similar to tlioso upon the pharyngeal wall
may !»e observed. In the exudative type
of the affection, two or three yellowish
points similar to those of chronic follieuhir tonsillitis may be seen
at somo part of the pharynx. Small ulcers are described by Cohen
And others as being present occasionally, thongh I have never seen,
them. The tonsils are often involved, in either chronic follicular
infinmniation 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
<'ord8, efippcially after using the voice. Examination of the naso-pharyiii
will reveal congestion of \i» muuoiis membrane, with, generally, abundant
secretion. Often there is submucous thickening at the sidea of the
vomer, which may appear gniyish white and slightly nodular, and ia
fiomctimes sufficiently large tn almost occlnde the posterior nares. Such
obstruction may also result from hypertrophy of the posterior ends of
the turbinali^d 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 jifutrt/nfji/i^i /tia-a, or atrophic fa) (it: ular pharyn.'
fitiU. Sometimes the entire pharyngeal wall will be found covered with
dried secretions. •
;\
Fio. St.— CtauKiD TauJOOLUt
PBAHTMaiTU (Ooasv).
344
DfSEA^SSa OP THE FAITCES.
DlAOjrosis. — Syphilis is the only disease with whirh the nffeolion is
likely to be coiifouiuleO. When there is simple congoftcjon, with very
slight eulargemeut of the follicles, it may be diftieiilt or impoeaible to
difiiinguish it from some oases of syphilitic sore throat, but in the latter
there are naually either the mucous patches of the secondary sluj^c or
the ulcers or scars of the tertiary period, llie presence of which rendera
the diagnosis plain. The remote poasibility of mistaking the ulcer of
chronic follicular pharyngitis — which is very rare — for that of syphitia
ntiiy be remembered. Chronic follicular pharyngitis may possibly be
confounded with tubtfrcnlar sore thruttl, but in this the ulcers are super-
ficidi and irregular, and the edges not distinctly marked: whereas in
chronic follicular phuryngitis 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 constitutiuntil evidences of tuberculosis
will have great weight in determining the true nature of the disease.
ruoiiNoms. — Chronic follicular pharyngiiiit 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
^oico. Again, the hypertrophic form of the diuase may terminate in
the atrophic^ which is far more troublesome to the patient and very ditfi-
cult to euro. The exudative form of the affection is geucrally more ob-
iitinute.
Tkbatmest. — The old adage that an ounce of prevention is worth
» pound of care conld well be applied in this disease, were it not that
the op|»ortunity is generally lacking to the physician, inasmuch as the
patient does not preseut himself soon enongh. A caution should be
giveu, however, regarding those exposures already mentioned which are
knitwn to exert a damaging influence upon the part-i;, for they not only
cuuxe the disease, but favor its continuation. Faulty digestion and elim-
ination should be corrected. In many case^ a conrse of diuretics and
bitter tonics is indicated. Arsenions acid is often of special service. Those
predispoeod to rheumatism must have appropriate constitutional treat-
nsnt. tiocally, silver nitrate is an old time remedy, but one which I
trnftfly recummond. It may be applied in strong solution or in the solid
itick, but, if the latter, only a small area should be treated at one sitting.
I have hud excellent results from powdered hydnutine (Form. 174) by in-
ttifllution into the naso-pharynx in cases presentingsereral fnlsrged folli-
t\v* of a deep pink color, providing the surrounding mucous membrane
tt inoint.ami the secretion— except in thenaso-pharynx — is not excessive.
1'Ih> piiwder remaius in the nasu-pharynx several hours, gmdually work-
HtH down the pharynx and thereby prolonging the effect. At first only
« iuiiill rgiuintity should he used, in order to ascertain the susireptibility
tfl Iho |uit ictit, since in some cases the remedy applied in this way causeft
f^yont |Hiiu. Ordinarily it produces nodiscomfort
. Ill mil' md oft«n in those more severe, local astriDfenls are
CUHOmC FOLLICULAR PUARvyams.
345
desirable, and troches of kmrnerU, either simple or compound (Form. "SA
and 41), will be most conreuientW a»ed by the putieut. Spmrs to th«
oro-pbarrnx of copper sulphate in solution of ten or twenty grains ad 7 1.,
tine chloride or tine snlplmte in the aame proportion, or meroury bichlo-
ride gr. 68. ad I i. are also usefnl. Somewhat weaker solutions of the same
may be used for the naso-phurynx, which in nearly all itistauce« requires
treatment; indeed, it is often more important to mediczite the uaao-
Ji
Tie. W.— Inoau)' MoDin^ATinif or Srcrlt'b BA-mmT, Thin hu two Iwm oHla. Tb« H»
rmdU ciidmIbI 'if larx« *i«c a"<I i-wlmu pUtnt, wlilub nuy bi* dvptvwwri In uny di^ml ilrptb hj- thu
aerewiih'iwo to th«>c«Dirp Tliitit ibfcurrvut tn>y Im accuntrlj' rvA-iiIiit«<1. IIki c«iihT)r battery
brft- Khiiwn I hav<> impiI tiarymr* «rlih ntu<4iMlh>fatftlr>ii.Ui<>tucli Inr thi-|iai>t Iko jrvanl )iarr> »it>rv>
oommonlr rrapVtj-rd a, stomp' hAlhTT w> oonDKlml that I cut Cttsil)' charx« It from tli« Edunu
enmtil. Ic U winifwhiit in.im conrmirnt, frbrn workioit wi>U, tlinn tlx^ luUrrj' hvn chawo, but
pharynx tliun the other parts. When the follicles arc much enlarged,
the above treatment will not be sufficient, anil there will be no great relief
until they are cured. To accomplish this, they may be cauterized with
nitric acid, chromic acid, or London pa^te, a smull quantity being applieil
directly to the surface of the folHole, not to the surrounding mcnibrune;
only two or three of the follicles should be treated iit eiich sitting. This
procedure nmy be repeated every four or five days until ull are removed.
Sometimes it is well to split the follicle with u sharp knife, and then
crowd into the incision the pointed end of a stick of silver nitruta.
lilj
PtSEASh'ti OF THS FAUCES.
fSnroo are in favor of scraping off these follicles with a curette. The
'nctnul cautery miiy be emiiloyed — as recommende^l for acute follicular
pharyngitis— hut the galvauo-cautery (Figs. 00 and 01} is the iMSt mttons
for getting rid of the hyjiertrophied 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 cautery, a whitish pel-
licle is observed about this cauterized point, which may extend for fonr
(»r five millimetres in every direction from the burn, and appears very
much like a diphtheritic membrane. This remains from five to even
twelve days, depemllng upon the rapidity of the reparative process and,
perhaps, atmospheric conditions. Frequently the patieuU retch, and
Fia. SI.— TxDAi^' CAtmatv EutrrwooBa (S-Salse).' 1, nttmrtlKl dMnrmlA mmmI fnr mqMrflcW
«AUlvfiiAlb>iii 111 hmyivv^t ; -i. kuUt'-Ukr f-Uvtivdr WMyi la hri'rniV'phie rLloill* : 8. 4. and 3. rlcctrodBS
for cauteHiiiiK th« lonaUs. follk-lr« in pbnonx, aad imMU i>pi>l>t in llir niwp ; \ ploctrodf for b«ae of
touftuts (If. «l>Mi §w>'*l'^ by k |ii«w of mtcAolls nbr«, for ttano-iihrnrfuk ; \ fl, nod 7, tubular Heo
iTotlcs. iDU} which rmrtotis cbspMl poinUof rkilnucn wtn may tut inBrrtc>] (or m-totu purpo*e».
gag easily, and in such coses it is evident how difficult it wonld be to use
the actual cautery. Where there are enUi-gcd veins, it is better to cut
them off with silver nitrate or the giilvano-cantery — the latter being
much the more satisfactory iu its action. Though the exudative form
of the disease has been considered peculiarly obstinate, it lias, in my ex-
perience, proved less Btubboru thim some other forms, when treated by
the galvano-cautery in the manner just described. Cases of simple
chronio 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 neo-
e«stiry to remove to a different climate before relief is found, but ordi-
uarily it is not well to adviw: such a course, for the climatic iuflueuco ia
very uncertain.
CHRONIC FOLUCULAR GLOSSITIS.
3i7
ACrTE FOLLICCLAK GLOSSITIS.
Acute follicular glossitis \% an inflammation of the folllrles at the
base of the tongue, in which severe pain \a caused b_v an attempt at
deglutition, lit) causes are probably not nnlikB thotte of atrntt folhc^
ular pharynpilis, and its jiathology la uUo similar.
Symitomatology.— Pain is felt not onl}* in the throat, bnt ntUiating
to the ears, and some patients speak of it as being almost altogt-tlier in
the eara, or near the orifices of the Eustachian tubes. Upon t'xumina-
tion of the ]mrts, we may find seveml aniall. rounded elevations of a
whitish huH somewhat resembling pustules, which may be digtribnted
all over the hum of the tongue, or confined to one or the other side,
particularly to that portion of the base which is often hidden from view
by contact with the external vail.
In some cflses, instead of these small follicles, one or more superficial
ulcere are to be found. 1 have seen one at least a centimetre in diume-
ier, where small ulcers had coalesced after rupture of eeverul folliclm.
These ulccrg are more apt to be found at the side of the base of the
tonguo, where they may escape notice except npon cjireful inspection.
rtl.*<iXOSis. — The disease is liablo to bo mistaken for inftammation
in the nasn-pharynx, buciinse the patient often refers the pain to that
locality. The diagnosis will be made by a careful laryngoscopio inspec-
tion of the base of the tongue, particularly of its sides, which must be
exposed by crowding the orgaii over with a spatula.
pRUGKo.«is. — Left to itself, the condition lasts a week or ten days.
Trkatmest. — Tlie most satisfactory treatment consists in the appli-
cotion 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 soQietiines surprising. I recollect one case especially,
where an ulcer a centimetre in diameter was found, in which the paia
was relieved within a few minutes after the first application, and in
forty-eight hours the nicer practically healed.
CHRONIC FOLLICULAR OLOSSITIS.
Chronic ftdlicular glossitis is nuL infrequently associated with chronic
tODsillitis, and is cbanictorized hy chronii^ inflammation <»f the follicles
at the base of the tongue, which become more or less filted with secre-
tion producing numerous yellowish white spots similar to diseased folli-
cles in the to u si Is, and atteudcd by various uncomfortable sensutiona
referred either to the tonsils or, nioru iicuunitely, to the base of the
tongue. The nature of the affection Is tjaseiitially the &ime as that of
chronic follicular inflammation of the tonsils, and it is appareutly dfr-
pendent upuu like causes.
348
DISEASES OF THE FAUCES.
SrnpTOMATOLOGy,— The principal symptoms of which the puiient
ooinpIuiD5 are sensationB of pricking or of a foreign body in the tbrout,
which uiuy be ]>re&eiit eontinuoaslj or only a part of the time, and which
mttv ur muy not U' ii^rgnivmed by the act of deglutition.
Dli.oSosis. — 'J'he diugnosis is made by an examination of the buae of
the tongue with the larvugeal mirror, without which it U seldom possi-
ble to see the diseased follicles.
Pbooxosis. — 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.
TttEATMENT. — When due to u rheumatic diathesis, or to distnrbimce
of the digestive organs, the treatment suited to these disorders is indi-
cated.
Locally, astringent troches iia represented by the troches of krameria
(Form. 38 and 41) are sometimes beneficial, and applications of more
active astringents, of stimulants, or of strong solutions of silver nitrate
Bometiun-'S prove curative. A more efficient method, and one which
finally must bu the resort in most ca8e8,is cauteriziilion with the galvauo-
cantery. This is usually followed by the most satieifui^tory results. Two
or three foltirles should be (cauterized at ea<;h sitting, by a small electrode,
vhieh should be passed to the bottom of earh, 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 euntinuod
until all of the diseased follicles have been dealt with and a cumjdttte
eure may be confidently predicted.
SCROPETLODS SORE THROAT.
1«MJ I
^
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 resemblea
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-pharyni or palate, but in the more atlvanced conditions —
which, indeed, arc 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 nvula with considerable portions of the velum.
Etioloot. — J. Solis Cohen (Diseoaed of the Throat) believes that
most of these are cases of simple chronic tufiammatiiju 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 diatheHis. Whatever the remote cause, it is
certain that a low form of inflammation, with ulcenitiou, occurs in chil*
SCJROFVlOrS SOBS THROAT.
sw
dm preseniing «hat v«s formerij knovii as Kbe Bcrofntoas diaUieM;
aeh] it u more ibtm poecible that, in most of these, hereditary svphUia or
tuberculosis cotUd be traced if a& accaiate h»iOfj eoald tw obtained.
STJirTOMATuLor.T. — There are no potttire qmploBu or signs ot thia
affection, hot nsuallT the chUd ii pale and leu vigoroas than other chil-
dren of the same age and surronudtngs; there is jometimes a tendency
to clear the throat of secretions fret^aently, but n^aallv this is not a
pronounced symptom. And even vheu extensive ulcemtiou ha« taken
pUce the patient does not comphun of pain. Diffimlty in deglutition or
alteration of the voice may be caused by partial destruction of the soft
palate or extensiTe ulceration of the pharynx. Sometimes a history of
inherited syphilis or tubercnlocis can be obtained, and npon examination
of the fauces more or less extensire ulceration will be found. These
nlccrs are at firpt superficial., but later are deep, with beTellod edges, in-
dolent surface, and slight discburge.
Diagnosis. — Scrofulous sorothront is to be distinguished from lupus,
tuberculosis, and syphilis.
External manifestations which may at once decide the diagnosii,
nearly always attend lupus. Cpon 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 iuttfrcHit>sis by the
comparative absence of pain, by a well marked instead of an indistinct
bonier, by the absence of fever and other evidences of tuberc^ulosis.
Scrofulous sure throat is diatingnished from g^phiiitir nlceration 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 puiiohed-
out uppearance common in &yphilis.
Scrofulous sore throat and lupus of the pharynx present the following
points of difference:
LCPCS OP THE PBARTSX.
O^nemlly in younj; ai)ii1t«. U*iially
associated with diHvuBo rif the tit(N>.
Congested, irregular nodule* about
elites or on base of i(kx*n», tvliith iii«
iisuiiDy oxlpiuliii^ in ^4.>llle plnces*
while lieahng nl noino other [i«rt of
their border; usually old ricalrirrs, *
Scrofnions sore throat and syphilitic sore throat can be diftcrentiatod
as follows:
SCBOPTJLOCS SORE TUKOAT.
Oenetally seen in chiEdren. Uftuatly
evidences of constitutional disturb-
ance.
Ulcers supei-flcial or deep, with bev-
elled edges, indolent buse, and slight
discbarge; do cicatrices.
SCROrtJlXrtJS BORE THROAT.
Genorally wen in children. Ulcer in-
dolent and usually lius u bevelled edge
not iniluruted or undermined.
Syphiutic aoES throat.
Qeiierally seen in ailiihh. Uloor
sharp 4'ut, induratedi ttuiuuilnjtB uu>
d^rmined.
350
PISBAaHS OF THB FA UCE8.
Tho difTereiitial diugnoais of tuberuuLir sore throat uid scrofulous
sore throat, will be furtliLT considered under tlie head of acuto tubercular
sore throat.
Prognosis. — If left to itself, the ulceration gradually extends, and
maj continue for many months; I hare seen ctoes which had lasted for
oyer a year. AVith improvement of the general condition and appropri-
ate local irtjatnient, huallng may he ex|HK:tod within a short time;
Teeatment. — 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 fnH)nent cauterization or stimulation by less active
agents. In practice, the thorough application uf strong tincture of
iodine to the ulcer two or three times a week has given best satisfaction.
Under its iullucnoe and the general treatment, healing soon begins., and
an ulcer an inch in diameter may be expected to heal within six or eight
weeks.
ACUTK TUBKKCUL.\R SORE THROAT.
Acute Lubercnhir sore throat is a rare affection occurring in about
one per cent of all cases of tuberculosis of the respiratory tract (Browne,
Diaoasesof theTliroat, third edition). It runs a rapid course, being char-
acterized by ulceration and great pain and the constitutional symptoma
of tuberculosis.
Anatomil'al and Pathological Cjiaeacteristics, — At first there
appear numerous small, gray granulations grouped in patches beneath
the epithelium, and if abundant, closely resembling the mucous patches
of sypliiliSf hut they lock the inllnmmMtory areolae which are found about
the latter. These granulations arc 8:tid to bleed easily when touched,
but this has not been my experieuce. They may be located upon the
palate and the pharynx, and late in tho disease may be found on the epi-
glottis and in the larj'nx. As the affection progresses they lose their
transparency, become hidden in a purulent or pultaceods covering, and
finally undergo ulceration. These ulcerations are shallow, hove no well
marked borders, but rather a worm eaten, irregular edge, and bleed easily
vbeu touched.
Ktioloot. — The cauae is the same as that of tuberculosis in other
localities.
RYMiTOMATOLooY.^tJaaally there are evidences of primary pulmo-
nary or laryngeal phthisis. The consumptive appearance, persistent fever,
rapid pulse, congh with or without expectoration, anorexia, and other
■ymptoms of tuberculosis are apt to be marked, but the pharyngeal
lesions may be independent of laryngeal or pulmonary diaeose, these
subsequently suixirvening. The one ]>rominetit. sometimes the first,
symptom of tubercular sore throat is inteii«e-pHin, sometimes experienced
upon phonation and upon attempts at deglutition. It becomes agonizing^
ACUTE TUSBRCVLAH SORE THROAT.
35t
largely preventing the taking of food, with consequent speedy losg of
etreugtli and rapid advance of the disease. Au early examination may
reveal congestion of the pharynx similar to tliat found in simple
inflammation, but in most caaeti tlie muL-oui< memhnino presents a
oharacterifitic grayish pallor with numerous somi-tntiispareut granula-
tions -which speedily give place to ulceration. The tubercular ulcer is
Bupcrficial, vith Irregular ill detiued borders, which are not umlermined,
and it is sontclimcs Burrounded by u faint blush, though usually there is
no areola of hypenumin. The floor presents indolent, gray granulations)
and scanty secretions.
In exceptional cjises the tuheri'ular ulcor hns a shtu-ply defined
border, which m.iy be slightly thickened and congested; it has a depth
of about one and one-biilf millimetres, and its base is covered with ft.
grayish white coating presenting an uppenrunce about midway between
that of the ordinary snperficial ulcer described above and the deep ulcera-
tion of favphllis.
DiAoyosis. — Tubercular sore throat msy be mistaken for syphilitic
or scrofulous sore throat.
Byphilitic sore thraat is not accompanied by the excessive pain, the
feter, and the constitutional symptoms of the tubercular affection; and
instead of the marked anaemia of the mucous membnino and small gray
grunuUtious, or shallow irregular ulcers with ill detlned, pale borders,
and scanty, graylsli, viscid secretion, it is characterized by the large,
sharply defined infiummatory ulctii-a of the secondary stage, or the deep
nlcers of the tertiary form with raised and often undermined edges,
granular floor, and profuse purnlent secretion. As also noted by
Lennox Browne {op. cit.), tlie enlargement of the parotid^ submaxillary,
and cervical glands, both superficial and deep, so commonly obsen-ed
in the tubercular affection, is. relatively infrequent in the latter part
of the secondary, and in ttie tertiary stage of syphilis.
From syphilitic sore throat, tubercular sore throat may bo distin-
guished as follows:
TCBKBCULAR SORB THftOAT.
No.«yphilittc history, QcuenUly in
adultit.
Marked coDsUtutional symptoms.
Fever, rapid emuuation.
Severe local pain.
Aphoaia, dysphagia.
Uloer usually superflciaJ, with gray-
lab, worm eaten appearance and rapidly
pragresnve.
Short duration.
Stphiutic »ori thboat.
Sypliililie history. U hereditary, it
may appear in children ; otherwise in
adultn.
Constitutional symptoms may be
marked.
Usually no fever.
Fraqueulty no puin.
Hoarseness, but usually ao aphonta.
or rtysphag'ia.
ITlcpr sharp out, with areohiof red-
d<^nMl. thii^kened tijtsue about it, some-
times umi»!iniined edffe.
May profi;ress mpidly but usuaJly
Telntively-IonjifV in dmiitron.
DISEASES OF THE FAUCES.
f Srrnfuhns norr thrmt, nnliko the tubercular, occnrs in childreo in-
stead of yoniiar ndnlts, ami lacks the severe puin^the fever, Bnd the irreg-
ilar, ^upiTtiiMai, poorly deiiiicd ulcers of the latter affectiou.
Between tubereulur aore throat and scrofulous sure throat the follow -
ig are the chief points of differeuoe:
TrBEBCULAa SORB THROAT.
Rarely seen in childi-en. Ulcersiiper.
liaj, wiih poorly deflaed bordeni.
Hectic fever Considerable cough.
Kupid eniociatioD.
Severe i»ain. ft-equeDtly Uio first
symptom.
Oyspuoro, dyftphonia or aphonia,
dysphugia.
Fulraonarytuberculoeisuaiiallypres-
«Dt.
SCBOFTXOl'S 60BE TRROaT.
Generally seen in children. Ulcer
deep, with sharply defined edg^s.
No fever. Little or no <:ough.
Slow pliy&icttl change.
But little or no pain.
No dysphonia, aphonia, or dyspha.
Ria.
Ho signs of pulmoaary tubercukma.
f Pboonosi& — Tubercular aore throat usually runs its course in from
six to twelve weeks, and nearly alw.iys termiimtes fittally. In exceptional
instances the duration is an much hs six mouths, iind in extretnely rare
Ciiees recovery may occur, or the disease may progresB slowly, the jiatient
under fiivorable conditinnfi living for sevend years before Buccumhing to
the constitutional disease. Death is caused rommonty by nsthenin.
Tbeatment. — The treatment recommended by Kraiise and Ilerying,
by thorough curetting the ulcers, followed by the application of lactic
ftcid, with occftsional use of the gal v an o- cautery, has elTe^ted a few curea
(Oleitsmann, Sew York MwUcai Journal, lB!>I), and similar results have
been attained by the use uf lactic acid alone in solutions varyiug in
strength from twenty to seventy-five per cent. !:jedative apjijications are
of mucli beneBt, chief among which are 'steam impregnated with bella-
donna, hyoscyamns, stramonium, or opium, as recommended (Form. 5(i,
67, and 59). Sajons (Dieease-B of the Noee and Throat) recommends a
ten per cent solution of cocaine applied often enough to relieve ))ain; but
the evil effectsof 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 aoid« 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 morpliinc or Jactui-a-
rium, or althea (Form. *^o, 'i9, and 36) are sometimes efficient in reliev-
ing the distress, but the good effect of opiates is uRiially counteracted by
the excessive dryness which they cauM*. When dyaphagia bet-omes ex-
treme, the feeding bottle may be used, as recommended by Delavao
stions of the Ninth American Laryngological Aasociation) or
ari'U/Liric suJiK throat.
353
nntritive enemuta niuy be employed, but tu vcU marked caa«8 all that
we oun hope for is to render tbo intient as comfortable as poBsible.
STPHIUTIC SORE THROAT.
SvplnliB mily affect tlie fftncfg in Any of its three stages, bnt the
caHii'al iiiiiiiifestrttion is seldom seeu iu tbu tliroiit, Ibough tht «-condiiry
and icrtiiiry furuia are comiuou. The chancre or priuniry lesion cif
(lypbilis. when prewnt Iu tlit; mouth, is similar to that which niuy oecur
in other parts, and Uists for live or six weeks; in the secondary stage ll:e
€rytheni:it<>u8 or niucous jMitrhep, and in the tertiary stage gunmiaLi L.r
deep ulcere, are cbanicterislic. When the diGmise is inherited, the seo-,
ondiirr symptoms nsnally occur wiibin two to six weeks after birth ; tlioi
tertiary, in early childhnod or at any time before the sixteenth ywir.
Anatomical and Patholcxjical CuAnAcxEHisTics.— Whoa chan-
cre occurs in the throat, it is nearly iiln-i;ys located ou one tonsil. la
the ^coiidiiry affection, uttually at first the fauces present a uniform dull
red erythema; llnK in |iart gnidually f;iili-a away, leaving erythematous
pfltohes which tend to symmetriwd arr.mgement upon the two sides of
the palate or pillars of the fauces, and sometimes upon the pharyngeal
wall. These ptitcbea are sepumted from healthy tissue by a distinct line
of demarcation. Mucous patches (also termed mucous tubercles or
broad condylomata) when uL-curring in iuffints, ure usually found in tbd
upper j>arl of the pharynx ami on the fnuces; but in adults on the pillars
of the fauces, or the velnm palati and the sides and base of the tongue.
They are circular or elliptical in form, slightly elevated, at first of a deepi
red, later of a gmyish white color, and, as a rule, symmetrically sitaatedJ
on e"oh side of the throat. These subsequently become the seat of
superficial ulcers; thoir borders i:rc distinctly marked and surrounded
by an areohi of hyperaemia, 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 bnt not in-
dunited 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 var)-ing from three to eight millimetres ia
diameter, and wnses 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 ulcenitioii.
Two varieties of ulceration occur In this stage, the superficial and the
perforating. The former is most fre<|uently found on the veinm, but
is also seen upon the pillars of the fcinces and tonsils; often having a
depth of one or two millimetreB. The ulcers have irregular, sharply
defined borders and secrete foul, dirty pus, which when cleared away
«3
354
DrUEAUSS OF THE FAUCES.
TOTeaU a floor jmle and itninoth, with here ant3 there fiinpoifl (^'annlniiona.
FisrfureB eometiineK extend from the edges into the flurronnding tii^ue.
Deep ulcera situated on any part of the fauces or pharynx «ie eom-
monly from three to five millimetreg in depth with cbtir-cui edges, often
undermined and indurated. Ulcers of the tliini Btaw;e, wtitther R'/gtielw
of gunimata or uoi^ uro apt to extend nipidly, destruring all ti»8tie in
continnity, not excepting eartihige and hone. Kreijnently perfontinn
of the p&Iate occurs (Fig. nui) as if hy magic, sometimes as the rognlt,
of a gamma, vhich in the palate occnrs preferably npun its upper snr-
faoe. Such Diccration may destroy a couaideriible portion of the velum
ftithin ten or fifteen days.
Etioloot. — Syphilis, whether inherited or acqaired, is probably duo-
to a epeciBc virus, u«t yet identified.
SvMPTfJMAToLOOY. — The primary affertion usually causes no symp*
toms, in the throat unlosti phagedenic ulceration ooenrs, giving rise to
pain and fever. lu the secondary stage, there is dryness of the throat>
"f
m. m-i .
SnmuTK.
with more or less aoreness and oconsionally a slight fe1>rile reaction,
•ome 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 u experienced,
especially on deglutition. In such cases constitutional symptoms ore
thoji apt to bo pronounced, and after a few weeks the patient may prc^eul
much the same symptoms, with fever and emaciatiout as one suffering
from advanced tuberculosis.
DiAitxofiis.— The primary aPTection le apt to escape observation, but
careful examination of the throat may discover a small ulcer sitoated
on :in indurated base surrounded by a slightly ecdematoas, elevated
mucous membrane. If this is associated with a suspicious history, aud
n>inaintt obstiu:ite to all tre:(tnient for four or five weeks, we may bo
zieitrly certain of our diagnosis
The secondary affection, in the beginning, is liable to be mistaken for
etUarrhal xorf throat., but after three or four days the derelopmeni
8YPHIUTW SOHK THROAT.
355
of symmetrical, erytliemutous patches distinctly outlined, or the grayish
elevated mucous palchea ur siiperlictal ulcers, witli areolee of iuilumnm-
tiou. will at once suggest the trite nature of the disease. However, even
then it is poasihie to confound tlie aHei^lioii with ^imph mtmbraimus or
hei'i^iit^ nore throat : hut the ?pecitic hiitory, if it can be obtained, or,
if not, the progress of the case for the next few <lny«, will settle the diag-
nosis. The RUperficiul ulcenition of this st:ige fihould not he confounded
with ncute tnl>erctil!irttoTe throat, if the lii8tury,coustitulianitl symptoms,
and appeuranc-e of the ulcer are taken into account.
The tertiary stage is liable to he mist-iken for grrofxttaux or tuhe-r-
euittr sore tlirimt, the distinctive features of which were pointed out iu
considering these diseases. The characteristic features of tertiary
syphilitic uluerutiou of tlie throat are: commonly uheonco or insigniti canoe
of pain unil ut eou:<tttuliuual symptoms: also the edges of the ulcer are
sharp cut, indunitcd, and sometimes undermined, uud the process is rapid.
In a very rare form of dtp lithe roii3 KVphiHt't; iilcemtion of tite throat I have
seen three cases that have beea uilstukea for diplitlivriu.
PHOON03I8.— The primary disease continues five or six weeks, and
then terminates spontaneously. The secondary alTeetion usntdly comes
on in from six to twelve weeks after inoculation, and, as a rule, dlsa])-
pears iu from six to eight weeks, or sooner under proper treatment; but
sometimes renewed eruptions make their appouranee from time to time
for several nionlhs. The gummata of the tertiary stage sometimes dis-
appear ax ihey eaime, but uttiially soften and ulcerate, the ulcers spread-
ing rapidly for two or three weeks afterward; suhaetjuently thay may
continue to progress more slowly for several months if left tu tht-ni-
selve*. The primary affection makes little impression on the general
hetdth; the secondary is sehlom dangerous Iu life, but the tt'rtiury is
often grave. The ulceration in the latter may perforate the hard palate
and destroy large portions of the »oti tissues, and may sometimes cunse
i^eath hy erosions of a large blooil vessel or by tiarrowing of tlie air passages,
(lioitrizatlon after uleeration frequently narrows or completely closes
the opening to the nnso-jdiarynx or causes stenosis of the larynx, iuter-
Jering with respimtion and phouation. Destniotion of the ]>alate in-
terferes with phoiuition, and with deglutitiou by allowing fluid to re-
gurgitate through the nose. Adhesion of the base of tlie tongue to the
j)haryngcal wall soir.Rtimes seriously interftTes with both respiration and
deglutition. In one oa«ie which has come under my observation, an
opening was left only two or three millimetres in width by six or eight
iu length. L'nder appropriate treatment the majority of eases can be
relieved and the disease checked, but sometimes, in spite of everything,
it goes on or the exacerbations frequently recur until death results.
Treatment. — For tlie primary affection cauterization is recom-
mended bv Boaie, while others favor a negative t:ourse. Even for the
356
DISEA8E8 OF THS FAUCB8.
aecoDdary lesions Bome are in faror of confining the treatment in
the majority of nutoe to local raeaenree. Mackenzie (DiHeaeeB of the
Tliroat and Nose, Vol. I.) stildom uses conatitutional remedies iu the
secondary stage, relying mninly upon local applicatinns of the zinc chlo-
ride gr. ji., ftd^i. for the erythematons eruption, or tho tincture of
iodine for muuoas patches, bnt he recommends mercuriaU for the in-
herited syphilis and in obstinate cuoea of the HC<|uired affeetion. Sajons
(Uimmses uf the Noae tiud Throat) advises (or the ttecondaryaffeotioa
local applications of silver nitrate, iodoform, and tincture of the chloride
of iron. For the secondarj- affection, I nsiniUy employ a spray of zinc
chloride gr. xxx. nd ? i. two or three times a week, directing the p*-
lifut to use ut home the same remedy twice daily in the form of spruy
gr. X. ad 3 i. For the mucous patches I sometiniets rely upon these np-
pHcations, and at others I use the strong tiiictnre of iodine or a solution
of copper sniphate gr. xx. ad 3 i., haviug thu putieut use tho sytmy at
home as just recommended. Usually small dories of mercury bichloride
and potJissium iodide are admiuistere^l itfLer each meiil, and in many
cases femiginons or bitter tonics are given before eating, depending
npou the patient's general condition. For the ulcers of tertiary syphilis
the strong tincture of iodine is the most elTlcient application, though
occflsionally the sulphste i»f copper, as recommended above, will be found
useful. Much, I believe, depends tipon the manner of applying the
tincture nf iodine. The nicer should be touched repeatedly at each
sitting (four to eight times), and a minute allowed between each applica-
tion for the piwta to dry. When the application is completed the sur-
face of tho ulcer should appear dry and glazed and of a dark brown
color. These treatments should be repeated <laily for ten to ftfteen days
and sniieeqnently less frequently nntil the parts nre healwl. .At the
same time the patient should be given the iodides of swlium aiul fKitas-
sium in doses of from 5 to 10 grains each three or four times a day.
Under this treatment even large chronic nlcers may l» expected to
heal in from two to four weeks. II there is a tendency to clcuure
of the entrance to tho naao-pharynx, or other vicious adhesions nro
forming, bougies should he 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 nicer are disappear-
ing, for at this time contraction takes place with wonderful rapidity.
Syphilitic sore tbroat ix infants, is » congenital manifestation
of syphilis usnally characterized by ulceration, the favorite seat of which
is the palate, naao-pharynx, or posterior pharyngeal wall. According to
J. X. Mackenzie, of Baltimore, nearly 6fty per cent of the cases occur
within the tirst year of life, and as many as thirty-three per cent within
the first six months. In some, however, the development is delayed nntil
near the nge of puberty.
SYPHILITIC SORE THROAT.
357
AsATOMicAi- ASn Patholoqical CHARArTERlRTlOfl. — Mucous
patches ure rare, this KUge having jirubably been ]Hidseil in intra-nUsrine
life; whon found, the^e patches arc apt li> be luimled in the upper jmr-
tiou of the pharynx. Ulcemtion is more coinmonty present, it* favorito
sent in order of froqueTicy bfing the fauces, uaKo-pharynx, posterior
pharyugeal wall, nasal foesw.gqittim, tongue, and finaHy the gums. The
ulcers present the appearance of tertiary syphilis in adults, already de-
scribed, uid are peculiarly prone to attack the bones and cartilugea,
Etiowiot. — The affection is either inherited during the intra-uterine
life or contrncteil during parturition.
SYMPTOHATOLtxiY. — This condition of the throat is usually associated
with syphiUticlesious iu theuoee, giving rise to eiubarrassuieut uf thenuaaL
respiration antJ difficulty in nursing. This in a sliort time is followed
by a serous di»chnrge from the nose, that becomes thick and purulent,
sometimes sangninolent within a few days. The lips are frequently ex-
coriated, and specific fissures, pustules, and ulcers develop upon the alfl&
of the nose, the lips, and angles of the month, extending outward upon
the cheek. Ulceration of the pharynx also may seriously interfere with
deglutition.
DiAONOsia. — The diaease is distinguished from nimph raiitrr/utl i«-
Jtammation by the profuse disclmrge from the nose, the obstmction to
nasal respiration, the occurrence of pustules and ulcers upon the lips,
and the peculiar ulceration in the pharynx.
Pkoqnosis. — When occurring within the first year of life the disease
is nearly always fatal. Older children may reco?er, but are apt to be
luft with disfigurement of the nose and partial destruction of the imlate
with consequent interference with the voice and respiration. Often deaf-
ceas results. The later the appearance of the diseaw, the better the
cbaiice of cure; but It is apt to break out anew from time to time.
Trkatmkst. — The treatment is eaaentially tlje same as for adults,
tliuugh children bear mercurials better. Local applications should be so
mild as to cause but little jtaiu.
'TER XXI.
DISEASES OF THE FAUCES.— Co«^i«iMrf.
DISEASES OP THE UVCLA.
AOVTS IKPLAKMATIOS AXD (EDEVA OF THB TTTULA.
odematous iuflAmmatioa of the uvula is a raro affection ex-
ntttRMiHUil with pUurvugilis or tonsillitis. It usually causes bat
ittle i>ain, but is atteudtid by some diseomCort in eating and by frequent
lesire to swalluw. The uvulu when u*demalous soinctiinua becomes so
torge H8 to interfere with respiration, and if it bo lon^ enongit lo toucli
the bftso of the tongue or epiglottis it causes an irritating throat cough.
^Kxhe affection is not diflicult of recognition.
H[ Trkatmest.— The ]>ropur trciitment consists in the application of
Htatriugent sprays or the use i>f astringent troches or gargles, and, if the
XBdeniH is groat, a few punctures may b« made near the lower end of
the nvula 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 onght to be removed. If
[the punctures iire not sufllcieut to allow the serum to escape, the re-
[moval of a, small bit of mucous membrane from the tip of the organ 19
generally effectual
CHRONIC IXFLAMMATIOS AKD ELOKOATIOS OF THE TTVtTLA.
Elongation, though sometimes o<:curring without chronic inflamma-
tion, is generally associnteil with it. It is apparently due to the same
tusos 08 chronic pharyngitis or tonsilliti*. .Sometimes it takes place
vithoat any appreciable cause. Xn itealth iiu.- uvula is from one-foni'th
to three-eighths of an inch in length. Sometimes when diseased, it may
become ihree-fuurths of an Inch in length without causing iuconveuience;
but in other patients, ovpn moderate elongation causes frefjuent desire
to clear the throat, with expectonttion of small masses of mncns, and an
irritating cough which occasionally becomes so excessive as to interfere
with the jMtient's rest, and in rare instances, by this means, to bring on
symptoms similar to those of serious pulmonary disease. An elongated
uvula sometimes oanaes spasmodic attacks of retching and vomiting and
ocoasionally reflex spaun of the glottis. The symptoms are usually
vorse when the patient lies clovn. In a fow ciises it gives rise to pain
and fntigne nft^r using the voice, and more rarely to hourseness.
niAososis. — ELougation of the iivuiii may be easily detected by in-
spection.
TiiKATMENT. — \Vliou ull Other causoa of the symptoms have Iwen
eschided, llie sujwrfliioua part of the orgiiii should be removed by the
uvniatome, scissors (Fig. 93), or the niisal snare (Fig. 808). Varioufl uvuLi-
tomes Imve been devised for tlie purpose, but they are not better iliaii the
scifi8urs shown in Fig. i^S, which iiro simple und well suili-il to the
purpose. The nasal anure will !h* found much more nunvGniont. By
it, »l>8ciesion ojin be done more arnurately, Jind fxnpsnive Ideedini; i«
less likely to occur. Tlie snare for tliis purpose is arnied with Xo. 5
steel wire, a loop JTiett large enough to esi^ily endoce the tip of the
uvula is formed, the physiciftii depresses the tongue with one hand,
and with the other slips the enure under the tip of the uvula, carrying
it up to within from one-half to three-eighths of an inch of its base. If
r the uvula appears swollen at the time, less should Im removed than
otherwise, and it is best never to make it ghort<»r tlmn norraiil. The
wire is tightened dowii nnl-il the tissue is secured, then tin- tongue
depressor is rerauvefl, and the physician, seizing the crnss 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-
ane as quickly iis 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 jwr cent gargle of earbolic acid may be iidvnnta-
geoQsly used sevenil times daily until the wound has healcii. In a few in-
stances alarming bemorrhago has takou place after cutting off the uvula.
Flo. n.— arHwoRH r»B AHprrATma thi Uruu, l||jto»>.
UALPORUATIONS AKI) NEW (IKOWTHS OF THE UTULA.
The uvula may be asymmetrical or absent, bnt the most frequent
malformation is bifurcation. This requires no treatment unless tho
organ is also elongated, when a portion should be reinored.
FapiUart/ i/roivthjf are not infrequently found on the uvubi, and if
large, by their mechanical effects they may give rise to the sjime symp-
toms IIS elongation. They are easily diagnoetioated, and may be readily
removed by the snare.
3fi0
PJSBASSS OF TUB FAUCSS.
Malignant groKths mrely, if over, first attack the nvula, though it
mav be involved by cxtcimion of thediseuse frum the tousils and pulucc.
The orgnn ia oft^ii involved in syphilitic iuflninmutiou und uh-erutioUr
but these cases require no special consideration, a« they were auffieieutly
described in speaking nf diseases of the adjacent piirta.
LEUCOPLAEIA BUCGAUS.
5yn0nyrfiJ(.— Leucoplakia buccaUs et Uugnalis. iobtbyosis linguae.
Leucopliikia buccidts is u chronic affection of the buccal nuicou&
nerobrane. characterized by thickening of the upithelium and the furmii-
tion of vrhite^ opaline, elevated patches, which usually become fiasurf>d
and ]minful. and, after continuing for a long time, are inclined to ter-
minate in epithelioma. The di^iease is very rare, occurring almost iu-
Tiiriably in men over forty years of age.
Akatomic.vl akd PATHOLooirAL CHABAfTERisTics. — The pntchea
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 Iwick uf the anterior pillars of thu
fauces. They consist of one or more small, irregular or oval spots wliii^h
may become confluent. A considerable portion of the tongue alone may
be involved, or the dorsum of the tongne, bnrcal mucous momhi-une. and
the game, one or nil may be aflfwted. The first apiKrarance of tlu^ wliite.
patch is preceded by hypericmia. and subsequently in the early stages a.
hypenemic areola is found about its borders. Before long the ]nitcli
itself becomes thickened, sometimes to the extent of kIx or tight milli*
metres, and the epithelium whieli has become hard and dr^' may be easily
removed, or in spots it may be spontaneously exfoliated, leaving the »]>-
pcamnce of an ulcer. The snrfuce of the patch is marked by numoroua
fine lines or furrows which by intersecting each other divide it into
small polygonal spaces. Some of tlieso lines may eJitcud as deep fissures
down through the thickened epithelium.involviug the submucous tissue in
a painful uxco rial ion. In cases of long standing, thf.< papilla' may be munh
enlarged, giving the surface a warty appoaniuce. t'nder the microscope,
the epitbelium is found greatly thickened, the pajtillw enbirged and
flattened, and the blood vej<*<elif diluted, with an accumulation of lnucocytcs
about their walls. The auperficinl layer of the mucous corium is infil-
trated with embryonic cells, and the deep layer is involved in vusoular
alterations.
Ktiology. — Excessive tobacco smoking is ranked as one of the mo«t
frequent causes of the disease, but it is probable that prolonged irrita-
tion of any character may have a similar effect on those predi«posed to
it. Thus, highly spiced food and alcoholics seem to excite it in some in-
8t-inces; and the occurrence of the affection in several meuihers of the
same familv led Bazin to believe that it is often the result of constitD-
LEUCOPLAKIA BUCCALI8.
3fil
tional syphilis. It is also attributed to the arthritic or dartrous diath-
ttsis.
Syhptomatoukit. — The clinical hiRtory of tho disease ifl not defi-
Bltelj known, becauso genemlly it has been dispovei-od Hccideiitully and
found to have exist^ii for some months or yonrs before it ha^ come under
the physician's observation. This is due to the fact tliut ut tirst the
affection causes no inconvenieiure. The small patch which tir^t appeiirs
gradually increases in size and at length stitTness occurs or painful tis-
snres form which first attract the patient's attention. Ultimately, in
the majority of cases, epithelioma results and rnns its usual course.
Sometimes the affection remains stationary for months, or uiidyr the in-
flueuL-v of some irritant it may rapidly progress, hut it uiny again boconio
dormant if the irriUiut Is removed. Ga«ea auociated with syphilid or
that have develojied into epithelioma are attended by much swelling of
the purt», and sometimes deep ulceration, which may erode the vessels-
and cause severe hemorrhage. In these, the lymphatic glands soon be-
ciime inv<.Ived, a sign not observed in the earlier stag^^s of idiopathic
leucoplukist. Often the first symptom is merely an uneasy seiisation^
hut in others the mucous membrane early becomes moro or less jMiiiifully
sensitive to spices, hot food or drinka. alcoiiolics. or tobacco. With the
occurrence of iiti^ures, pain may become more intense and almu)«t con*
gtant. uUhough in soniB it i» prcBeiit oidy at intervals. There are no
ooiistitntional symptoms until epithelioma is (]evelope<3. r>:ite in the
disease, speiiking, mastication, and swallowing usually become (Iiffii:iilT»
especially when epithelioma occurs. In such cases also profuse saliva-
tion is often a veiy annoying symptom.
Diagnosis. — Leuooplakiu nuiy he misinterpreted for what Guinand
has termed the professional patches found in glass blowers, for smokers'
pat4-rhc6, mereuriul patches, psoriasis liiigwEe, syphilitic patches, and epi-
iheliomn unconnected with leucoplakia. The pro/efiswnal patches
occur indyiti old glass blowers. pitrticularly bottle-makers. and are found
symmetrically upon both sides of the muuth, on the hiterul surface of
ihe gums, and around Steno's duct. Smiii-pr's palchtJt are more irregu-
lar (h:in thnse of leucophikia, and are commonly located near the com^J
miesurep of the lijw, hut not upon the tiorsum of tlie 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 diseafw na*
der cnnsideration. Meminni puti'hes are not so thick as those of leuco-
plnkia, are never quite white, and are found on all part^ of tlie tongue,
but particularly whore it is pressed against the teeth. \x\ pmnamsliHyna
which sometimes accompanies psoriasis of the skin, the patches of epithe-
lium assume a white, opaque appearance and after a day or two they ai
thrown off, tbeepitlielium being speedily restored ; but soon other putcheft^'
appear and go through a like conrae until after a time a large part of the
dorsum of the tongue may become denuded and of a uniform red color^
362
mSSASEH OF THE FAVrES.
with crcsccutic markings or depressions entirely tmlilco the a|ipOar:incO
«( leitcoplakiii. Syphilitic /talchea are not bo white iw those of leiicu|ita—
kin; they ure nsuaily round or ovnl and more regular in form, seldom
occurring on the check, but found principally upon the tip or margiu of
tlw tougne and often on its lower surface, which is never inrnUwl hj leu-
ooplukiu. The syphilitic patches are thiuner than the patclies of leuco-
ptakia, and the lymphatic glands are much ijouner involved. The pain is
more severe in leucoplakin than in tlie Hvphilitic diwu^', and anti-^ypbi*
litic treatment causes no improveaieat, but on the contrarv may aggravate
the affection. When syphilis and leueoplakia coexist, the dia^uo^i^ is
diflicult. Concer arising without previous leucoplakia ia distinguujhed
from the latter by its history ; the induration of the tissues and the final
ulcemlion are not preceded by the chronic white patch, but are attended
by more constant pain, with profuse salivation and a very ofleusira
odor.
PnooKOSIK. — The duration of the disease varies from a few months
to fieverni years. The majority of cases ultimately terminate in epithe-
lioma, which runs ita course to a fatal is^tie.
ThkaTJJEXT. — All sources of irritation, [mrtirulariy theuseof tolmrco,
alcoholic stimulants and strong condimenls, should be at once removed.
If the digestive organs are deranged, thev should receive proper uttentinn,
Asi<le froiM these measures, mo»<t authors lM>lieve treatment to I>e of little
or no avail. Araenious arid, the alkalies, mercury, and the iodides have
been recommended, though in the absence of syphilis the latter seem to
bft injurious. For local application various rausties, sul-Ii as silver nttrat*,
zinc chloride, tincture of iodine, and the solution of mercnry nitrate have
been recommcnde*!, but none of them seem of any value except in rases
complicated by syphilis. On the contrary, siKtthing applications tteem
to have been the most lieneticial, though giving only temporary relief.
I have succeeded in curing one well-marked case by repeated careful ap-
plications of the galvano-caut«ry, made to a small spot at each sitting and
in such manner as not to destroy the healthy tissue beneath.
Fsr a more c-omplele expofiition of this subject the stwlent is ivfenTd to my
iv, Leuco|ilHkiii BurcitliH, eU-.. in the Traosactioas of the Amerk'au Luiya-
r^ologlc&l AssoclatiOQ for lt<H5, pu^ &7.
ACUTE TO>'SILLITIS.
Sffnonpfns. — Amygdalitis, eyuanche tonsillaris, quinsy.
The tonsils, which are located between the pillars of the fauccA, are,
the nornuil condition, scarcely visible and never large enough to project
beyond the edges of the anterior pillars. They are essentially lymphatio
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
>f converting into sugar, but this is certainly an unimportant function.
ACUTE TONSILLITIS.
3fi3
rpon the fr« surface of these glands are the ori6ces of from twelve to
eighteen lacnnee or crypts which are lined with a continuation or pouch
of the niucoas membrane and surrounded by numeroutt (spherical and
lymphoid follicles. These, together with softer lymphoid Lissne, consti-
tntc the substJiDce of the tonsil, and arc the parts more or less involred
in the diseast* under considcrution. Acute tuiiKillitis is most prevalent
in humid climates and duriog the spring und wiDter months. It is
more frccjuently observed between the ages of fifteen and thirty years,
cspeciuily in subjects of the rheumatic diathesis. It is jwculiarly prone
tu attack those patients in whom the tonsils art' hypcrtrophiwl; and those
who have oiiim; Buffered from it arc liable to rttpeutnd attacks. It is onl/
occasionally mtnessed in yonng children or the aged.
Anat<imh:ai. AXh pATiiOLOiiirAi. Chaka< TKKisTics. — The inflatn-
mation may attack the muciins membrane covering the surface of tho
tonsils, it m:iy be mainly confined to the follicles, or it may involve tho
whole subntiuice of tho gland, with or without tho peritonsillar connec-
tive tissue. It is frcfjnentiy confined to one side, but in many wisetr,
when the disease has nearly run its course in one gland, the other will
become likewise affected. Tho mucous membrane covering the tensity
the pillars of the fanoes, and a jwrtion or all of tho pharvnx is red anit
swollen. The uvula is generally swollen and eIongatec3,jtnd is freciueutly
seen adhering to tho affecteil tonsil. In the follicular variety of the dis-
ease, tho oritiees of the crypts may become occluded and the lactinie dis-
tended by tho changed secretion, in which event rupture may ilnally
occar, with a discharge of tlie contents, or, on the other hand, the pen):
up secretions may become the centre of a suppurative process leading ti>
u tonsillar abscess.
ETiorxnn'. — The disease is usually attributable to exposure, the rheu>
matic diathesis, or chronic enlargement of the glands. Among the oc
casional causes of theattackare: errors of diet, suppression of tbenipnsfs,
a strumous constitution, and heredity. Uigston Fox (Tninsactinns of
the Medical Society of Ltjndon, Vol. IX, p. 2aT\) believps that, wbero
both glands are simultaneously involved, the diaea^o \n almojit invnna-
bly of septic origin. Tlie follicular variety of the dimease Is ihoiight by
some authors frequently tu result from diphtheria. This view, however,
does not accord with the experience of the great majority of phyfJciane,
though undonbtc<Uy a few cases are of diphtheritic character.
SYMPTOMATOLutiY. — Most patients give a history of previons similar
attacks. The disease is usually preceded by malaise for seversl huura
and attended by acrhing of the hack and limbs, and is often uRhrred
in by a slight chill and f.ver. Thii U speedily followed hy 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 he great depression, cold perspiration, insomnia, rcst-
leesnesc, and sometimes delirium. The patients are usually worse during
3G4
DTSEAREH OF TUB FAUCSS.
the night, and experience moat pain enrljr iu the mnrning on nnconnt of
the dryness of the throat In the inception of the attnck there iire usu-
ally sensations of dryness or pricking in the jtarts, soon fnllotrod hy pain,
which is aggravated by deglutition and after a time becomes ren.' severe,
even on attempts at awatlowing the saliva. This pain is referred to the
region surrounding iho angle of the jaw, and radiates toward the ettrs.
Oooasionallr there is severe headw^he, winch i^aggruvated hy movement^
of the head. Owing to the tumefaction, the patient is frequently nnnble
to open his mouth more than half an inch; partial deafness is common;
und the senses of taste and smell arc stimetimes obtonded. The face be-
comt!s pufly uud awoUeu, the skin hot. the pulse rapid, and the temper-
ature may rise to 103", 104^ or 105° F. A high temperature is more to
bo expected in children or in persona suffering their first attack. Artio
alatjon is ditliciilt luid enutmintiou muffled. The swollen glands m:ty
seriously interfere with nasal and oral respiration, so much so that
patients frequently fear suffocation, which indeed in extremely rarft
cases, is an actual danger. There Is little or no congh, but the patient
Is frequently impelled to clear the tliroat of a thick, viscid sccrelioa
which causes much discomfort. The tongue is coated with a yellowish,
white fur. while the breath is ven.' offensive. There is increased thirst,
and UHtially loes of Bp[>etite. Even when there is a desire for food, the
pnlient can seldom take it on account of the painful deglutition, while
attempts at swallowing tluida oftentimes result in their regurgitation
througit the nose. The bowels are nearly always constipated. Upon
examination of the fauces, the congestion and swelling of the parts uiU
be readily distinguished, li is often dcfiiruble to make the e::amination
with the aid »f a luryngoscupic reflector, for the patient is unable to
open the uiuitth sufficiently to permit a thorough iuspectiou with ordi-
nuiy illumination. In the fullicitliir type of the disease, the orifices of
the crypte may be tilled with a yellowish white secretion which causes
round or oval patches from four to eight millimctrca iu diameter. In
exceptional inGt:ince< a rush has been observed upon the skin.
DiAOSosis.— Acute tonsillitis is to be distinguished from scarlatina,
diphthi^ria, piilegmoiious tonsillitis, and syplilli.B. Thc> essentiul poiuts
in the disgnosiii ure the hititury. swelling of the part^, diltirulty in opf*n-
ing the moath, mid severe pain on deglntition.
In children, j«r«r/«/i'H(» is usually ueliered in by vomiting, which is
not the cjiso with tonsillitis. The fever is often higher, is always more
iwrsistent. and after a few bonrs a bright red rash appears upon the sur-
f.ice of the body. Usually the congestion of the fauces is mnch more
diffuse in scarlatina thuu in tonsillitis, and the swelling of the pnrts is
mocli less. The |)««uliar appearance of the tongne in soarblina is not
obsened in tonsillitis.
Acute tonsillitis may be distinguished from scarlatina as follows:
ACVT£ TONBILLITia.
aos
Inflnnnnation and swelling oftoiuula.
But little rednesAuf pharynx or palate.
Pain about ang'le of jaw, ort«n re-
ferred to tiie ears.
DitHculty in openiag^the mouth.
Tongue coated jellow.
Usually noerupUoD on s(da.
BCABLATIXA.
Ooni-ral redness u( fauces, sotnd^
times appearinf; in patches, »onietiuieti
little or nohWelMn^' of tonsits.
Pain, usually conrtn^d U» the throat.
until lute in the disease.
No UiiBcuity in opening' mouth.
Sli-awbcrry red tongue;
Cliaract«risl)c rash od skin.
The foTcr is at first commonly lower in (Uphtherut tima in tonsillitis,
there is no difficulty in opeuing the mouth;, and usually there is but little
pain. Upon examination of the fances, there is found a thick, gravisk
M'bite memhraue uniformly covering ii large portion of the throat or
confined to one or two patches upon the LousiIh. These putclips uro
much larger tlian the yellowish masaus seen at the orifices of the crypta,
and are lees numerous, and they appear to be Uid npfin the mucous mem-
brane instead of being beneath it or even with its surface. Ju cases of
bilateral ffrllicular tonsillitis, the disease is frequently septic, and paraly-
sis of the phAryuge:il niusclee may follow, very closely simulating that
of dijihtheritt. Probably some of theise are truly diphtheritic in ehar-
acter.
AcQte foUicnltir tonsillitis and diphtheria present the following dif-
ferential points of diiignosis:
Acute Foujctii^K tonsilutis.
Tonsils Jaflanied. «nUr^d.
WhiliKh or yellowiidi depotut at
oriUces of crypts.
High fever.
Difficulty ID opeoing mouth.
DiPHTUKKIA.
Tonsils uot alwa\-8 enlarged.
Thick, t^i-uyixli whiti_' membrane on
fauces or tonsils, or possibly conQned
to one toobii. nuicli lari;er than th*
deposit of totfiLDitis.
OfteutirtieM sutinoriiial teitiiM>raturc.
No dimculty in opening mouth.
PhlegtnonoHH tonnUHtiit \» more likely than acnte tonsillitis, to be coij-
fined to one aide of the throat. The swelling and pain are greater, the
difficulty of opening the mouth is more pronounced, and after four or
five davB rigors indicate the formation of coneiderublo pus, while fluctn-
atiou may occasion ally be delected, especially if one finger is placed on
the tonsil and the otlier behind the angle of the jaw externally.
We can usually readily distinguish fijphiliiir mre throat from acute
tonsillitis, but there are caeea 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 swelliug of the parts
osnally occur in symmetrical patches upon both sides; and the conges-
tion is seldom of that bright red character seen in tonsiUitis. In the
3()b
DISEASES OF THE FAUCES.
■econditry diseast; super&ciiil ulceration and tnucoiiB patcbos, with possi-
ble eruptions upon the skiti.aud in the tertiary form, deep ulceration with
moderate cougeBtion, :i peculiar swelling, together with the history and
other symptoms, will usaally eniibl<^ the physician to make the diagnosis
easily.
From syphilitic sore throat the disease is distiuguishcd by the fol-
lowing points of difference:
Acute toksilutis.
No Hi>e<-inc liivtorv. Indainniatiori
and »wellin;j. Parts bright red.
Oflen e<»llt*lion wf ^'uUowish seert-
tloDR in fcillirle^.
tii^h ff>voi-, acute puin.
Difficulty in opening' mouth.
SVPUILITIC BORE TUKOAT.
Sypliilitic hifttor}*. Comparatively
littlt* itidiimmiition or swelling.
Muouiis ]mtchcs ii^uully syniraeU-
riral.
But little revwrorpain.
Usually no dilBculty in movinff jaw.
Pko«no.S!8. — There is very little danger to life from the digease, al-
(h<mgh de;itli hiis been known to occur in a few instuni^es. The afTection
often termiinites in chronic hypertrophy of the glamls, and not infre-
quently a simple indammation eventuates in suppuration. ]t is usually
the forerunner of other similar attacks, and is occisionully imnicdialely
preceded or followud by acute articular rhcumutism. It often termi-
nates in four or five days; sometimes, however, it lusts ten days or two
weeks, and in exceptional casns as long as tlirce weeks.
'I'kk.vtmen't. — Persons suliject to lonsiUilis should avoid all exposure
likely to excite the intlammatiun, and should be nareful to keep the
digestive organs in perfect condition, attending especially to regularity
of the bowels. Gnaiacum has been highly refonimondod for aborting
the disease. It is given in the form of troches, each containing two or
throe grains, every two hours duritig the beginning of the attack, or
the ammoniated tincture in doses of a drachm every fourth hour may
be administered in milk. Although tliis remedy has the sanction of
high authority, 1 must admit having seen very little^ if any, benefit
from its use. Brushing the tonsils with a sixty grain solntion of silver
ritnilu will cut stiort the attack in probably about one in four cases.
Aconite, opium, and lielludunna given in small doses, frequently repeated,
haTp the power of speedily abbreviating the disease in some instances.
Aconite may l>e given in doses of half a minim of the tincture every fif-
teen niinulf-s until sweating or other constitutional effects are produced}
and thereafter less frequently, about once an hour for four or live hours,
and still ]a.ter once in two, three, or four hours, according to the febrile
syniptonis. The tincture of opium may be given in doses of one minim
every fifteen minutes at first until the patient exiKrieuces relief
from the sensations in thL* throat, and subEinjuently once in from two to
four houns, according to its influence upon the pain. Tincture of
belladonna may be given iu a similar way in dosee of a half-minim. By
ACUTB TOJVSILUTIS.
W,
some uf these loeaaares tho disease may frequently be aborUtd: but
it will be found that u remedy which acts well in one person will often
be entirely i:iefncient in auother. In the beginning, conatijiatiou should
be relieved by the employment of a mernurial or saline cutharlii-.
Ice held continuously in the mouth, or upplied externally by means of
ice hugs, will fr«ijueutly check the coniiueiiciiig itiflunimation. Fre-
fjueut gargling with strong sulutions of potassium chlorate luid nitrate,
in water as hut as can bo borne, is very bcnoliciiil after the disease i»
fairly eslablishfU. For this purpose it is my custom to order one
part of the chlorate and two parts of the nitrate, and direct thi* jmlienL
to Hue a heaping tpriRpooiiful of this in half u ti^acnjt of hoi water t-very
half hour. Gargling with a one-b:iU per cent to two per plmiI solution
of Ciirbolio aei<l is also useful in many caseA. A one per cent solution of
salicylic acid is also recommended. T^nionaile may be biken frequpnt.ly
to clear the throat of the tenacious mucus. Dobell's solution is also an
excellent mouth wash for this purpose. Whenever there is evidoneo of
a rheumatic hubit. gimiaeum is indiaited and may be udvontageousily
combined M-ith small doses of o]>Lum and medium dose^ of the potussiuia
bromide, which relieve tin* pain and lessen congestion. If, in spite
of th«se various rcmeilies, the infliLnunation progresses and the toni^iU
become much swollen and pain/ul, si^iirifu^ation, deep incisions, or four
or five simple punctures will often give great relief. In making an in-
cision, the bistoury should be passed with its back toward the ontc-r por-
tion of the tonsil uud the cut made toward the median Hue. Where tho
gland is very large, two or three of these cuts should be niude. When
the patient is subject to fre<i^uent attacks and the tousiU remain largo
after the innamnuuion has subsided, removal of the glands should bo
advised. There are some patients who sutler from recurring allucks of
ueute 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 ghtnds be re-
moved during the period of an acute iullammalion, while they are cou-
tjidembly enlarged. The main objection to this prncechire is the exces-
sive hemorrhage which •■omerimes follow?. These rase*' may be very
itisfaotoi-ily trcaUiI by repeated punctvires with the galvano-cautery. In
prying out this treatment two or three pnnctnres should lie made at
^acb sitting, this nut to be repeated uutil two oi three days after the
soreness ottMstoned by the last cauteriziiliou luis subsided. The treat-
ment is necetisarily protracted, as ten or a dozeu cautorizsttonB will usii-
ally bo found necessary. In some of these cases I have obtaincii e\cel-
Icnt rcBults by passing a vulsella forceps through the foneslnt of the
toQsillitome. seizing the gland, drawing it well out, and then cutting it
off with the latter iustrnmeut.
PUB ABES or TUB FAVCBH.
PHLBOMOXOrS TOSESILLTTIS.
Sfnomgmf, — HoppanitiTA toiwllilig, ahaoew of Urn **»»^l#, qfiuBsy;
jJkUgncttam tore thn«t
PhlegmoDOU toonllitu u a rappustire inlhmwwtion of the toaufl
Mod ptriloninUr ttarae, ch«nct«rized br (be foraution of a cinauD>
Miribed abtctm. U occtin mutt freqaentlj in children or joong adolta;
•eldom beforvthf: twith jtmrot iige.antl nut commonlr after the CfairtieCii
yesr< Fetmns wh'^ hare hail it onoe are mnch more liable to attacks
than othen; and tho*e haring chronic enlargement of the tonsiU ara
peculiarljr »abject to thin Tsriety of inflanimation.
A?(ATowicAL AM» Pathoi/kucal Cuabactzeistic^ — ^The inflam-
mation attaclt* the macotu membrane, tbe glandular, or the periton.
cillar tijwDP — •umetimen j>art and sometimes all of the tisraes — and fre-
quently extvndii doirn to tbe jheaths of the mnsclea. Sometimes the
moaclea themwUeM are inroWed, bnt nsoallj the forco of the attack is
expended upon the conneclire tiwae about the gland. The iwelling is
neurlj atwajB unilateral, iind the abscen which fomis i^j, I think in nt
laait four-fifllu of the cases, outside of the gland itself. i
Btiuukiy. — The causes of the disease urc the same as those of acnte
tonsillitis, with the addition usually of some debilitating circumstance
which huB rendered the patient peculiarly susceptible to suppuratire in-
Aammation.
SYmToMATOLOOT. — Inquiry into the liietory of such a case fre<)iently
roTenls that tho person has Imd kindred attacks several times during
the previous two or three ycard. Tbe locul and constitutional symp-
toms in those cases are essentially the same as those of ordinary acute
tonsillitis of tho severer grade. Superadded to these we nearly always
find rigors at tlio time suppuration takes place, and sometimes a pecuU
iar, sharp pain is nssucinted with the formation of the abscess. Swell-
iu^ uf the part is ezcossive, so great in some instances, even though con-
fined tu one side, us to fill tbe whole fnucus. As tbe disease progresses
the spot at which uu opening is about tu take place may be distingnished*
This is at first more livid tbun tho surrounding tiReiic, and Hfter a time
it booomos yellowislt and slightly prominent, and (inully tbe tissue gives
way and pus cscnpt's.
IhAdKosis.— Tho dis4a«e is to be differentiated from the same alTeo-
tiuns that are IlnUu to bi- mistaken for acnte tonsillitis. It is not always
easy to distinguish it from acute infliimrMiition of the glands without
su])pnnttion, Tho essential points in tbe diagnosis are the sharp pain
and rigors at tbe time of suppuration, and the occurrence of fiuctua-
tion. oeoaaionally to be detected by palpation. However, in many cases
tho tissues sr« so teuse that jMilpation will not give distinct fluctuation
even though oonsidcrublo pus be present Then an ciploriug needle
must bo fimjduyed.
I'HLEGiiONOVS TONSILLITIH.
3(;9
PROOJTOSIS. — We oxpoct 8tippuration to occur from the third to the
sixth (!»}:. 1/ the caj^e is left to itself, the abeccss will usunll)' D|«n s])on-
taneously Hhout the lonth day, and the patient will so f:ir recover aa to
l>e out of doorei within three or four day& after the fihereas has b«en
evacuated. So far us life is concerned, the pro^osis is faTorable. There
have been, howerrr, c, few exceptions to this rnle. Convalescence is
usujilly very rapid, though somftixnea the iuflamnmlion is followed by
some paralysis of the muscles of the fauceK, which m.-iy last several veeks.
Piimlysia of t}io palate cuURing indistinctness of speech, and regurgita-
tion of fluids tlirough the nose when the patient attenipts to swallow, is
the most prominent of these manifestations. In rare instances typhoid
symptoms super^'ene upon the acute inflammation.
Trkatmext. — Early in the attack the disease may be aborted as in
acnto tonsillitis — in about one case out of four— by the application to the
inflamed glaud, once or twice a day, of a sixty gruiu solution of silver ni-
trate, two or threo ajiplications usually being sufficient. If the case is «eeu
earlv, 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, nacd in the form of troches, or the limmonialed
tincture as alrctidy recommended for simple tonsillitts; but it is useless to
continue with it longer than forty-eight hours. My personal experience
with this remedy has been lansatiiifactory; I liave never seen an attack
aborted by it, though some Ijave apparently been shortened. If J.bortive
measures prove unavailing, wo seek to cnnduot t.he inflnmmjitinn to a
speedy resolution. For this purpose, aconite, opium, find anti-rhcumatic
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 jwitient is relieved or the constitutional effects of tlie
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 clo^e together, and as many more onco
un hour. In most of these cases, after the first twcnty-foitr hours,
sodium salicylate gr. viiss., with jwtassium bromide gr. x.. every fourth
to sixth hour, are especially benefici;d. Local applications are valuablo
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-
glingonce au 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 hy saline cathartics. Scarification of the tonsils wilt
S4
370
DISEASES OF rnS FA.UCBS.
aomeUmefi gi\e great relief, eren before suppnration has taken place.
Pas should be evacutited v.s ivon ua discovered. Pain from the incision*
may be in great part prevented by u few applicatiuus of a ten per cen^
spray uf coc-aine. Some patients think that if the tonsils arc cut then
are more liable to subeeqnent attacks, bat there is no foundation for
finch belief.
HYPBRTROPHT OP THK TONSILS.
Sytton^m. — Chronic tonsillitis. This inclndes chronic foUicnlar ton<'
sil litis.
Hypertrophy of the tonsils is an affection characterized either by a.""
eolleciiou of secretions in the crypts of the gland and oonscijucnt irrita-
tion, with or without hypertrophy of the parenchyma knonu us — chronic
follicular tonsillitis, or by eiuiple hypertrophy of the glandular tissue with
but little involvement of the lucunip. About two-thirds of the cases occur
in boys. It is most frequent in youth or in young adults, bnt it is also
very common in children, and is congenital in rare instances. Tlie tm-
doncy to the diiMiue diminishes wict) a^lvancing 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, cuttiogfl
with a creaking sound, owing to incre.iae in the connective tissue. Some
uf the lac:uii:e may be filled with an extremely offensive secretion of yel-
lowish color and cheesy consistency. When the follicles are involved.
M-ith bnt littln hypertrophy of the glandular tissne, this secretion will
found in «iveral of them.
Etiolooy. — The disease is moat frei^nently the result of repeated
acnte attacks of inflammation of the gland, esperinlly when occurring in
subjects of a strumous or rheumatic diathesis. But the starting point
often seems to have been an attack of diphtheriu, scarlatina, or mensU
Again it has also been attributed to chronic follicuhir pharyngitis nni:
to awpiired syphilis, while occasionally it is supposed to be of hered-
itary origin. The view has been advanced that follicular disease of tl
tonsil is caused by bacterial development in the tacunte, hut as many
varieties arc found in such cases and na bacteria aro always present in de-
caying organic substances and associated with dead tissue, their presence
here is not suflicieut reason for believing that they cause the dise;ise.
SYMlTOMATOLonY. — Sometimes there is the history of a hereditai
tendency to the disease, and usually a history of noisy or snoring respira-^
tion with altered voice, and frerjueni acute attiicks of innf<illitis. !i
children particularly, partial deafness is a frequent symptom. Ii
rare cases the senses of smell, taste, and si^iht are said to l>e affected.
Pain is seldom present, except when th*.* laeuuu become much distended
hv the secretions, bnt the [latient often ex{>eriences more or lees die
comfort in deglutition, and sometimes complains of a bK^nse as of a foi
If XPERT ItOPltY OF THE TONSILS.
;i7i
oign body in the tbroiit Where the gliuids are large, particnlarly in
cliildren, the open mouth, dull eye and stupid appearance are almost
clmnicteristic of the disease. The voice is usually thick, as though llie
piitiout had something in the mouth when speaking; it may be luisky or
lioarsc, or may jiossess a gutturul or nasal i^uaiity. Some of Ihes^ jKitients
j;re easily fiitigiicd by speiiking tor «ny length of time. Bespiration is
obstructed in proportion to the enlargement of the glands. This is more
especially notieeuble during sleep, wlicn the respiratory movements are
often painful to behold. As a result of [H)or ai-ratjou of the blood, there
is frequently great deteriurution in the gencrul hciilth.
There is but ntrely actual danger of fmfTocation, though serious symp-
toms pointing in this direction are occasionally observed. Cough is not
nsuiilly present, bnt it may sometimes occur in severe ptroxysms. In
many jwitients there is a frequent desire to clair the throat of niucns. I
have seen children who hiivc coughed much at night, esjiecially during
the vinter, in whom the cough haa been immediately iind pernninently
relieved by removing the enlargt^d tonaiU. Continued difficult breathing
in children may cause deformity of the elastic chest vails, which take
the form of the pigeon breast, or the pyriform chest in which the upper
piirt ia 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
nlrributeJ to hypertrophy of the tonsils, are probably the result, in most
oases, of associiited liypertrophy of the pharyngeal tonsil. The enlarged
glands may sometimes be evident e.xternally, at the angles of the JHW,
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.
DtAONOsis. — 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 OL-nur, jmlpution. with one finger
on the tonsil and the other externally, will reudily detect the enlurge-
ment,
PttO«Mosi.s, — Tho disease may be expected to extend over several
years: hut when occurring in childhood, spontaneous recovery not infre-
ijuently 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
indio:ited. Persons with tlieae glands hvpertrophied are subject t«i fre-
quent att.Hcks of ai-'Ute tonsillitis, and it is probably a fact that in them
the throHt afTections of scarlatina and diphtheria are more dnngerona
thiin in lliost* whose glands arc normal.
TitKATMiiST. — In young children where the glands are soft, the re-
lUBSAMBB OF TBS PA WES.
appliaivm of powdered Klan or o<h«r Mtrin^entB, or iht mm
hriution it the «ngte of the jsv. or the inccnul admmi«trml
Jie iodide ol ittm, or aamm tHher ynmnlvam
pctfed
eoanter
of the ^mp of the iodide of irati, or aam» eilwr prtpiiitioii o£ iodine.'
will oeetrioaeDy cnrethe diweeigbrt thii —ner oftuMlniiiiitii tooiui-
oertatD to be reooomended exoepting where the petient win tolerate no
other. £nlefged tooali bsj ■otnetiinee be rednoed by repeated injections,
into Ibe nbstaooe of the ^and, cxf iodine, ergot, or cari»oUc acid : or bj
dcctrvJju, bj the galTaDo-caatenr. or by caatertnition with chromic acid
or other c«acti<s. The galTano-cmaterr is e^wctan.r osefnl in the trMt-
meiit of chrwiic ffJli«ilT tomilliiia. It is highlj reeoauneniicd faj
D
Fml M— M*Taicr's T<
CM itaei, wtttt ffMatn m ricbt tti^lM to iMndkc
C. H. Knight, of New York, and otben for redaction of hypertrophT in
iheee glanda. bat it ia a tedious prooees: usnallv from ten to twentr or
thirty eittings will be required before the desired end is accompltsbed,
aod eaoh of these will canse bat little lees discomfort than excision, vet
the method is to be recommended where there is danger of bleeding,
where the disease is mainly confined to the follicles, and in some caaes
where the cbronicslly inflamed gland is not sufficiently Urge to be
remored by other means. ElectrolvMS may be nseful in some in-
stances, but it is tedious and not very satisfactory. Enacleation of
the whole gUnd by the finger has been ref'ommended^ but ita ac-
oomfdisfament is difficalt nnlese the mucous membrane has been first
Fie. te — Ta« Mjun m Fie. M, fvoeatts pUcH oblk|uH;r-
cut around at the base, and even then there is unnecessary bruising
of the surrounding tissues. lu adults, the (]uirkeftt, easiest, and uU
together modt eiatiHf.ictory procedure is removal hr rnejins of the ton-
sillitome, which is fnr preferable to the old method by means of the for-
ceps and bistoury, beoiuse of the rapidity of the operation and the small
dangt^T of bjeeilin^. Miiny varieties of the tonsillitome are used, but
Fnhneitt<K'k's, also known »s Mathieo's (Figs. 04 and 05), hjia proved most
intinfiictory. It is suitable for nil coses, and will sometimes engnge a
ghiTtd wliich cannot be secured by other varieties of the instrument. In
performing the opemtiuii, the patient is to be placed in a good light, and
an assist4int should make pressure behind the angle of the jnw with the
finger so as to crowd the ghmd well into view. The openitor should
then depress the tongue, encircle the tonsil with the ring of the tonsilU-
I
HYPERTROPHY OF THE TONSILS,
3:3
tome, press tlie instrument firmly down to the baae of tlie gland nnd cub
it off Tiih a suigle morement. The other may be removed in the same
wuy a few miuuCes later. The glunds muy first bo partiully aiiu.'st]ietized
by u spray uf couaiim. but the operation is not usually very painful
without it, and cocaine is soniewliat objectionable as it tends to
increase the blewling. wliich sumetimeit comes ou two or three honra later.
It is well to hare tlie patient use frequently a gargle of a solution of
one and one-hnlf per cent of carbolic acid, uutil tbc vuiind has healed.
Some recommend that only a »lice be removed from the tonsil, with
the hope that the remainder rill 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 KutTer from a recurrence of the growth, or at least
irom repeuted attacks of acnte inHammntion: therefore it is better,
■when possible, that the whole gland be removed. Thpro are some cases
of chronic inflammation of the tonsil in which the gland becomes large
only during the acute eiacerbutions. These may be treated by tho
galvano-cautery or, as recommended by Lennox Browne, the gland may
Fm. Oft.— INOAU' TOMn. FOCCSH (X-S ■!!«).
be removed during an acute attack of inflammation, notwittistauding the
increaeed danger of hemorrhage. In such cases I have obtained very
gratifying results by nsing a mlsella forceps and the tonsillitome, as
indicated under acnte toTiFJlhtis.
In adults, as a rule, ecraaement is a less satisfactory operation than
excision by the tonsillitome; but for you n^ children it is much pref-
erable, because it may be done under the ans'Sthetic 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. 90) whioh I have had constructed for
this purpose, and then slip over the furceps and down over the gbnd
the steel wire loop of the snare wliirh is used for removing nasal
polypi. As' the loop is drawn tight, it slips nnder the blades of the
forceps and either cuts the gland close to its buse, or better yet, by slid-
ing beneath, completely removes it. Duriug the operation the child's
mouth is kept open by a gag. t have found it preferable to remove the
undermost gland while the patient i» 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
874
DISEASES OF THE FAVCE8.
then drawn forward uutll tbey strike the anterior pillar. At the same
time, pressare is inatle externally behind the angle of the jaw, the for-
ceps are crowde<i Howii, the blades engage the upper and lower ptirtiun
of the glaufl, griisping it tirmly, and the hnndlet* are locked. The isuartt
is then slipped over tlie forceps and the gland cut off and removed. Thia
may often be done without the loss of a drachm of blood. To avoid
removing tlie uvula at the same time considerable care is neoeesary that
it be n(^t caught in the forceps or snare with the toueil. Where the an-
terior pillar of the fauces is a^lhercnt to the gland it should tirat be sep-
arated by a blunt hook and the finger. A strong nvula holder similar to
that shown in Fig. K4, though less bent «t the hook and with a larger
handle, answers well for this purpose. Treatment of follicular tonsillitis is
unproiuiBing hy the ordinary methods, yet the diiiease may sometimes be
cured, by Jngertiiig into the follicles, one after another (two or thi-ee at
each sitting), a sinall quiintity of silver nitrate or chromic acid, the re-
"Mned secretions having first been squeezed out. Treatment by means
of the galvflQo.cautery is usually very satisfactory, and in using thiis in-
strument there is no necessity of lirst squeezing the secretions out of the
folliclea. 1 use an electrode with a point consisting of a loop of plati-
noin wire about a contimetre in length by fonr millimetres in breadth,
the toQBil is first anaesthetized as well m may be by cocaine; the |H)int is
then j>aB8ed into the disease<i follicle, heated, and moved about for a second
■Oaa to touch its entire surface. Two or three follicles are treateil in
this Way at each sitting, and excepting in rare instances a few days later
these points will !>e found to be completely cured. From five to a doxen
sittings may bo recpiired to cure cases of tliis kiml. The treatment
should not be repeflted for five or six days; that is, till twoor three daye
'*»ler any soreucas occasioned by the preceding cuutoriziition has disap-
peared.
Excessive bleeding is not common after tonsillotomy, but a few
*=aso8 of alarming hemorrhage have occurred, and ihero is a possibil-
ity of death from this cause. Though the danger of this is so small
*8 hardly to merit considemtion, yet we should always be prepared to
check any undue hemorrhage as speedily as possible. The methods
*hich have boon found most effective for this purpose are: the sucking
of ice. rubbing powdered alum upon the cut surface, compression of the
Btnmp of the tonsil by the finger or thumb or by means of a sponge
wituiHted with a strong solution of tannin or of iron persulphate, which
Way 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 c;ise. In lw»
such cases I have resorted to the guWano-oiiutery, once with |>erfect
success, but in the other I wKt< obliged later tu use compression Uj
CONCRETIONS IN THE TONSII^
3:5
neuna of cotton eatnrat«d with penulpbitte of iron. Hot wntpr i\ml
various other snbstAnccd have ulso been used suecessfulljr; but in
the most severe homorrhnpc that ever ocotirroti in my experience, after
all other metho<U liad fuileU. the bh-eding stopped 10 soon its fflinting
occurred, and did not nrappeiir. This hiirmonizes with tho suggestion
lade by P. Bryeon Delavftn, of New York, who recomniendfi that in ex-
Hv© lieniorrhiige after tonsillotuni)" the limbs and urme be corded bo
uB to reuiD as much )>lood in tbem us possible, and that fuinting be en-
«onrugi*d; he having observed that, iiiull serious cases, as soon as this
took place the bleetling stopped. When advising removul of the ton*
uls, we are often asked as to its proUible effect upon the voice, and
occasionally us to its influence upon the generative organs. Ta the tirat
we m;iy unswer poaitlvfily thut 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 gon-
«ratiTe nrpins, thongh the statement of Chnssaignac indicates his be-
lief that hypertrophy of tho tonsils tends to arrest growth of these parts,
«ud removal of the tonsils favors their development.
CO^CKKTIONS I.N THE TONSIL.
Synonym. — Calculus of tho tonsil.
Concretions in the tonsil consist usually of a collection in the lacansB
of desiccated secretions from the follicles, by which the gland may be
much enlarged or inflammation excited. Some of these :ire hard and
others soft. The hard consist of the phosphate and carbonate of lime;
the soft, of the (fe/>n8 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.
Erun-otn. — The affection is due to inflammation of the lacunse.
SvMPTOMATOLtxiV. — There is usually a pricking sensation in the
tonsil, with sometimes a little difliculty in swallowing. The gland is
,«wollen, 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 maas with e. probe, we can readily determiue whether it is hard or
«ofL
Prookosis. — Where small, the concretions are frequently expelled
•pont&neously. Their persistence predisposes to hypertrophy of the
tonsils and acute or phlegmonous tonsillitis.
Treatuext.— Kemove the concretion, and if neoessary cauterize tho
«mpty crypt.
S}«
lflHt£AHE.S OF THE FJV'KS.
MYCOSIS OF THE TO'SOjB.
MyeocLt of the thrcut » u parasitic dueaw of tbe ta
portioiitf of the throat, chanicterized bv TeUovish vhhe
bliug JD some cuea tbow of chniuic follicular toD&Uiii&.
ASATOHUXL AXn PATH0LO41KAL CHAaACTEWSTICSw— TW dlpMlT
D«uaI1y oecurit in DDnieruui imaJl. veUovish or vvHcnruh vUte ftchw
from two to fire milliniHrci in diamet«r. These are foond
wiihiu the crypt* uf ihetMuil or more freqaentlr ck»K to thar
but arc not uncommonly wen npon the pilUrs of the taaces or tbe
pharynx, and uftea In coniiderable numbers npuu the base of tiw
lori^ae. The deposit may in some ouci be &u soft m to be casCy
ecruped off, bat iti other inxtuncea it ia quite hard. Sometimei it u «a
]>roitiinent 05 to Iwrome almost polnntnilatedr and often it jvuuuts a
jKipiiliry or warty appeonmce. According to DelaTan, acrmpiii^ fnm
the di«eafled part, when examined microaoopically, show tbe preaenca
of granular matter, pus corpuMflea, leucocytes. choleist«rin, and, noei
important of all, tbe leptolhrix buccalu (Reference Handbook of
Aledical .Sciences, Vol. V'll). This organism attacks mainly the outer
luyers of epithelium, but sometimes extends deeply into the mnooaa^
wliieh explains the dinioulty, iu certain instances, of its removal by swab-
bing or scraping,
Etiulouy. — The causes of tli« affection are not definitely nnder^
stood, but it is Httid frv|uiiiitly to arise from carious teeth, where tho
leptothrix finds a i.-onguniiil soil.
SvMlTUMATuujii), — Frtxpiontly mycosis gives rise to no inconTen-
ieuce and Is only ilisf'oTnrotl by accident; but in other cases pricking^
6eu8:itir.iiig and other «yntptuiiiN iiimilar to those of chronic follicular ton-
sillitis ure ex]>unrmced,
DiAONosiA. — The affection is liable to be mistaken for acute or
chronic folliculttr tonsillitis or glosHitls, upon which, indeed, it may bo
engntfted. From the urultt nffiHttions, It may readily be distinguished by
the absence of congestion and swelling of tho partji and febrile symp-
toms, and by its prolonged i?<juriut. From rhront'c foUicolar aJFectiona
of these parts, it is to be distinguijthed by the position and appearance of
the deposits, and by a microscopic examination, which in this disease
reveals a large number of the micru*orgitnlsnis already referred to.
deposit in mycosis is either soft or hard ; and it "KcurM, us a rule, iu si
masses than tbut of chronic follicular inflammation; although iu
many cases it is found within the crypts, on careful inspection it will be
obtferved in some places clinging to the surface of the mucous membrune
at the orifice of the crypts or wen remote from them. The wart liko
and Bometimea pedunculated appearance which obtains with Pome of the
masses is never found In fullicuhir tonsillUis or glossitis. The foreign
MYCOSIS OF THE roXHlLS.
377
products are usufllly smaller and much more numeroos in mycosis than
ill cither of the disenses just uamed.
Mycosis may be differentiated from acute follicular totisillitis us fol-
lows:
Mycosis.
No tnllamniation or sw^lUn^.
Absence of fobrilo ftrmptoms.
Piulunt^eil foiii-se.
Dt;|iofkit itofl. or liaiil and in small
ina««(>»: may 1«» found either at oriflcea
ot c-iypts or remote Trom lliem.
ACITE FULUCULAB TuVsllXCnS.
Inhaiiininlion and swellins.
Fever.
Brief history.
Collection of Koft. yellowisli secre-
tions in tht* lacunae.
From chronic fuUiculur tonsillitis^ mycosis is to be distinguished bj
the following cbamct<;ristics:
CHBOMIC rOLUOCL&R TONSIIXITH.
Often liistory of KlniiuoiiH dia(h<»is.
or of il)|ilitli*M-iii, !>i:ar]iititia. or measles.
TuiiHils usuuU^' enlar^cfJ.
Deposit witliin tJie lacuna.', often in
lar^ majsftes, not udhereni to tlw
uiUL-ouH membruDe.
Mycosifi.
Often Jiistor>' of carious teeth only.
Tonsils UNUolly of normal sLkt.
DepuKit in small masses; found on
mucouK inembt'uoe, and may be remote
fi-oiu oriUcen of crypls. They often
spiiearlikedeoulorixed warty <;rowthH,
firmly attachiHl to the mucoun mem-
brane and standing out two or three
miUiiiK-tiv» from ttie surface.
PiiorjNosis. — The affection^ if left to itself, is of Long contiuuuncer
and, if the masses arc 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 tliroat have little or no influence upon mycosis, and, in
order to eradicate it, thorough and radical moasures .must be adopted.
DelaTan recommends froqnent applications to the throat of garglea or
j-lprays rontaining either mercury bichloride gr. i. ad 3 iv. or sodium bibor-
^stegr. XI. to x\. ad 3 i.; but especially acrapiug uff the deposit with a sharp
curette and then applying the galvanu- cautery to the site of the growth.
I have seen no benefit from local applications of an antiseptic, stim-
tilantj or caustic character, excepting the treatment by tlie galrano-can-
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 fire being treated at each sitting, and the process repealed
once in four or Ove days until all the growths have been destroyed.
There is but little tendency to recurrence of any of the masses which
hare been thoroughly treated by the galvano-cautery. Carious teeth
thoald, of course, receive proper attention.
Tubercular ulceration of the tonfiils is extremely rare as a primary
■Jesioii, but in not uucommon iis n concomitant of advAnced tubercnlosis.
Anatomical anu Patholuoical CHABArTEKisrirs. — Usually iho
euriane of tbe Uttm] i« jiab- (irnl more or less covered with a viacid,
^velJowiKh gruy secretiuu, beneath which the tissues appear erode^l or
^prorm eaten by irregular snperficiiil ulcere, which nuiy by extension
^iivolve the pharyngeitl wjill or hirjux. The borders of these superficial
TJlcera are not sharply Jeliiied. hut irregular, and there is little or no
Jf* '"'K »f the (»HrrouiHlins parts. Sometimes, however, the ulcers are
much deeper, and exceptionally the ed^es may he sharp cut aud elevated,
everted, or according to some authors even undermined, but these latter
appearances are extremely rare. Sometime* the parts are slightly more
ongesied than the surrounding tissue. In the deep uh;eriition which I
ftve seen, the borders liavc been clearly cut, but never underniineil a* ia
«yphiii8 nor indunited as in maliguant disease. The surface has pre-
, iited a pale, granulated appearance, bleeding easily upon being
ucneq. Microscopical examinations of scrapings from the parts show a
«maa amount of fibrous tissue, epithelial and pus cells, nith abundance
of grauuliir matter, and occasionally giant cells, but the bacillus tuber*
-ulosis cannot often be detected.
oVMpToMATowoY. — lu all the cases which have come under my ob-
*ervution, painful deglutition has been the moat' prominent symptom,
■iid m the major number this has been severe. Uauiilly, even Ihongh
the tubercular process is slight in other organs, the constitntioiial svmp-
• toms are very pronouuced. The pulse is rapid, the tempemture rises
^wo or three degrees every <l8y, the strength fails, night sweats are com-
nion, and the appetite is usually poor. Cough and expectoration may,
»nowever, he absent or but slightly troublesome if the lesion ia confined
to tlie faucial region. As the disease progresses, constitutional symp-
toms become more and more marked and the evidences of tuberculosis
• iu other organs rapidly develop.
l>iAaNosis. — The disease may be confounded with syphilis or cancer.
^h& esseutiol ]K)int« in the diagnosis arc: painful deglutition, the con-
»*tit«tional symptoms, and the comparative absence of induration.
It is distinguished from ayphiliK by the absence of a specific history,
^y the pain upon deglutition, which is usually much more severe than
in Byjihilitic ulceration, and by the pronounced constitntional symptoms.
Again, when the ulcer is BU[>crficial. its worm eaten and irregular ap-
pearance, with the pallor of the adjaeent surface and absence of indura-
tion, are distinguishing features; and when the ulceration is deep, thtt
ilight induration, if any, the irregular border of the nicer — neither
«vertcd nor undermined and seldom sharply cut — and its comparativelj
i
I
TUBBHCULAR ULCBHATIOS OP THE TuNSILS.
379
light color and grunulnr. easily Llaeilingiinrrace, will genre todiBtingniRh
it from the epwific aflfcction. Anti*gyphilitiR trojitmeviit, when vigorouely
pnehed, nsiiatJy oanses rapid improvement in thespecific disease, where's
it aggravates thp tnbercnlar affection.
Tubercular ulceration of the tonsil is to be distinguished from eyphiU-
tio ulceration by the following characteristics:
Tl-BEBCULAR rU*EaAT!OX OF TONSIL.
Little, irany. dtv^lUnfi;.
Ulcer IB uttualty »ii|>erflcial, not
filiurply dednetl, but may be ileep aitd
irrt'^iilur.
Pain, fyvtT. rftpiVi imlse, asiiiilly evi-
dences of tuberculosis ]» other or^iu.
SYPBrLmC rLCKBATIOK OP TOXRIL.
Syphilitic history; induration.
Ulcer may be superrtciiii or deep,
edges well defined, nmy be imdenuiaed
and everted; indurated base.
Usiially little or no pain or fever,
'vrith normal pulae.
The deep tubercular ulcer is diDtiuguished from cancer of the tonsils
by the coiupuratire absence of induruliou, which is usually prononnced
in oaucer ercn fur several weeks or months before uloeration uikes
place; by the appearance of the eilges of the nicer, which are not everted
in tuberculosis, and by tlio chitracter 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 iimlignant
disease, and is not at all likely to be confuuiitled with it. Paiu usually
oc;ciini earlier in cancer than in tnberculusiv, 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 iu 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 njaybedistiiiguished
as follows:
TCTBBBCnJlR CLCEBATIOX OF TONSIL.
Little, if any, nweUinf;, with pallor
instead of congestion of parts,
Usuully ulcfri8sii|tL'r(ii:iul und irreg-
ular, not iiliar|i]y dellned; whitish se-
cretioDB.
Fain doefl nutoccur until after u1c«r-
stion tiBf) coninteiiccd, mid ih^n is ex-
iwrienced fspecially on swallowing.
Fever, rapid pulse.
Usually no enlargement ©( cervical
£;IandB.
Oencnilly associated with i>ulnio-
nary tuberciilusi»
pROONosiB. — When the disease
easel may be cured if taken early
CaICCEB or THE TOHSIL.
Parts Bwollea. indurated, and con-
gested.
TJtcvration deep with abrupt borders
and reddish or grayish wliite surface,
fetid veHowiRh secrelionn, and fungous
gTanul;itionK.
l*ain marked before, as well as after,
ulceration, and often sharp evenwhen
Uiroat is at rent.
During^ (init few nionthH little if any
fever or accelerutiuti of pulse.
Enlarged cervi«il glands conipurk-
tively early in the disease.
Usually marked cachexia.
occurs primarily in the tonsil, manjr
and given thorough and energetic
380
DtSKASES OF THE FACC£S.
U
treatment; but wlien it develoi>8 subsequeut to ttiherculosia in other
orgauH, little niort! limn lempomry relief of tlie iliseafie can be hoped foi^
Tre.\tmest.— Where the ulueratiun is aecondary to genoral tuberoa-
losifi, conBtitntinnnl treatment it) of the most valno. When the disease
is primarT, deetniction of the affected tiasues by scraping, and the ap-
plicatiou of luetic acid, or the galvano-cautery will oecafiiomiUy be fol-
lowed by perfect recovery. The part should he anjPHtheiized hy cotiaine,
and it miiy then he scraped with the curette, and subsequently the lactic
acid may be applied; but some cases do quite as well if the acid ia
thnrouglily applied without proTiouB scraping. Ijaotic acid is used for
this purpose in strength vnrying from thirty per cent to one hundnnj
per rent, and miiitt he applied daily, anil with thorou^hne&i, for three
or four days, and afterward less frequently for two or three weeks untU
the ulcer lieals. As a ruU^ when the strong ucid is employed, preriotu
carctting is nnnecesaary. If the ulcer is not large and docs not readily
yield to the lactic acid treatment, the surface should be tonched with
the gaivunoH^antery, and subsequently lactic acid may be employed.
For temporary relief, the parta 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 loeal measures are adopted, all sources of irrita-
tion, especially tobacco smoking, should be removed. Constitutional
treutment will be of the utmost importance.
CA?ICER OP THE TONSIL.
Cancer of the tonsil is a comparatively rare affection; but seven cases
have come under my observation mlchin the hist five years, one being of
the melanotic variety. One or both toneila may he the seat of the dis-
ease which commences as a tumor in the substance of the tonsil and
grttdoally and steadily extends, involving not only the whole gland, but
the surrounding tisanes. Ulceration usually occnrs within five or six
months from the commencement. The affection is attended by more or
less constant pain, especially upon deglutition. This is frequeutly Ian-
cinating in character and radiates toward the ear. A pronounced cachexia
is developed in some instances, daring the later portion of the disease.
DlA«NO.sis. — Cancer is to b« distinguished from hypertrophy of
the hnsii by the history, age of the patient, and course of the dis*
ease. Ilypertrophy 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
constitntional symptoms, and is not followed by ulceration; furthermore
unlike the malignant disease, it may l^ist for years without seriousIy^
affecting the patient's general health.
CANVSlt OF TUB TONSIL.
381
(fftncer is to bo distinguished from hypertrophy of the tonsil as
foUoM-a:
Caxcsr of tonsil.
Generally seen in those past mitldle
Ijf*. Iniluration of siirrountlitig' tissues
and congestion. UnilHtcrai.
Late ulceration with reddiiih or
grayifJi whilesiiiTace, Tetid secretions,
fundus frraniiUitions.
Severe pain. IT&ually characteristic
ca<.-hexia.
Hypebtbopht of tonbiu
Generally svvn in children and yotinff
iuliilt». Hy|H>rti'ophy with but little
if auy redness. Generally bilateral.
No ulceration. Whitish dc|.>oKit
found in the lu-iinee, no pecoliar se-
cretion.
No pain. Fre<iiiently open mouth,
dull eye. and Htupid appearance, but
no cachexia.
Cancer of the tonsil »nd syphilitic nlcerstion of the tonsil present the
following differential diagnostic points:
Cancer of tonsil.
Mud) Hwelliag and induration, mem-
brane darkly congoKted. Unilateral.
Late, ulceration with reddish or
pmyish white surface, profuse fetid
iiCcretiouH and iunguus gninulutiuns,
Laucuiutiug puiu.trcqueutly marked
before an well as iiflcr ulcerution.
Usually marked cachexia.
Syphiutic ulceration of tonsil.
Comparatively little hwetlinj; uuti
induration. Uniually bitaterul.
Syphilitic hitttorr. Ulcer may he
superficial or deep and undermined
with indurated biiseand everted edges.
Little or ao pain.
^0 peculiar cachexia.
Cancer of the tonsil is distinguished from tubercular ulceration by the
signs pointed out in considering the hitter uffeetion.
Pkooxosia. — The disease usually runs its course in four to eight
months, and probably is always fata].
Treatment. — If seen early, the tnnior should be removed by snare or
gal vano. cautery ^craseur if possible: or later, if the growth is so lirge
as seriously to interfere with respiration and deglutition, a ttimilar pro-
cedure, though giving no bupe uf cure, Jtiay happily be followed by devel-
opment of the tumor in some other direi'tian less immediatelv dangerous
or distressing. I have seen two rawes iti which removal of the cancerous
tonsil was followed by perfect cicatrization and no subsequent trouble in
the fauces, whereby the patient was sared from much of the distress
which would otherwise have attended the later stage of the disease.
Keceiitly I have Kucceedud in retarding the growth for several months
by frequent injeclions into Lho substance of the tumor of six to ten
minims of a twenty-five to fifty per cent solntion of laetic acid.
After niceratinn has taken place, surgical procedures arc 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. Hi) may be employed with no litUo satisfaction.
Foreign bodies of great vjiriety have been found lodged or impacted
in the phan'nx, the most frequent being pitiues of meat, fragments of
bone, bristles, false tcctli, buttons, coins, uud needles or pine. Some
people iu whom there is inipiiiied seusibilitv uF the mucous nieuibrune
are speciully predis})Oseil to iiueh lofigeintiuts. I<arge bodies generally
lodge at the lower part of the pharynx or tn the vuUeculne between the
hue 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 ft tonsil or in the depressions between the gland
and the pillars of the fauces.
Symptom-vtolouy.— Largo bodioa, unless speedily removed,, may cause
8ufT(K;ution, but this u^^ually onsnca only whuu the substance has beconto
impacted in the larynx or (Fsopliugns. Hard or sharp subsUinces cause
pricking sensations or more or less severe pain, e8pe<iiully on deglutition^
and, iC they remain, intlammation and swelling soon follow. Even after
the body has been extmeted or has passed into the stomach the patient
often complains of similar sensations for some time. Ulceration and
even absness may follow if the occluding substance remains for any
length of time.
DiACNosis. — The diagnosis must be based upon the history given,
und a careful inspection of the jxirt; but it is to bo remembered that
Bensatiuns of pricking or actual pain are often felt even after the eouree
of the trouble luis been removed. Ilysterieul women e^pecijilly, often
insist for weeks or mouths that the foreign body remains, iu tpite of :ill
a&suranoefl to the contrary. It is to be remembered -Am, that small
Indies may actually remain for a long time in the crypt of a tonsil, or in
the vallecnle, escaping observation.
Prognosis.— Occasionally immediate death from snffocation is caused
by impaction of a foreign l>ody in the pharynx. A fatal issue may liko-
■wise reRuli from perforation of large arteries or other vital parts by
nlceration, but often the body is either swallowed or expelled by the pa-
tient's own efforts. In many instances these substances remain several
veeks, giving the patient much discomfort but cot endangering life.
Treatment.— The foreign body should be removed as soon as practi-
HKTttOPHA R rmiEA I. A SSCEHS.
3Ba
ciblo. Unless «een at ohcc, & most thorough and patneti^king exumina-
lion should bo made, with the parts well Hoder the iulluence of cocaine,
and if nothing is found, a pledget of cotton sliould be brushed over
every part with the hope of removing or bringing into view the possibiy
hiddun object. Two bodies, especially in the case of hsh bunes, are not
infrequently present in theaumccuse; therefore if theiinusual senfuitiona
persist, another examination should bo ntodc. As a rule, when the sub-
stance has been reraored, the sensatiyna disappear withiTi 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 tu the application of astringents or silver nitrate.
KETKO-PHAKYNliEAL ABSCESS.
Retro-pharvngeal Hlwoees, is ft circumscribed suppuration of the sub-
mucous tissues of thu pharynx, giving rise to swelling, in consequence
of wliich there is interference witli reejuration and deglutition. The aflee-
tion occurs most frequently in iufunts, having been observed oven in the
new bom; but as a result of syphilis it is eompai'a lively comniun in
adults.
■ Anatomical and Patholooical CHAKArrrKRi.sTii.s.— The abscess
may be located in tlie ])Osterior wall of the naso-pharynx, the oro-
pharynx, or the lai-j'ngo-pharynx. It maybe developed near the median,
line, but in about three cases oat of four il is contiued to one side. ' The
loose atUicbment of tbo mucous membrane by cc-llujar tissue to the
muscles beneath favors the formation uf au ahiiL-e^ in tliis locality and
allows pus to burrow easily in any dire^-tion, though it is inclined to
gravituto downward. Il sometimes extends even to the mediaetiunm.
I recoDpct cue cafw hi which the sinus, left after Uie ab<tc<>wt had opened,
could be traced from tite lower part of ihe oro-ptiaiynx downwanl and baokwanl
ten inches.
The tnmor formed by an abscess has a broad base, and the surface is
smooth and usually not mnch discolored, especially when occurring in
feeble children; though in adnlts an abscesB resulting from syphilis, is
often considerably congested.
Etioloov. — The affection in children is nsuully idiopathic: yet if
the ultimate cause could be traced, it would probably be found tode|>eud
in most instances upon an inherited scrofulous ur ayphililia diuLhetiis.
The exciting cause is often expoi^ure to cold or to the prolongeil heat
of summer. It may follow simple acute pharyngitis, ficarlatina, erysip-
elas, or tonsillitis. In adults it mo4t commonly follows syphilitic diFcase
of the cervinil verteVff. Some caws follow wounds inflicted by swul-
lowing pins, bones, and other foreign aubHtances. It is said to have fol-
lowed stricture of the a>sophagu$, owing to the mechanical irrit^ition at-
tending forced deglutition.
DISEASES OF THE PHARYNX.
STMPTOMATOLonv. — The nffertion usuaMy comeB on somewhat slowlj,
being first iiiflioiited by siilTtioss of the neck, witli deep seated pain,
M which \s referred to tho puhiie when the obsfcss is far uji, but is com-
f motily felt deeper und m»y fxteiid over the entire throjit. Dysjinwa and
dysphagia geiifniUy uriae from niechanicul obetriK'tion, iv result of tho
IBwelling. In children, 'jonvulgivo symplums often uL-ciir. According to
Kokni. idiop;ithie abscess may develop in forty-eight hours, and secondary
'abscese in from seven Lo ten days; while that form proceeding from dis-
eufied bone is still more chronic iu its course. Primarily, the patient
Usually experiences slight chilly senBations, but occasionally distinct rigors,
With headiiche und slight rime of temperature. The pulse ia usually weak
and compreBsible, the head ia thrown backward or inclined to one aide,
■ and sometimes there is painful tumefa<;tinn of the sides or front of Cbe
neck. If the abscess is ]ot:ated in the n;iso-pharynx, it interferes only
with nasal respiration; if iu tho oro-pharyux, it does not affect respira-
tion unless of large size. If, however, tho discuse should be situated in
the laryngo-plinrynx, a comparatively small abscess, by crowding the
nincous membruue forward over tlie larynx, may speedily eiiuse severe
dyspnoea subject to frequent exacerbations and accompanied by cough
and Bterturoue breathing. Abscess in the naso-pharynx gives the Toiee
a nasitl twang, and in the laryngo-pharynx may criuso hoarseness or com-
plete aphonia. Deglutition may be seriously tlisturbod by large abacessea
in tlifl naso-phuryni. Tliose located in the oro-pharynx or laryngo-
pharynx are freijuently attended by choking from tho passage of fluids
into the larynx. Abscesses iu the naso-pluirynx may escape observation
»on inspection, bnt ortlinarily a dusky rvd tumor is visible which is doughy
to the touch, yet somewhat elastic, but late in tho affection may yield
distinct dtictuation and have the appearance of pointing.
DiAONOHis. — A differentiation is here to bo made from croup, uidemu
of the glottis, foreign bodips in the larynx, and cerebntl or digestive dis-
orders c-ausing uonvulsions. Retrn-pbaryngejil ub^coiis is distinguished
• from fedeiiia of tkf gUtftiit hy inspection, which reveals tho phar}-ugea]
instead of lar^'ngeal swelling; furthermore, by lifting the glottis, the
dyspufpa is relieveil in an abscess sitniited very low, but not in a-dema.
Hetro-pharyngeal abscess may be diagnoiiticated from a-dema of the
jglottia by the following points of difference:
4
BSTKO-raABTNOKAL AfiSCCSS.
Pharyngeal swellins.
May be localefi in oro-pharynx or
lai-simo*!'! iur>' D X.
Lifting lur.vnx relieves dyspocnL.
Hay it)terfer« with nasal or obstruct
luiTtiiretd i-eKpirntlon.
Kather tDnidiouf in its dex-e)o|Hn«nt.
Corapurutjvoly long tluration.
ffiPEMA OF TaS ULOTTIS.
Lar>-D.eeal nwelliof;.
LocaleO at (rlotlift.
Lifting lurynx tlo«s not reltova ■
iitm.
Does not interfere with nnval rcspi'm*
tiao.
Cornea on vuddenly.
Sltort duration.
itETUo-PHA R yya eaj. a liscBsa,
as*
Loss of voice or extreme hoHrseneBS, symptoms not present in retro-
pharvngeal abscess, uttend vroup ; in cronp there is no swelling or
iiysphftgia, both of which are marked in retro-pharyngeal Absouss.
It may be distingnished from foreign bmiks in the larynx by tlio
histor)' and signs found by iuspcotiou und palpAtion, together with the
quulity of the voice.
Between retro-phfiryngeal abscess tmd foreign bodies in the larynx,
the following are the chief points of difference:
RETRU rUAaV>'UEAL ABSCESS.
Inspection reveals atiimorio th**orn-
phurj'nx or larynfe*a-pharj'ax. Kather
slow tlevelopiiieot.
No liuurseui-ss.
FOREION BODIES IN THE LARTNX.
History of at-^ident. Iiiitpeot ion and
pu I pat i on may reveal pmtf oce of
foreign body. Sudden obKtniction lo
KHpiiudon or ileglutitioD.
Voice usually inucb altered or lost.
It can only be diagnosed from ronvulitirg dimrders by a carefnl ex-
Hmiuation of the pnrtu imd detection of the tumor.
Pboososis. — The affection neualiy teruiiuutes in recovery, idiopathic
cases eonvuicdcing in from three to five days, and secondary cases in from
seven to tcu duys, though fatal results arc not infi'quent. Abscesti due to
spondylitic luiiy last from tlirec wecka to several niuiitlii^, and usually
proves fiital in the i^nd. In fuvonible cases thu abscess opens spontane-
ously, unless sooner relieved, and with the escape of pus the more violent
symptoms at onro siibBide. Pus may burrow into the areolar tissue of
the neck or into the ary-epiglottic fohls and obstniet 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 lu either instance. Death
has been known to result from ulceration of the internal carotid artery,
Tbeatment. — If the case is seen early, the abscess may sometimeB
be aborted by the continued sucking of ice, or by cold applications to the
neck. When pus forms, it must bo evacuated as soon as discovered. The
incision should he made as near to the median line as possible, in order
to avoid injury to the iuteruid cnrolid artery; and as soon as the open-
ing is made the patient's head shouhl be tlirown (piickly 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 eiigo of the table. An ordinary bistoury,
guarded to within a quarter of an inch of its point by a wrapping of
cloth or iidliL-sivo plaster, \a a good instrument for the purpose.
Tonics and supporting lre:ttment are necessary; the syrtip of the
iodide of iron lieing a most usefnl 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 shonid not be
given unless it thoroughly agrees with the stomach. In children when
25
38U
DI^EAl^ES OF THE PHARYNX
there is u tendency to couTnlaionbf potussium bromide should be admin-
ifitered freely in the eurly itnge.
TUMOEIS OP THE PHARYNX.
Kon -malignant tumora, especially of the papillary rariety, are com-
panitively frecjuent on the pillars of the fiiuces, tonsils, or posterior whJI
of the pharynx. These uHUiilly riiry in t!ize tram three to ten millinK-
tres in diameter. Large fibrous (Fig. 'JT) and Tutty tumoris tire uUo eomo-
timee seen. -Small tumors cause but little incoiiTenience, except oc-
casionally a troublesome cough or sensatio.i us of a lump in the throat
during the act of swalluwiug. Wheu uomiug iu contact with tlie epi-
Tu. Vt.—YxBKawi vw Labtxoo-Pvasynx. TUia woa k Iatkv fibrous growth allached Ia t&»
low«r pArtlot) of the pb&ryDX by a pedlcb- sbiiul lialf ou liicb lo dlunetrr. It «m removed b; th«
itael wtr« sove ibovn to HitMltlnc of uakI l>olypl. rba b«M n* vubMHiuoDUy caatortanl wtth tbo
gulinnu-oaulary. So nscurreoov.
glottis or larynx. Urge growths may interfere with respimtion and deg-
lutition.
Tbkatmknt. — Small growths maybe readily removed by the foroepo^
suare, or gal va no-cautery. Largo formations, if pedunculated, maj be
removed by the ordinary snare, the galvano-eautery ucraseur, or 6craeeur8
of other forms. In cases of large or raerular growths, care mutt be
taken not to cause suffocation during their removal, and aometimea pre-
liminary tracheotomy may be necessary.
CANCER OP THE PHABTNX.
Cancer is rare in the upper portion bnt not bo infreqnent at
lower part of the pharynx, where it joins the (esophagus.
ANATOMICAL AXD pAxnoLOGiCAL Chabacteristiob. — Cancers of
the hirnigo-pharynx usually first attack the posterior wall, and jiossing
around the sides subsequently invade the lar)-nx. They are more com-
monly of the epitheliomatous variety, but those of the pharyugo^ral
cavity are very often of the scirrhontt form.
ftiYMPTOMATOLony.— When the diseiiso occurs io the p ha ryn go-oral
space, it ufiuully causes constant pain, often radiating toward the ear, and
CASCER OF THE PHAKTNX.
387
is grentlv aggravated by dogltitition, especially after nlceration begina.
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 diRicuUy in swallowing, ami aa
the disease advances respiration becomes eniharrusscd. Cancer at the
lower portion of the pharynx usually comnience» on the posterior wall
near the level of the arytenoid rartihiges, btit giadually extends until
'rt involves the larynx, eiuising tumefaction, hwirscncss, and dyspntsu.
Scirrhous growth in the iipper pharynx niukes 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 prugreRiiCiJ, induration txtends and may involve tho palati\ pillars
of the fauces, and even the posterior nares. Ulceration follows and ex-
tends over all the affected tissne, the ulcer presenting :i reddish or
grayish white surface covered with fetid secretion and here und there
fungous granulations. The cervical glands at the angles of tho jaw
are usually involved, comparatively early in the disease. Cancer at the
lower part uf tlie pharynx usually appears first as a gniyish white, fungous
Tegetation covered with secretion and surrounded by a zunt; uf red and
swollen mucous membraue. As it progrfssea, extensive ulceration may
occur, and all tho aurronnding tissues may l>ecome indurated, but tho
cervical glands are not nsually nnich enlarged.
DiAONOsis.— Cancer of the pharynx is not apt to be mistaken for
anything excepting syphilitic disease or fibrous tumors.
We may generally readily distinguish AV/f«".t (jrav-ths by their pedun-
cnlattnl form, firm consistence, and by absence of pain and ulceration.
Ab a rule, ^yphilin can be distinguished by the hiatury, the less anntunt
of pain, tho iirencnce of old cicaitriccH, or by tho results of morlication.
Under the influence of i)0ta8aium iodide given freely, the syphilitic
patient usually increases in weight und improves in general health,
whereas in a person sulToring from cancer, although tins trpatment
may appear to be beneficial for a few days, the wflight does not incresise,
and it is soon apparent that the general condition is growing worse.
TBEATMEXT.^Palliative niensurcs only c^m be adopt^l. Opiates, when
well borne, may bu given intcrntdly in sufficient ^lunntities to relieve
pain. The spray of morphine, carbolic iicid. and tannic acid (Form. fl3)
will be found beneficial from its property of mitigating the pain, modi-
fying the offensive odor of the discharge, and exerting some restniining
influence upon the ulceration or subjacent inflammation. More than
this cannot be accomplished in the present stattt of our knowledge.
W'heu deglutition become!- difticult, food may be administered per rec-
ttUD or by the u>sophageal cube.
388
I>JSEJ.S£S OF TBS PHARYNX.
NECROSES OP THE PHARY>'X.
A^T^STHESIA OF THE PBARYXX.
AnfeBthesia of the pharynx, a rare affeotion, is characterized hy the
patient's inability to feel tho bolae of food, some portions of which ara
liable to remtiiii in the plmryax and subsequontly to bo drawn into the
larynx duriug iiiapiration.
Btioloot. — Transient local ansethesia is produced by the internal
admiiiiiftriition of morphine or thp bromides in large quantity, or by
local or general ana-flthetics. As found in practice, this affection is usuully
a seqnel of diphtlieria 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 como to drend taking anything bqfe
liquids or semi-aolids.
Prognosis. — Fulluwiug diphtlieria, or when asBociftted with hysteria
or acute disease, the prognosis is favorable, but in other instances recoT-
ery cannot be expwted.
Thkatsikxi. — When well marked, food should be given through the
cesophagenl tube. In remediable cjises, tonics and galvunism are indi-
cated, but especially the internal administration of strychnine in large
doses. Wlien faithfully followed out, promising results maybe exjtected.
Str3"chnine should be given in small but steadily increasing doses and
carried to the point of physiological toleration indicated by mild mnscu-
lar spasniB. The dose slionld then be diminished, but may he again in-
creased, aftor a few days, to un amount just short of that which caused
the spasms; this dose may bo continued nith benefit for days or weeks.
UYPER^STHESIA OP THE PHARYXS.
Hypeneetheaia of the pharynx is of common oecnrrcnce, bnt can
hardly be called a di6eR«o. It is often nssociatetl with acute iuflanima-
tion of the pharynx, and is frequently found in persons given to the
excessive use of tobacco or alcoholic stimulautii. It may be produced by
elongation of the uvula, and it is one of the munifestAtions 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 deglutitiou of solids, so that patients prefer to take liquid or
semi-solid food; but usually the condition causes no inconvenience ex-
cepting when tho physician attempts to examine the fauces or introduce
the throat mirror. Hy|)er«8thcsia utlending inflamm.itiun may be re-
lieved by sedative trouhes of slippery elm,altheu, lactuourium, or opium.
PAHJiSrHESIA OF THE PHARYNX.
3R9
The intenml admiiiielration of from tL-ri ti) twenty grain doses of po-
i-ipgiiim bromide three or four tiiiiea ila'tir, uiid the inhulation from a
FToam atomizftr of a solution of the gamo, gr. xx.-xxx. ad 1 \., will also
be found benofiejal; a five percent solution of carbolic acid will also
give a good result, and may sometimes be particularly beneficial when
tilreration is present. To relieve the hypeniesthesia which interferes with
laryngoecopic examination, the sucking of ice for fifteen or twenty min-
nlcs will often answer an excellent purpose, but it may usually be ao
complished more speedily by spmying the pharynx five or six times with
a tea per cent solution of cocaine.
PAS-ESTHESIA OF TUE PnARYSX.
Parsesthesia of the pharynx, a com^mon afTection, is characterized
chiefly by ihe presence of sensations of hent or cold, pricking, or swell-
ing; or the patient may imagine he feels in t]ie throat some foreign sub-
Btanoe 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, eulargcmeut of the follicle-s in the phar-
ynx or of the glands or ve-ins at the base of the tongne.
PitOGNosis. — The patient fihouhl always be assured that it is not a
serious disorder, fur fretjuently be is tormented with fears of cancer; but
be must also be told that the condition, in spite of all treatment, may
remain for uiuny months, though it is likely eventually to subside.
Treatmest. — Enlarged follicles upon the pharyngeal wall, or enlarged
glands or veins at the base of the tongue, should be destroyed M-ith the
galvano-cautery. If tliia does not relieve the sensations, the application
two or three times daily of u apniy of morphine, carbolic acid, and tannic
acid (Form, 93), and the internal ndministration of the bromides, with
nerve tonics, is likely to be most beneficial. The sensations are fre-
qnently associated with rheumatism; under such conditions, anti-rheu-
matic remedies should be administered.
NErRALGiA OF THE PHARYXX may be characterizetl by the same
symptoms as pnriesthesia, hut more commonly by actual pain. It is
often dne to the fame nonditions as neuralgia in Mther portions of the
body Hhd frequently results from the rheumatic diathesis, when it might
properly be termed chronic rheumatic soro throat. The treatment con-
sists of :ii>p]i«:ation3 uf aedalive, astringent, or Rtimulatitig apniys to the
throat, combined with the internal administration of putitssium bromide
and nerve tonics.
890
DlSEASEfl OF THE PHAItYNX.
SPASU OP TBE PHARYXX.
Spasm of the pharynx is a rare ftffection except fls nesoctatpd tpim
acute inflammation of the fauces or hydrophobiu, mul it is tisiinlly ol
the tx)uic variety. The affection is sometimes associated with Kpaam of
the ifsopbitgus, and ts cbamctorized by sudden ejectment of Quid np«n
attempted deglutition.
Etiology,— Pharyngeal epasm may bo due to acute pharyngitis,
tetiinusjhytlrophobiii.. or certain disorders of the brain. It isoceusiunally
& reflex pheiiuineuou occurring ui the course of chronic pbiiryugitis, and
in a mild form may result from swallowing food which is imperfectly
masticated. It may be purely a nenroais, xvs ob6cr\'ed in hysterical jiersona.
Symptomatoixxjy.— The spasm is marked by sudden ejectment of
food on attempted deglutition. It may occur only at certain times of
the day; the patient periiaps being able to eat breakfafit and dinner
easily, but at eupper he may find that be 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 cousiJerable 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 tiible, or, without warning, the food \& forcibly
ejecte<i from his mouth.
DiAftXosis. — The affection is to be distinguished from stricture or
paralysis of the oesophagus and from pandysis of the pharynx.
Solid or liquid foods arc swalloweil with more or le&s difTionlty in
ntnrlure of Hie wsuphttju^, according tir tlie degree of Btenosis, but the
bolus is not, as a rule, thrown out forcibly, though sometimes thie occurs.
In such cases persistent difficulty in the passage of an oesophageal bougie
will settle the diagnosis.
Dyspluigia is present m jMiraly sis of the pharynx or mmiphaptx^'hui
the food is not suddenly expelled from the mnuth. In the sposmodto
affection, acconling to I^nnox Browne (Diseases of the Throat, sec-
ond edition), un important diagnostic sign in protracted cases is ob-
tained by placit)g 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.
Pboonosis.— The affection may last for weeks or months, and is
sometimes so serious a malady as to necessitate the administration of
foo<i per rectnm.
Treatment. — The treatment consists in the ad ministration of tonics
and nerve sedatives, such, for example, as quinine, zinc valerianate,
arsenious acid, potaseinm bromide, camphor monobromidc, and asofte-
tida. If associated with spasm of the cesophugua, the occasional passage
^f an [Esophageal bougie will usually bo found moat beutfici&L
PAHALYHTS OP THE PHARYNX.
3dX
PAItALTSIS OF TEE MIARYKX.
PiiniTrBis of one or niorp of the constrictor miiflcles of tin* phnrj'nx
nijiy liB uiiilaU>ral or bilatenil, jmrtiul or complete. It U phnmctonzed
by (lysplmgiu and the accumiilatinii of salira which the patient is unable
to swidlciw and whicli therefore drips from the month.
Etiology. — The pumlysis may be idioputhic. but the moat common
can&c ie diBease of the medulla involving the origin of the Tagtm and
glosso-pharyngeal nerves. It may also result from other c^rebml dis-
eaaes. It sometimes follows syphilia, cerebro-epinal meningitis, or «nn-
etroke, or accompanies facial panilysis, or diphtheritic paralysis of tbo
tesophagns. It sometimes occurs in iho course of acute febrile diseases*
and is then commonly one of the prer.ursors of death.
Symptomatology. — Amonjj tlie most clearly ehiirsictoristic symptoms
is ditficulty of swallowing, even of the salivii, which constantly collect*
and streams from the mouth. Liquids also are often tiiken with great
difliculty on ftcconnt of ninuinji^ into the trachea and exciting cough
and spasm of the glottis. This is caused by aasociateii p.iralysis of the
depressors of the epiglottis. Deglutition is generally accompanieil by
contortions of tlio neck and face, from the efforts made to iissist the
pRs^go of food. In chronic disease of the brain and Rpinal cord those
symptoms sometimes occur long before the fatal termination. In the
jMiridysis associated with facial paralysis, the uvula usually deviates
towaiil the healthy side, and the palute scarcely moves on phonation.
Paralysis of the pharynx following di]>htheria usually comes on ten or
fifteen davs after convaleecenco begins, and is characterized by dvsphagia,
especially on attempts to swallow lluld. inability to e.vpectarate, and a
peculiar nasal timbre of the voice due to paresis of the palate, with non-
closure of the pjifcsago to the nnso-pharynx. The sense of taste is oh-
tunded, and the velum is usually relaxed U]iou one side. Pandysia of
the pharynx is fre{iuently associated with jmresis of the uisophajrug,
in which condition solids are swallowed more easily than flnidii, and l:irge
boluses than small.
Paralysis of the pharynx ig often one of the eiirly symptoms of pro-
gressive bulbar paralysis. In this affection loss of motion is nsnally first
uumifcstcd in the tongue, lips, and palate, causing at first indistinctness
and slowness of speech, but later, difficulty in mastiwition and finally
dysphagia* with more or less dyspncra duo to spasm of the glottis caused
by entrance into the larynx of liquid or BoHd food. The voice is weak
find often aphonic, and there is inability to prononnoe the labials h,
w, m, p, or the dentals f, d, v, n, and th.
Diagnosis. — The diugnosis depends upon the history, symptoms, and
ngna just described. The continuous character of the paralysis distin-
guishes it from spasm of the pharynx.
PsoGNOSis. — When due to tcmponiry canaes, when following diph-
zn
PIUEASSS OF THE PHARYNX.
therm or other nctite tlMCRses, or vhcit oasociated with facial |HirH]y9:«»
recovery muy be cxpeeti'd; but ciwos Ue^wndeut upon progreesive ttUbur
p&ralyeia always end in tlftitb.
Tkeatmbm. — If food iitmnot bo sir&lloved, it muet be administered
tj means of the u<Hophag«ul tiibi* or |ht reotum. Internally iron, qoi-
jjino, iirBOiiiouH ucid ami Btryt linine, cspeiiuUy the hitter, are indicattd
in mofit (uuw'fl, Atid sometimes ounsitlemble boneSt will bo obtiiiued In*
change of air unil areite. Mere, as In nmi-sthefliaof the pharynx, the moet
pronounued bunofit will iiauull) bo obtuiued fromstryclmiao, iu large and
gradually increiMin;^ doses.
SCALDS AKD fillRNH OP THE PHARYNX.
Injuries by heat arc not iinoommon, especially among chililren of
the poor, in whom tbey freqnently follow inhalation of steam from the
teapot. Tbey are Humetinietf cauited in udulti*, by tbo inhalation of steam
flame, or hut utr, as in buriiihg vi'tiaels or buildings. In t^uch cases the
tongue, polute, ;.inl often tin? narus and oesophagus are similarly affected.
Syhitomatolohy.— There U acute puiu nnd distress in the throat,
with rjuickened pulse and more or less fever. Usn:illy the larjTii is in-
volved, and swelling uiul dyspna'u uro spevdy result*. Cohen states that
when sniuke 1ms biien tiilmUil, the sputum is blackish in colorfor serenil
days (" PiniuiNi-s of Ihn Throat"), Dysphagia is always j^resent.
If JMwn early, the iifTwled parts are of a whilisb color due to burning
of the mucous membrane, and shortly afterward patches of the mem-
brane are found to bo destroyed, and severe inflammation with marked
■welling enines.
DuuNiHiH.— The diagnosis may be easily made from the history,
symptoms, und apptntrunee of the parts.
I'ltodNiiHis. — In many instunees ine aeeident is speedily fatal, and in
all eases where the burn is at all severe the prognosis is verj' grnre. If
the patient lives longenongh, sloughing and excessive suppnmtion ocenr,
and vicious iMlhesions. tngetber with chronic larjijgitis uud stenosis of
the larynx and trachea, ure apt xo follow,
Tkeatmext. — Cold compreeses, with sueking of ice and soothing op-
plications, should l>e employed, mucilaginous drinks being given if they
cttn be swallowed. Xourisbment must lie given by enemata, whei>
deglutition is impossible. If dyspncBa supervene, tracheotomy must
be promptly performed to prevent suffocation. Unfortunately, how-
ever, in these cases the openttion does not often prevent u fuUil issue.
SWALLOWING THE TONOCE.
The so called swallowing the tongue is an extremely rare Aoeident.
Moat of the cases recorded seem to have occuned in ehildren suffering
from whuoping cough. A cose which I re{>urted to the American
PTSEASKS OF THE VAU.ECULJE AND PYRTFORM HINU8ES. 3!t5
Lnryngnlogicil Sooictj at its annnal meeting, 1880, occurred in a ledj
suffering from hysteria. It was chnrHCteriKod by a spasmodio action of
the hyo-gloMUB and prohabJy also the stylo-glossus muscles, which drew
the toDguo into the phar}'nx in such a position us to prevent i'L-»pinttioiL
There was no cough. The accident may prove speedily fatal.
Treatment. — Tlie tongue should at once be drawn forward to pre-
vent suffocation. Subsequently the primary disease should receive ap-
propriate treatment.
DISEASES OF THE VALLECUIiiE AND PYOIFORM SIXCSES.
Ulceration of the valleculw at the base of the tongue, or of the pyri-^
form sinuses of the hiryux, occasionally occurs from injury in swallowing
hits of bone or food, and sometimes from inflammation of the gbindular
gtructore. Ulcers in either piwitioii give rise to pricking sensations and
pun upon deglutition, and tliose in the pyriform sinuseB are attended
also by con«:h. I'pon inspection with the laryngoscope, the vallccnlae
arc commonly found filled with secretions, which must be wiped away
before the cunse of tbe trouble can be discovered, and it is usually nec-
essary to anesthetize the parts thoroughly M*ith cocaine in order ta make
a complete esantinatton.
Treatment.— If foreign bodies are found, their removal nsunlly gives
prompt relief. If uh-era e.xi«t. thev iire genontlly s]>eedily cured by
tuucUiug thorn onuu ur iwiuu with u tiulutiun uf bilvur nitrate, gr. Ix. ad 3 1.
CHAPTER XXIIL
PISEASE.S OF THE LARYNX.
ACUTE LARYNOITIS.
Sffnottymit. — Acute catarrhal larjngilis, cynancRtj larrhgea, atigina
lari'nget^ angina epiglottiJea, iu flam nui lion of the iHrrnx.
Acute laryngitis is a simple catarrhul inflannnatipn of the mtieous
membrane of the larynx, clmrarterizoil by pain, (lyspntra, clyaphonia or
aplioniut KtriiluJous breathing, aiul cough.
Anatomical and Pathological CHARArrrniSTics. — In mild casea
thoro i^ congestion with slight swelling of the mucous membrano, cither
nniformly or in patches; the luttcr are morti commonly fonnd at the
posterior cnil of the vocal cords, the posterior i^ommisunre, or on the vcn-
irioiilar kind. In more severe cuHeH the mucouB membrane is a'dema-
lons and deeply congested, the epiglottis i? thickened and fluccid, the
ary-ftpiglottic folds nro swollen into thick, pyriform bodies, and the ven-
tricular bands may be bo swollen as to overlap und completely hide the
cords.
Etiology. — Indoor occupation, malnutrition or defective excretion,
und excessive nse of alcoholic stimulanis or tobacco, aro among tho
principal predisposing causes. Certain diftenses, as measles, Ecarhitinr,
and variola, also fiivor its occnrrence. Among the exciting causes are
exposure to irriUitiug vapors ur drugs, to wet and cold, or to draughts
of air, also violent cough and excessive nse of tho voice, especially in the
open uir. It is :iUo frequently due to extension of inflammation from
the neighboring mucous membrane.
SYMrTOMATOLO<i\.— The affection usually coivv?s on insidiously, pre-
ceded by a mild rhinitis, pharyngitis, or bronchitis, and is finally nshered
in by alight rigors or chilly ^ensittions. In severe eases there is some-
times a pronounced chill followed by rapid development of thesy;iipto.-n?.
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 n feeling of
constriction, tho tendency to congh und clear the throat becomeB more
IToiiDuneod, and the swelling may give rise to sensation as of a fc»rtign
body. I'ljQ p(,j,j jg aggravated by deglutition, and tenderness is usiiidly
elicited by palpation. At first respirutioii is not affected, hut as soon as
^^clliiig occurs dyspncca comes on, and iu severe caacs hecumes very
I
ACVTB LAHYUQiriS.
o'J5
distressing. The patient cannot lie down, is very restless und indices
fiuiilic cfTorts for breath. At Lliu coMLmeiicement of the atlofik, the fuc6
is fluslied nud the eyes are bright, but, iu dyspntea develops, the face
becoDies livid uud anxious, or of an ashy hne, and the eves prornide :.a
in strangulation. The skin, which is at first hut, purtiuulurly in chil-
dren, becomes cold and clammy; the pulse, \\i tirsi full und bouudiug,
grows weak and Irregular, and the temj>erature rises to 102', 10.1", or
lU-t" F. The voice, iu the beginning hoarse and shrill, later may bo weak
or entirely lost. The cough, at first resonant and clejir, becomes convul-
sive, brazen or croupy iu character, and there is a slight expectoration of
tenacious, glairy mucus until toward the end of the disease, when the secre-
tions become muco-punilent in character, and profuse when the bronchi
are also involved. Children suffering from acute laryngitis are proue to
croupy attacks at night, probably due to the collection of secretions
about the glottis. The tougue is usually white, furred, and red at tba
Rft^ ipu pUHiiiii III tJLOu or VocAi. Ooatw.
liqllMef 90*enA wiib » Tliln wbliult fftiM
Tvi. «.— BrpKHricuu. Ullckatioii op En-
OLCTTiH. Mrrp«tlc ; eovrrwl with a Ihln
tip. Upon laryngoscopic examination, the congestion and ewellin* are
readily detected, and occasionally small erosions, particularly at the vocal
processes, are observed. In rare instances, superficial ulcerations of an
herpetic chnrarter are seen, though these are not apt to be aji^soeiated
with much congestion aud swelling of the parts (Figs. 98 and 'JB). As
a result of the swelling, there Js frequently paresis of the ni-ytenoidons or
of the thyro-arytenoid muscles, giving rise to the gaping of the cords
(Figs. 1S2, 1S3). Occaaionallr, oven before hyperocmia occurs, the patient
becomes hoar^, and upon examinatioit paresis is found to be present
A mild form of laryngitis frequently attends iis^thmH or bay fever.
DiAG.vosis. — The disease is to be distinguished from laryngismus
stridplus, true croup, paralysis of the vocal conls, and foreign bodies in
the hirynx. The chief fealnres in the diagnosis ore hoarseness and
drvnejis and pain in the larynx, with hyperemia and swelling. It is dis-
tinguished from Jonjnpsimts strutulua by coming on more slowly and
being attended by chills, fever, congestion, and swelliug of the parti*
The following are the difTercntiul points peculiar to acute laryn-
gitis and lar)'Dgieniu8 stridulus;
Sf)(l
DISEASES OF THE LARrifS.
ACOTE UlRYNOITIB.
Ooo^eeUon aod swelling of mucous
mem hrune.
Fever.
GcDerally pain.
GraduiU accession, and ol swvvral
dajrs ditratioa.
LjUlVNOiaMCS STRIDCLCa.
No congestiuu or swelliii^ u( raucoiu
membmne.
No fever.
No pain.
Sudden io its onset and short in
duration. Allnck usually at nig-hi;
may not be repeuted.
It is distinguished from true croup by the age of the patient nnd bv the
greater amount of pain, congoation, and swelUng; by the ecauty temicious
sputum and absence of false membrane. Wh«n occurring in young chil-
dren, it is not always possiblf tu iiiukL* an accuntte diagnosis.
Aoute laryngitis ta distinguishod from jiaral^xis of the vocal enrtli by
the pain, congestion, and swelling, which are not present in the hitter
disease: and by the other points presented in the following table:
AciITE LABYNOITIS.
PaiD, coDgestioD, and swelliag.
Voice liarsh; sometimes aphonia for
a brief period.
Short duration.
Paralysis of Tiu vocau cotccm.
Entii-<> absence of pain, coni;e:4ion,
and nweliJnK.
Aphonia pi-onounced, especially if
patient is fatigued; ispi-(>8entthrou(^.
out course o( dtKcase.
Long duration.
It is to be differentiated from foreign fmttujt in the larynur by th#
history and by Inryngoscopic examination.
Pnooyosis. — Mild cases usually pass off in four or five days, and
others iu moat instanced soon yield to suitable remedies; but occasion-
ally the swelling and con8e<|iicnt obstruction of the glottis are so great
as to cause deatli. Neglected cases, or those in M-hich the patient again
exposes himself before the inAammatioa has entirely aubeided, are liable
to end in chronic laryngitis.
Treatment.— C'old compresses renewed every half-hour or hour are
found iiHist ctTet'tive in the beginning of thediseiise. If these fail, seda-
tive vapors or inlmlatious of steam impregnated with opium, belladonna,
or lupulin (Form. 55. oG, 57), together with liirgo doses of potassium
bromi<ie and warm compresses, will be found more effective. The dis-
ease is sometimes aborted by the early atlministnition of ten gniin doses
of Dover's powder or quinine, or small and frequently repeated doses of
the tincture of aconite or oj)ium, one minim evt-ry half-lionr or hour for
ten or twelve hours, or until the physiological effects are obtained, ntid
subsequently less often. Saline cathartics to keep the bowels open are
usually desirable unless the affection is aborted within twenty-four
hours. Iu all cases in any degree severe, the patient ghonld 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-
g«nt sprays (Form. 88, 90, 94) once or twice doily wiU be found very
BUBACVTB LARY1XGITI8.
3ft7
beBeHcial. Somotimi'S eomprcssei] tablets of jiotr.ssium clilonit(* iire also
useful. If OHlcmu occurs so utt seriousJv to impede tlic rffl])i ration, Hcar*
ificition or rupture of the swollea raembrftne is indicated, tliough the
••(•ces^ity for it m:iy sometimes be removed by tulmiuiHt ration of the
nuid estmct of jaborandi. or itH active principle pilocarpine, m sufficient
quantity to excite profuse diaphoresis and siilivation. ScarlficitiJoD is
best practised by meatis of tlie guarded laryngeal lancet (Fig. 100). The
mucous meuibruue may sometimes be ruptured by the finger nail, the
edge of vrbieh has been roughened for the purpose. Severe cases may
rei]uire intubation or tracheotomy. In children where there is donbt as
to the diagnosis, the disease should be managed in the same way as trae
FlO. 100.— MiCXKKEIE'l l^tTXaEU. 'LxTKTCt OS OrdiDUT flili),
cronp. It is generally best in the beginning to give a free calomd
purge and follow this by the treatment suitable for trne croup, iutubftr
tion or tracheotomy being performed as soon as there is serious inter-
ference with respiration.
SUBACUTE LARYNGITIS.
Snbacnte 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 tocongh,
with but little or no fever. The cough is laryngeal, hacking, and
more or less paroxysmal, and the expectoration usnally consists of a small
amount of clear, tenacious mucus. The causes are the same as those of
aimte laryngitis, operating in a milder degree. Upon inspection of the
larynx, more or less congestion is observed, bnt frequently none except
along the edges of the vocal cords at their posterior extremities.
PttO«NOf*i«. — The prognoaiB is favorable, and oftuu the only treat*
ment needed is care as to exposure, and confinement to the house for one
or two days. Even this precaution i& neglected by most patients, yet the
great majority recover within five or ten days.
Tkeatmkkt.— Local and internal treatment fuitnble for mild cases of
acute laryngitis are appropriate lu the subacute fcm, and mild ostrio*
398 MSBASBS OF THE LASTSS.
gent spnjs are ecpeciallr indicated in the latter portion of the attack if ibe
jntient suffers fran boaraenew, tidHing in tbe Uzrnx, or a caidencf- to
CMigli. TTnleH tbe padent is earefal not again to expose bimaelf, tbov
ii great liabilitT to recnrreoce of tbe attack, and, if this is repeated a lew
times, cbionic buyngitis id tbe probaUe aeqneL
TRAUMATIC LAKTSGITia
Traamalic LirTngiUA may lesnlt from tbe irritation caused hj foreign,
bodies, from tbe inbalation of irritating gaaes, or from mechanical injurr
in operations; bat most commonly it occurs in children from swallowing
boiling liquids, strong acids or alkalies, or inhaling £t«am, as, for exam-
ple, in attempting to drink from a tea-kettle.
SncFToiuTOLOGT. — After the accident causing i^ the inflammation
oomes on almost instantaneously, with acute pain, and oedema of tbe
epiglottic and deeper portions of the larynx vhich caoses great dyspnoea.
The tongue and throat are red and angry, or vfaite from detachment of
tbe epithelial layer of the mucous membruie or from plastic exudation.
The oedematoas epiglottis can often be seen vithoat the aid of tbe
laryngoBcope, starding up behind the base of the tongue. It iz Eeldom
poksible to make a laryngoscopic examination.
DiAGXOSiSw— The diagnosis will be easily made from tbe history, and
from tbe appearance of the month and fauces.
Pbogsosi-s. — The prognosis depends upon the extent of the Injury,
bat is commonly grare, especially when the disease resalts from scalds or
fuma.
Treaihext. — Tbe affection can sometimes be aborted by painting
the ;^>arts with a strong solntion of silver nitrate. However, this appii-
cstion ifi not devoid of danger from spasm of the glottis. FoU doses of
jaborandi mar be tried. Constant applications of ice to the neck, and
the sucking of ice, should be practised; or, in its stead, hot applications
or inhahtions of steam. The parts usoally become oedematons in spite
of these measures, and then scarification or tracheotomy mast be prompt-
ly performed.
CHRONIC LARTNGITIS.
.Vynonvm*.— Chronic catarrh of the larvQi, larvngitis 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 mple adults.
AsATOMiCAt AST) pATHOLOOiCAL CHARACTERISTICS.— There is hy-
peremia of the parts, which may be general or eireamsrrihed, shading
off gradnally into the color of the snrronnding tissue. FsuaHy there is
bnt little swelling, occasionally small blood vessels upon the epiclottia or
tbe vocal cords are cnlai^ed, and in rare instances nodular excrescences
cHRONic LARvyoins.
399
are met witK Xot iufrequently slight eri>8ions are Doticed, j»articnlar1y
between the arrteiioid cartiluges^ but often these couiiUt dimply of de>
etruction of the f]nt)ie1inm and cxinnot be dUtinguUhe^l except by the
absence. of the peculiar glistening appearance characteristic of healthy
mucous membrane. Exceptionally RmnU ulcers occur upon the Tocal
cords at the vocal processes (Fig. 101).
In nnusual instances hypertrophy of the 8oft tissues exists.
Etiology. — The disease is occagionully primary, but more frequently
it is the result of repeated attaclc& of acute or subacute mflAmmutioii,
uud therefore is generally duo to like canses. The cxcossivo use of
lobucfo, clirouic alooholisui,. and the conataut inhalation of irritating
dust or ]iarticle8 of metal us observed in metal-griudurs^ millers, and
others, may sometimea be classed as canses. Not iufrequently the dis-
sase follows from over-use of the voice, eapenially in the open air, or
irhen the individual is already sulleriug from acute or suhacute tnfhim*
Fm. Ml.— CATjut«B*i. VicsK or Ti
COMD.
VocUL
Fn. H?.— Cbbokiu Catakkhal I^rykoitu
wrm WroMii-n,
mation of the organ. The diseaae eometimes is a sequel of measles,
scarlutiiia or otlier eruptive fvvsrs, and in rare instances it resulta
from ecfemn.
All long continued uFectious of the larynx, its cancer, lupus, or poly-
poid growths, may linalty set up chronic iufhuuuiatiou. Phthisis and
syphilis are frequent causes.
Syhi'tomatolo<>y. — In some cases the syraptoms are not marked, and
the patient only complains of sometliiug wrong in the larynx, with
hoarseness and ntore or less dryness of the Ihrout. especially after expo-
sure. These patients often expectorate small pellets of thickened mucus.
Sometimes they ure suddenly startled in the niglit or at other times
with a (tense of tiuffocation due to spasm o{ '.he glottisi. and uttcnt'et' by
a feeling tis^ though a crumb of bread had dropped upon the vocal corda.
In mild cases there are no constitutional symptoms, but in those more
severe there may be emaciation, fever, and nipfht sweats, as results of
the disturbance caused by the frequent cougb. Among the common
msations experienced, are pricking or burning iti the throat and a
frequent desirf to clear it. Varying degree;! of hoiirst-ncas are observf-d;
in some this symptom is noticed durinp ordinary converwition, in others
only when singing, and in still others the singing voice seems natural, al-
400
DISEASES OF THE LAJiYA'A.
though the voice is very hoarse in its ordinary use. In otherB dinicalty ii
noticed only on attempts at shouting. Sometimes early in the morning
the patient is very hoarse, but alter two or three hours the Toice becomes
neai-ly nonital as a result of physiologicfil stimulation of the circuUtioa
in the parts. In these cases, the voice usually again becomee hoarM
after a few hours. In some instances taking of food greatly clears the
voice. In some the tones are clear during quiet conversation, and
hoarseness is only expericaced after talking or singing for a half-hoar
or more. In nearly all caste, however, the voice eventually becomes
continuously strained. Persons suffering from this disease commonly
tire easily on attempting to talk for any length of liuic, and with the
fatigue the voice usually becomes more and more harah and uuuatnraL
Tlie 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 voict- for
half an hour. Respiration is not affected, barring those instances where-
in the laryngeal opening is considerably narrowed by inflammatory
changes. The coiigli usually consists of simple hemming efforts to
clear the larynx of small pellets of mucus, but it sometimes becomeii
frequent and severe, especially during the night.
Two kinds of laryngeal cough may occur in this disease: onediy, harsh,
and brasiiy, with little or no expectoration; the other moist, the spntom
being brought np with little difficulty. This latter i)ye is usually asso-
ciated with chronic bronchili^, in which case the expectoration may bo
abundant. As a rule, the sputum consists of simill masses of mueus, gray-
ish in color frum 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-
paireJ, 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 bo noticed on the vocal
cords and the arytenoids, but may involve the ventricular bands or
epiglottis.
Sorootimofl nodular excrescences exist, varying in size from one to
fire 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 tra<thoma. In some cases slight erosions may be
seen, being more apparent by the loss of that *' peculiar sheen " which is
•cen upon the healthy mncous membrane than by a visible depression.
This condition is most likely to occur on the inner surfaces of the ary*
itenoid cartilages just above the posterior ends of the vocal cords. Tha
I
I
CHRONIC LAHYNQITI8.
401
laryng€Jti tnacoiis membruio is sotnctinifs dry, bat, as a rule, the socre-
tioiis aru somewhat iueruiuwd. Often flukes o{ more or less discolored
niucua utay be lieeu udheriug to the cords or slightly sticking litem to
each other^ aiid in other instances a less tenacious .-ind thinner eecrelioa
is seen in a very tliin layer upon the cords and other portions of the
larynx, or stretching between the vocal cords in respiration, but, as bo-
'-^^ "Jm
PiB. loa.— CBuoKio CATAwiiui. LARrmnm.
Fio. IM.— <.'ATAJuuuL LAKvKatTiB mnn ifw-
fore mentioned, the secretion 16 never abnndant if only the larynx is
ivolred. In many examples oi the discjise the trarheal mnrons mera-
>ninc is also congested, and often accretions mar be seen cullectcd upon
its surface. There is as a rule comparatively little thickening of the
laryngeal lisftiies, excepting the vocjil cords, which may bo swollen to
two or three limes their normal size — hut the epiglottis or one or both
arytenoids may be thickened from twenty to fifty per oent.
Id unusual instances all tlie sofl |Mi.rLs are liypertropliieil, and exceptionally
tiic chungos are so great a& to Himtilat« malignant tlUoaitt?, or ag;^ravateO forma
of ityphillLic hii->*ngiti3. It hiLs been siuted Uiat the larynx Kometimes appeara
to be dilated, but I have not seen this condition.
Subglottic hypertrophy, consisting of a grayish welt jnst below the
vocal cord; is occasiouaLly seen, and it is probable that the same condition
Fio. im.— SiJOirT SrMiuxrnt: <£oaiA ix a PimiuiQAL rATmrr.
at the outer portion of the under surface of the cord may acconnt for
8ome of thot^e cases of hoarseness where the physical condition of the
larynx appears nearly or quite normal. This condition might easily
escape observation bocanse of its location beneath the cord. Sluggish
movement of the cords or want of proper approximation, is not uucom-
26
4oa
DISEASSS OF THS LARYNX
^ utonly the result oC mechanical interference vith contraction of the Wyn-
gejil tnuiicles, or thickening unU irregularities of the mucouH membrane.
Tbe glands at the baae of the tongue are quiie often eulargeil, and Bome-
times they seem to stand In n oansativc relation to the laryngitis, (u
Mtnui instances a varicose condition of the veins may be noticed in tin-
same locality. The pharyngeal wnll may be normal or it may be rcluxci)
and studded with enlarged folliclei!, while, again, It will l>e found dry and
glazed, or partially coated with secretion. Perhaps tlie most constttnt
changes which accompany chronic laryngitiB are found in the nasal cav-
ities, which in, the majority of cuees are more or less obstructed by exos-
tosis nr enchondrosis of the septum^ or by hypertrophy or swelling of
the turbiuated bodies.
DlAQXosis. — The diaenae may be mistaken for paralysitt of the vocal
corda, wdema of tlie Lirynx, tubercular or syphilitic laryngitis, or for
cancer; u definite dititinclion only being possible after careful laryugo-
neojiic examination. In chronic catarrhal laryngitis the parts nearly
always remain of normal contour, and are but little swotleti> though
iiiore or less congested; uleeRttiuu is rare.
Constant hoursene&a is caused by pUralyais of the vocat cords, and
dysphonia is especially pronounced when the ]>atient is fatigued; there-
fort* the voice is usually better in the early nioruiug tlian in the evening.
In simple catarrhal iiiflaminatiDn, the hoarseness in generally worse ejirly
in the morning. In pandysis, there is no congostion or swelling, but
there is marked loss of ntovement of one or both qords, in which respect
it differs from laryngitis.
Chronic laryngitis is to be distinguished from paralysii of the vocal
cords hy the following characteristics :
CHBOKIU CATAnKBAL tABVNaiTlS.
Parbi slightly tJiickencd. More or
less congwtJoii.
Slight loAS of movement of cordti.
lIoarMnesR usually most marked in
tlitt monunj^.
1'AllAl.YiUS OP TUE VOCAL OOKDS-
Xo Kwetliii^'- ur coo^estioo.
Marked Idas of inovenient of uae or
both cordn.
CoDstaot hoarseness ; usually less in
tlio morning.
D>*<>|)li(inia especially proaouneed
when patient is fatij^ied.
Swelling of tho mucous membrane is c»u6ed by mlema of I he lar^TW,.
the parts generally apjieariug from three to five times as lai^e as normal.
The mucous membrane is usually pale and ha« a semi-tran6|>areQt ap-
pearance. Sometimes it may be considenibiy congested, but in all cases
it appears as though serum would flow out if the mcmbnint: weie punc-
tured. In these respects chronic laryngitis is quite dlffercu:.
From wdema of the larynx, chronic laryngitis is to be distinguished
as follows:
CHRONIC 1.AHYN0ITI8.
403
>H1C CITARRRAL LARVSdrTIS.
Prolong.'d couret; i^li^lil swelling of
porta, wiUi ntoi'e ur less redoess of
rnenibi-ane.
lleepimUou normul.
CEdESU. 07 TUfi LA8VSX,
Slioit duration ; grt^t swelllog of
porlfl, with chang'e of color; iiicmbmne
pole, »i?iiii-tiiiO!>{Mirent.
Labored re»i>inaion.
Simple cfttarrhal inflammatiou is liietinguished from tuhermlar
iari/nffifivhy llie history, by the coiigtitiitioiial symplomg iind by tho color
and contour of tlie parts. In the enrly Rtage of tnboicular laryngitis
Ihere is freijue-.iily :iii»?mii; of the orgjin iiiul Bometimesof the soft jHiUttf,
insteu! *)( congestion as in chronic catiLrrhal inflammation. In some
c:i8fs, however, tlie color in th^ two diseases is not very disgimilar: but
in tho tubercular affet^tion superficial or occnfiionally deep ulcnration of
the vocal cords and ventricular bands or of the posterior comniissiire.
or the epiglottis, are soon discovemble, which are not obsen'ed in tho
simple ctitarrhal dieeaee. In the later stage of most cases of tubercular
laryngitis there is peculiar pyriform swelling of the arytenoids and ary-
eplgluttic folds, the parts being paler than in he:ilth, tkrce or four times
their ordinary th'.ckuL'SS, and having an appearance of solidity instead of
that of wdemu. Clccnitiou is usually associated with this condition, or,
if not present at first, it speedily fullows. The lo(<i of strerigtli, rapid
pul&e, fever, entaciation, and night sweats of tubercular laryngitis are
very seldom found in the simple aitarrhol inflammation. In the tuber-
cular alTectiou pain is a common and distressing symptom, but it seldom
occurs in the disoaso under consideration. Again, iu the tubercular
affection there are generally signs of disease in the apices of the lutigs.
Simple catiirrhal inflammation and »yjihilitif /tirynyifijt cannot be dis-
tingnished in all instances, especially when there is simple redness with,
slight swelling, althougli usually the history of the case, tho old cica-
tricea in the pliarynx, with srairs or deep ulcers iu the larynx, and distor-
tion and thickening of the organ, which has a pecnliarly t^en<to appear-
ance as compared with a'di.>ma or tuhercnlosia, are sufficient to enaLle
the physician to make an accnnite diagnosis,
fietweeu chronic catarrhal lar>'ngitis and syphilitic laryngitis the
following are the chief points of difference:
Chbokic oatarrsxi. LARYNnmS.
No specific hiatory.
Normal contour of parts.
No evidences of ulceration, punt or
present.
SYruiunc i^BV:!om8.
Syphilitic liiston,'.
Sonielimes distortion of ports by
old f(ciitrlce»or ihickening^.
Mucous patches, scant, or ulcers g«n>
eratl7 present.
We find mnlirjnafif dtseriHe of iht inrf/nx usually attended by more or
less pain and marked in the beginning by ciroumscribed congestion
which is speedily followed by tho development of a neoplasm, that '
•ndMllT »clvwic«, inTolring, as a rule, »U of the tieanes urith which it
fomrmin conuct, causing distortion of the larj-nx, and fimill}' undergoiug
Jm) Blwntioo. Catarrhal laryngitis never has this bistor)% thou^^h I
lkav« s^ru * few (^B^ i" which tlie swelling und disiortiou of the paru
w*r* strongly suggeetivo of malignant disease. In such iustancea notli-
- Ijjjj i-v>i>('inueil obaen-ation of the cjise for some time will enable iho
phT«tcimn lo m*kt' an accurate diagnosis.
The diffi-rrntiul diagnosis of chronic cuturrha! larvugitis and malig-
(dtsMM of tb" larynx is as follows:
Malignant dkcass or lartkx.
Circiiiti4M:rilioil D'dnos.i anil sWelUa^;
contour of imrlii iiiuchcluit^'U.
I'roiUKi need |«iiii.
AphoDia ami Oysphaf^ia.
Evehttiully ulocruLion. with offen&ivi^
tMnchargv.
CKMCOO CATABBIUL t^RYNUmS.
Hodinta uiii'-jrn* coiisestiou and
H^>»«en«s, but no d>-s(»liasla,
No ulcemti""!.
Piousosts. — The disease I'snall]' nina a rcry protracted course, last*
Snc for months or years, though there is a strong tendency to iuiurove*
Bient at times, with subsequent recurrence (,f the niuro pronounced
STinptoms. It rery rarely, if ever, terminates fatally; yet there is sonio
reason for believing that very protr-icted iiin:inintation, after involving
Ihr trachea and bronchial tu>K.*s in greatly debilitated patients, may
eTcntnally terminate in uonRumption. The tlise-asc is not intraeuiblo if
tli« exciting causes can be removed and the predisposing tendency cor-
rrotod.
Tueatmest. — In every case of chronic laryngitis it is the first duty
of the physician to remove the causes if possible. With this end in
TieWf the excessive use of tobacco and alcoholic stimulants, and some-
timiis even the use of tea and coiTec, should be interdicted and the oon>
dition of thedigestivi' organs must bo carefully regulated. The patient
must avoid all exposure to damp and cold, or t»j the vitiated atmospheru
of crowded rooniii;. Ho must avoid the inhahition of irritating dast and
gases, and must keep the stin and other excretory organs in a healthy
condition. The ]>artd involved aluaiUi he pliiced. as nearly as posiiible, at
l-xest, especially during all acute cx.icerlHitions of the discuue. Singing,
ehoutiug, and excessive use of the voice, especially in the open air, must
te prohibited; and when there is much irritibilHy of the parts, the
patient should converse only in whispers. There arc some cases, how-
ever, of a chronic low grade of tuUuiamaiion that sceui benefited by
niodenitc use of the voice, wliich stimulates u How of blood through the
]>arlfi,atid thus promotes ubdorption of iullammalnry jiroducla. I'aually
prolonged systematic trcatmont. consisting of repeated applications of
stimulating sabstanccs. will be necessary before the disease can bo cured.
TheTarious substances used for this purpose may be applied in the form
CHRONIC LARYNOITIS.
405
of poTFdcrs, sprays, or pigmcDts according to the tolonincc of the patient
Biui ilio iuclinution of tlie pliyslciun. Ab u rule, sprays give the pationt
less inconvcnJctice aud arc on the whole preferolile, though oct;ii6ioiially
puwdent answer an excellent ]>urposo. iind sometlnies pigments, espe-
cially when iipplied by mouns of a cottun i>rob:Liig (Fig. 107). are very
cffectnal. Thesn applications slioulil bo made, when possible, every day
fur one or two weeks, until cunsJderablc aeuto cougeslion o? the parts
has been excited; tlieu ouee in two days for a week or two, and after this
leeu frequently, accurdiug to the improvement of the oase. It is well
r
Tta. 106.
Fm. IOT.
Pio. inc.— Daviinuw's ATUMizxxfl, Bkt No. mt, ron UrrrcK Use (1-3 »lz9). ForIb« vpeviAUiit,
to whom tlmetdaoctijc^-t, U will 1n> fnuiid prt^f'-rnUla to lu*e these botrivehi'M liyBnuptii Ri^rin^-
dl|i to tb» eilfce of n niuAt. TtiM tnciVtly uriLh wliii-b Uw tljM may he chitii«4(l to Uirow * apray lu nay
dlreictlaa tiiHkm enrh of (liitv boltlM cquirakMlt to four of tbe «ntn'E«r rubes to coouiKMi UM.
rbcy iMfty Im ubhI wlib t her hard nibtNTrattachmpolsliowaattwitaia ot vut tiutuumooareMieotljr
irllb lite Darldaon cut-oir.
Fio. lur.-IitaALR' LAftTJiaut. AppLir*TOR tcopperstftir, l>-SBlaPl. The cation shnuld Ijc wnoBd
Aniily upiin tha point, aod tu prevent the |M>uiihlIity of ncddent n UirMd aliould be tl«d about it
will) a iilip-kuut anJ wuuikI abcut (Ins HUifT up b^ ih« handle.
also to have the jiatient at tho same time aso weaker applications to tho
larynx by gprjiys or inhiiljition each morning and evening. It will he
found thiit ililfereiit Imynges vnry excec<lingly in sensitiveness, so that
an application which will cause uo discomfort whatever in one may in
another produce extreme pain. It is therefore necessiiry to try weak
medication ut finst. und always to regulate the strength by the effect,
wbicli amy be judged quitt« accurately by the sensations of the patient.
Applications which are ma<le by the patient himi-elf should never
cause discomfort for more than twenty or thirty miiiutvs. Those made
1
40G
DiHEASES OF THE LARYITX.
by the pbyaiuian, if dully, should not cause einurtiiig for morv than an
huur, uud, if every ttecoiid day, uot more thun two houre; in either coce
jirtuul ]min ttliould not lust more than ten or fift4-'4^>n miiiuEvt;. The par-
ticular remedy to be employed i*, as .1 rulf, :i nuitttr of little cob8»>
quuiice, the objoct being merely to stimulate the mucous membnim;
though it wilt hxi found that in some ciises oue substtinoe niil really
work belter tbiwi any other. In most iiistitnces a change from time to
time will hii«teu recovery, for vbere a single agent is ns«<l for a long
jH'riod the jmrts appear to become so accustomed to It that it hiu but
little effect upon thera. The tupiciil remedies commonly employed in
this diaeaso consist oi zinc sulphate or chloride iu solutions rarying
in strength, from gr. ij. to xxx. ad 5 i- of distilled water; solutions
of iron chloride, iri. Ix. to cw. ud 31.; iron und aniuionium sulphate,
gr. v. to xxx. od 3 L, or copper su1])hnte, gr. x. to xx. ad 3 i.; silver
nitrate, gr. x. to 3 ij. ail 3 i.; tannin, gr. xxx. to Z i. nd : i. Tinctnro of
io<Jitio or turpentine, the fluid extract of thuja occidontalis, and vari-
ous other substances are h]mo in common use. The zinc and copper
saltji have proved most fiitisfuctory in my
hands. Usually in tlie bt-gjuning I njiply u
spray of a solution of zinc i-ulj-hate, gr. ij.
ad 3 L, and if this c:iuscs no discomfort a
!imall quantity of a solution of gr. xxx. ad 3 i.
is appliw] immediately afterward, antl should
no smarting result, a more thorough nppU-
ei:tion of it \& made, the aim being to produce
M..MMMMUM ^ reliction which the patiu-iit will fetd for one
Flo. ioe.-P*nt«oi«*»ATo»niKB. or two liours. At the next visit the solution
No. mi. ouiSnrut, stMwTur. Loxo may be modified according to the effect which
luLS been obtained, and the time that it has
been felt. Other remedies may be oniploycd in the same manner. 1
usually make these applii^tions in the form of epniy viih an air pres-
sure of thirty or forty jwunds 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 recommi*nded by some authors are in most cases objectionable,
because of the spasm of the larynx and tho great discomfort they cause,
while their beneficial effects are seldom greater than those of milder ap-
liliuitions. For use at home I give the patient weak solutions of similar
astriiigenU (Form. 88, 02, 94). These the jmtient applies cold with
some suitable atomizer.
Steam sprays seem to cause relaxation of the parts, which farorssnb-
oetpient inflamnuition, and therefore they are not recommended. Uow-
ever. tliey may sometimes be used with more or less henefit at night
or when the patient is noi going out of doors for one or two hours.
«;nnox Browne particularly reconiisends such inhalations us benaoin.
CURONW LARTTiUITia.
phenol, creosote, or camphor. If these are nsetl irith varm water, the
piitient must not go out ot iloora for some time afterward. They iiiay^
be employed in some uf ttie liglitcr oils, as for cxanijilu. liquid
alholcno, and applied hy means of some of the rarioud nebulizers or
fttomizei"s 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 aoid, iodoform, iodol, berherine muriate, gum
benzoin, myrrh^ alum, zinc snlphate. and silver nitr.itc. Boric acid and
iodol or iodoform in equal parts constitute a very useful stinniliint iiud
antiseptic application in some cases. Itoric ncid alone is slightly more
stimuliiiing. Equal parts of gum benzoin, bismuth, and iodol or iodoform
make an exoidlent jfowdcr, still more sllmuluting. Tannin, in the pro-
jiorliuu of from two to ten per cent, vrith sugar of milk, is sometimes
useful. One part uf berberine muriate to two parts of acjiciii forma an
excellent application for certiin cases, especially where there is a relaxed
condition of the mucous membrane and enlargement of the folHclca.
Equal parts nf alum and sugar of milk answer well when a decided
effect is desired. Silver nitrate 1 never employ in this way, though it is
recomiucndcd hy good authority. With most of these powders it Is well
to combine about five pL-r cent of pulverized starch to prevent jiackiug,
and all of llurni should be thoroughly triturated. Stimulating or seda-
tive troches will often bo found beneficial; of tlie former, troches of am- .
moninm ctimponnd, kriimeria compound, or benzoic acid componnd are
excellent exanijiles ("Forms. U, -JfJ, 4S). Of the sedative troches wo
have laotuoirium, tcrpin hydrate and cannabis compound (Forms, '.ill,,
33), or morphitie, antimony, and ipecac compound (Form. 33) are good
examples. M'hen cough is a troublesome feature, sprays of potassium
bromide 3 ss. to ' L ad ; i. will often bo found very uaefni.
Irritating cough may sometimes be readily relieved by a few light'
inhrtlatioTia of chloroform; for this purpose a small bottle may be given
the patient to carry in his pocket for use us nccdcc^. Aside from tliia
local treatment, it will often be found of the greatest importance to
cure coexisting disease of the pliarynx, base of the tongue, or nasal raiv-
ities. Enlarged glands at the base of the tongue, or varicose vein^,
should he niduced by cauterization. Follicular enlargements on the
pharyngesil wall must be cut down by the cautery, and hypertrophio
rhinitis or exostoses of the septum must be met by projwr surgical pro-
cedures. Other forms of inflammation or obstmotion in the nares or
pharynx must also be remedied, for the laryngeal disease enn seldom be
permanently curod while these affections remain. In some insbmces it
will lie found ilesirahle to apply caustics, sneh as silver nitrate, chromic
acid, or the gulvano-cautery point to enlarged follicles In the larynx it-
self. In such cases the larynx shouM fir?t be thorongbly anmsthetized
by a twenty per cent or twenty five jier cent solution of cocaine, and
then the application should be made accurately to the parts diseaud,and
4m
DISSASEH OF THE UiRJSX.
to DO otbeff cure being taken tbas ibe esoterirUions mn nerer extensiTe
or MTere. After any of thcK upcntiotu the jatieot fifaoold apply cold
conipro— ea to the neck ior from tirelre to tucntr-foar honn, to pivreot
nod at) reaction.
TRACHOMA or TUB TOCAL CORDa
SjpumjfM' — Chwditu Inberon.
Tnehoau of the rocal oorda is » chroiuc inAoimnation of the Umiz.
characterized hj rooghness or a granoUr appearance of the rocoX buds,
with iome swelling, and more or leas alteration of the voice. It it
fonnd most frequently in siogers, bat raaj ooeur in otben. I hare seen
oDe case in the person of a farmer vbo nsed his Toioe very little m
ringing.
Akatohical axd Patoolooical CBARArreusncs. — The dist-aee
appears to consist of hypertropbr uf the connective tissue, which resnlti
in a oodnUr or gnnolar tbickeniug of the cord.
Tm. la^TbCBOHA or Vocal CMm iwxtnaA
EnoLOOT. — No e{>ociat oanses of the affection ure known, aside frt>m
repeated over-nne of the voice especially when the larynx is congested.
Stjiwomatouwt. — The symptoms are those of chronic laryngitis,
Ce., hoarseness or aphonia, with more or less ooagh and expectoration.
Vpon lar>iigoscoiiic examination, the cords are found congested and
thickened, and presentiug u nodular appenronee (Fig. 109) of the sur-
face, with uneveiiiietis of Che edges.
fliAuNosiB. — The diagnosis will be based upon a history of chronic
huyngitis, vith the physical appearances just mentioned.
PnooN'(K*is. — TIjR duniiion may h<! months or years, bat prolonged
rcfll and judicious treatment will ntiuully promote a cnre.
Tkeatme.vt.— The treatment consists of the application of mild
oanstics or mincTal imtringenu tu the *amo nmnner as recommended fur
chronic laryngitis. liy this course, peri^ij-tLMitly carried out, a cure may
usnally be effected. Owing to the obstinacy of this uffection. Carlo
Lahui, of Milan, haj recommended flaying of the vocal cords, or, in . '
words, stripping off of iheir hypertrophicd nujouna miMubnine by n.
of ordinary hiryngeal force|)a (.l/Y/titr» */ Lurgngohtjtft IB80), Oharles
PULEBECTASm LARYNeSA.
409
K. Sftjoua, of Philai]eli>liiii, line rppommended touching Rmnll areas of th&
cord with chromic acid at intervals of several days (Transactions of
the American Lnryngologipal Association for 1888). This treatment
seems to prouiiiic well uud shoutcl bo given n fair triiU uftor the ordinary
meusuros have proven nnanceessftil. In applying the chromic acid, a
very small portion should bo fused on the end of a guarded applicator
Fia 110,— IxnALA* Oiriinaif Acid AppLtrAxtm xvn Haxduh <1-S tixai. Thw l* n I<jnic AlnniinluiB
wtrf, iimpnrly ciiriMHl tin- •m-wpcnJ with t1i» fnin-lnl nnirlr. nnd jrunrded BMh« imd I>r n pkc" of
niblvTluljiiiif w'hii-li |>ti>leciH IJm- iinriN lint lit ■»■ linirlinl fmn) riintact villi Ibe njEMit. Ttir- lilt
o(nibtM-rtiil*inKi<ipr«rrat(st from vltpplo^ cDC hy a »llk tbrcud which Is UedftlMUtK owl tvviuDd
anmnd Uto xteia up to Uie hwxUn,
(Fig. 110) with wliioh the part shonld be accurately touched, the larj-nx
having first been antes thetized by cocaine to prevent injury to other
parts.
PHLEBBCTA8IS LARTJiGEA.
Plilcbectasiii laryngea is a variixise condition uf tlio laryngeiil veins,
chaructorized by mortj ur 1b9S altBruticu of the voice and dist-uuifurL In
tlie larynx.
AXATOMICAL AND PATHOr.ORICAL CllAHACTERIRTICS. — In mild CaSOS
I fine Toins are seen running along the epiglottis and the lower portions of
I the ventricular bands; in niort? severe t-aaea the enlarged veins appear
I tortuous and extend also over the vueal cords and arytenoid cartilages.
Tn. 111.— IjiOALH' G*LVAMO<'AVTBiiT ItAKPLE tH abet. In this Urn circuit iiclowdbrmoTlii^
tlM floRvr from the mnlAK IwtUiu.
EilOLonT. — There is no known cause of the disease.
Symptomatology.— Tl>e patients usnally complain of nneasy sensa-
tions in the luryux, of sliglil coiijitli. lui'l of more or less hoarseness.
Diagnosis. — Tlie diiignosiw id madu by careful inspection of tho
larynx, caro being taken not to luistjiko for cnlurgod veins tho blackened
mucus which Boraetimes nollects upon the surface.
Treatmknt. — Topical applications of strong astringents may be
made, but the most satisfactory treatment consists of destruction of
SHAKf S- - ■=.f>/llTH
410 • DISBASSS OF TBS LARYNX.
the Tein by repeated small canterizations with the galvano-cantery, »
period of from ten days to two weeks intenrening between the open-
tions. Intiu-laryngeal caaterization Bhoald be made with an electrode
provided with a small fine platinnm tip, which will heat or cool qnicklj.
The best handle for this purpose is one in which the circnit is closed
on relieving the pressare from a spring (Fig. Ill) instead of by the
iiMiiul metliod of pressure; this allows the circuit to be completed with.
the least movement of the electrode;
CHAPTER XXIV.
DISEASES OF TilE LARYNX.— £^i/in?«d:
MEMBRANOUS CROUP.
Synonymt. — Trae croup, exudative laryngitis, menibmnoua larj^a*
git is.
Croup, ill the atrtct sense, is \\ disease of the laryngcml mncnus mem*
brane chamctcnzed by the exudation uf infliitnm:itory lymph, forming
false membrane, an<l attended by more or lesis nuiKcnliir fipitsni of the
larynx. Mackenzie and t*ome other authors, together with a large num-
ber of the profession, believe it idertical in nature with diphtlieria, but
] am convinced that tlii-sc arc two distinct diseases. ^Lost of the older
writers, and not a few uf the more recent, agree with Aitken, who says
■of this i-.flfctiun: '' Any one who Imti seen much of croup iu children can
have no difliiulty in recognizing it aa a disease Olstinct from diphtlieria
in it« attack, itii (-our&e,aud results.'' I know of nu U-ttrr dr-linition
for the dirit^aiic ttian that given by Tjennox Browne (Diseases of the
TIjroat, Hveotitl edition), who detintu it iis a pseud o- membranous inllara'
niation of the air paHtuiges, non-itkfectiouB tind non-contagious. The dis-
«a80 occurs most frequently in uliildren betwe«n two and seven years of
nge. It seldom occurs iu older cbildruuT and i& e.\lremely rare in young
infants and in adults.
Anatomical axd Patholooical CnAnACTERisTTCS.— The inflam-
inati:>a is almost entirely conGned to that portion of the larynx above
the cords. The falitc membrane, thougli deposited partially ufion the
epiglottis and ventricular bands, is mainly ftmud ulmnt the glottis itself
and upon the vocjil conls. The inflammation may extend to the sub-
mucous tissues, resulting either in spasm or paralysis of the lanrngeal
muscles. The false membmne i*i comparatively thin, only involving the
epithelial layer of the mucous membrane, whereas in diphtheria the
whole thickness (»f the mucous membrane is affected.
Etiolouy.— Those wlio believe in the itleutity of diphtheria and
croup attribute this to a speciflo contagium, the action of which, how-
ever, they admit may be favored by the usually renognixed cjinses of the
diseuaes. In some instances there is undoubtedly a strong hereditary
predisposition to the disease, and in a large number of caiM?s its onset la
certidnly favored by acnle laryngitis. The disease is also favored by
poor general health. Thcra is little doubt that the majority of uises are
Al'i
VIUKASK^ OF TUB LARTNJT.
by
directly due to improper t:lothiiig or to life in damp, chilly, and
ventituted rooms. The disejtHe U pei-utiarljr prt-valunt in the spring
fall months, when tlie outdoor tennieraliire is bo warm thiit it is hart
necessurv for :ipiirtiiieuLH lu hv liL-iited, Uici'tjforo ut thifl time tuHUj
houHCB Jiro kept at a lempenilureof from 60" to 65° F. Tiiuadults,
are working about, and who aro necessarily in higher strata of air tl
the childrL'U playing ujiun the floor, du not notice tlie necc-ssily for mi
warmth, but the little ones become chilled, u sli>;lit catarrhal luryngitw
auperveniMJ, and, whether or uot this is the direct cause of eroup, it oer-
iuinly favors ihn development of tho falsa membrane. The disease U
not t^oTitagloufl, ami it seeniJi to liavo bepn sjitisfaetorily demonstnited
that it cannot bo inocubitod from the false membrane, though M
kcnzie and others hold contrary views. Tho theory that this disoi
18 often tho direct result of certain ptomaine* generated within
patient's own body seems to mo reasonable.
SrMrroMATOLOOY. — For tho sake of convenience iu description,
disease may be divided clinically into three stngcs — a caUirrhal, nn oxn^
dative, ami a sulToeative.
77((! catarrhal stage is usually preceded for about forly-eight hoi^|
i' a feeling of malaise attiMided by slight fever and anorexia; later
there is considerable fuver, cough, hoarseness, and s<ime dyspitcna. In
the latter i)art of this stage the false membrane begins to form. ■
In the rrndfitire Ktage the false membrane is being gradually 3^
rapidly deposited in the hirynx, spasmodic action of thu muscles to-
comes more frequent, and dyspna?a moi"c and more severe- There is
citlier hoarseness or complete nplioniu, and cough may or may not bo
troublesome. Finally, the nicmbnine becomes so thick as to seriously
obstruct tho glottis, giving rise to the last stage.
[n Ike. aufforatii'e ^/aye, dyspnopa is constant, but still more or less
aggravated at times by spasm of the laryngeal muscles. As the stage
advances, all of tlio symptoms of gradual suffocation supervene, and
finally, in tho majority of cases, tho patient dies from the effect of im-
perfect aeration of tho blood.
In tho first stage tin- tcraj>eraturc is miscil from one to three degrees,
and tlie (uilse is (piickcncd from twenty to thirty beaia per minnte: yet
frequently the friends may not notice these symptoms until tho child
is suddenly wakened at night sti*ugglin^ for brcjith. This puroxysm,
wliieh is due to spasm of the ijryngcHl mneeles, continues for n few min-
utes, and then rcay i>aeaoff till the following night, or other attacks may
opcnr from time to time during the same ni^ht. In the interval be-
tween the attacks the child br«ithes wich compamtivo ease and soon
falls into a troubled sleep. It usually plays about tho house on the fo|.
lowing day, but more or lees hoarseness is notice<l, and at night all of
the symptoms become more aggravated, i^gain, there may be an Inter-
mission iu tho symptoms during tlio day following, and it is not un-
ytBMJiRANOrS CROUP.
413
usual to find the ohiUl rnnning about the houRo nftor a Becond night of
suffering and unrest from the paroxvBms of true troup; but on ihe
succeeding night tho sufTocativo stjige genornlly begins, in whieli there
is constimt djspncea, with occasional paroxysms which add greatly to
the distress. The spasms uro less pronounced than iu the catarrhal
stage, because earbouic acid poisouiug renders the muscular action t>lug-
gisb. There are scnie iinfortuiuite caiiHii, however, in which the dtseuso
runs rapidly through tho three stagehand many terminate fatally within a
few hours, lutiio exudativo stage, hoursene&s is persistent, there Is a pe-
culiar shrill, harsli cough, which needs to be heard but once to be remem-
bered, and ocrjisiunally partiek'S uf faUo membrane uro cust off. Fevei
and anorexia are usually preseut, there is cunslaut'dys{)nu.'!i, and inspira-
tion and cxpinition uro both prolonged, ej!|)eciully the former. The sufftv
cative paroxysms now become more fre<}uent and severe. At the onseb
of one of these, the child suddenly springs up in great ahirm, the eyes
stand out like those of one in strangulation, tlio nostrils are dilated, and
the respiratory musL-Ies tense with tho violent effort at inspiration; in
a few seconds Lhc counlonuuce becomes livid un<l the child almost ceases
iu efforts to breathe; but finally the spasm relaxes, air agiiiu eiitei-s the
lungs, lividity disappears, and respiration becomes unre mure normal, so
that uxeepttug for the liDiirsenetiS it would hardly be kuowu that the
child was ill. Oue such attack usually lasts two or three minutes, and
may be renewed after ii short interval of rest. Kerurrenee in this man-
ner piay titko phwc several times; but usually after the first three or
four paroxysnts tlic chlhl falls into a rcstle-ss sleep that may last for sev-
eral hours. H the larynx can be examine<l, we find it congested, with.
lioro and there patches of thin, yellowish white membrane upon tho
surface. Iu this stage tho child is extremely restless, throwing itself
about the bed, or every few moments asking to be taken up or laid
down in its fruitless searcli for comfort and the oxygen it needs. Thi^
face and gcnend surface are ashy pale, with lividity of the Hps and
finger nails; tho skin, which has been lint in the Jirst and seeoud
fltages, remains so iu the eurlior [Hirt of this the third stage, but latct
becomes cold and is bittht-d iu a claintny perspiration. The ]}u]so is
Cjuick and snmll, the voiee weak or lost, and the t-ough fi'uble or sup-
pressed. The tongue usually is coatcdj aud there is much thirst, but
no desire fnr fnoil.
In the first stnge of the disease tho respiration may be accelerated, ae
in other catjirrlial affections of the mucous memhmne, but in the later
Btagos the breathing becomes slow and hibored, and with each inspim-
tion there is sinking in of tbo soft j^artji of tho chest. Tliis is most
marked at the lower end of the stiTuuni and over the false ribs, but it
is also noted in the interclavicular nutidi and just above tho clavicles.
DiAOSOsis. — True croup may he mistaken for catarrhal laryn-
gitis, laryngismus stridulus, or for diphtheria. The essential points
jtJSSASES OF THK LAUYPfX,
-. ?, jy^,. graduully iticreiibiiig lioarsencBS, slight oonati-
^!mI cnii»nBis* HvBpn** *"^ ^'i** formation of false niombrune
ll»c*«*nr^ to iho lurynx.
T7 g^ifffhal hrvHi/'f'" flicro is commonly considoriible pain ia
^. imrttking. oV sffttllowing; thery is but little tlyspuu^a, the
!-^*hArt (ind sliari'i there is no expeotomtion of fidse membrane,
^»^iii»kine"ibf diujfnosia, but it is diflkult or quite impossible, in
** * f t«i nr obscure instancea, und tlierefore donblful cases should
l-lix«tedii»crou|i.
Km acute laryngitis the disease is to be distinguished by the char-
^tcriTtk«I'rt-pentea below:
nfipinktion Sfldoni becomes slow and labored; all of which
tjjstinguis'i it from croup, la typit^al cases there is no difS-
J|8J(»RA50U3 CKOt'P.
a«i,cmlI.V occurs iocbildren.
Slight pain in eougliing. spealtinif, or
•wallowing-
C^ugh l>»i-s»' «■"' striduloui.
Harked dyspnu-a.
Slow. hU)ored rcspiralioiv
ftise membraue in laryiut.
AcifT« LABYJI0IT18.
Cionorally occurs in adnltJi.
Mai-kPi) congeRtion of parts^ Bill
MarlctMl pain In ooughini^, speakiag',
and '^Witllowm^.
Cough sUarpaQtlsliort.
8liglit dvspuiru.
Ite«(pinition nearly nunnol. or mag^
be increased io Irequem y.
Tenacittus, soanty hputum, but no
false membrane.
tartfntjimiinn yfridulus differs from iTOup in tliut it comes on sud-
denly when thti child is apparently well. It is not attended by infiam-
mHtiou. "r quickening of the paUo, or fever, and the dyspnoea passes,
off in Q fow minutes, Icsiving the ehild breathiug with perfect etwc until
another paroxysm occurs. Sometimes the paroxysms are uot repeated.
^ «uon lis the attack is over, the voice iHSTooies normal.
From laryngismus stridulus croup is to be distinguished as follows:
MKMBRA^tOt'S C80UF.
Sli);bK;onge»Vion und swpllinif.
Fever, rapid puis*-.
,. Slu^r in development.
l«abor<iHl and slow respiration, but
fth irikroxyams of more ]>rononDc«d
kdyttpnupa,
Aplionia and dyiiphonia constant.
Prescuco o( fulxit rnvnibrani.-,
Comfmratively lonj; dur.ition, usu*
ally two or three dajit.
LAKTNDiaMUfl. aTRIDtn.U8.
No t-ongestion or swelling.
No fevf-r, pu)»e normal except dur-
ing paroxysm.
Sudden in its ouaet.
Attack may not be repeated ; res-
pirution and voice normal except dur-
ing ifaroxytin).
Voice normal except during* brief
paroxysms of dyspocra.
No False membrane.
Shurt duration.
IfEyfllRANOVa CROUP.
413
uruaI to find tho rthild rintning about the house after a second night of
suffering and nnroRt from tho paroxj'sras of trup proup; but on the
eucoeedicg night the Rnffoftitive Btiige genonilly begins, in which there
is coustiint dyspnceji, with occasional pjiroxysms wliich adil greiitly to
the disticiss. The spasms are less prouonnced than in the ciitarrbal
atagc, because carbonic acid poiiwuiug renders the muscular action sJug-
gteh. There are some unfonnnute rases, however, in which t}ie dieeiise
mns rapidly through the three st^tgfSunU many tennin;ite fatally within a
few hours. In tho t-xudative stage, hoarsent'ss is persistent, there is a pe-
•culiar shrill, harsh cough, which needs to bo beard but once to be remem-
bered, aud oCL-iiti ion ally partick-s of false membrane are cust oil. Fever
and anorexia are usually pri-senL, there is constant- dyspiia-a, and inspira-
tion and expiration are both prolonged, especially the former. The sulTo^
cative paroxyBma now become more frequent and severe. At the onsek
of one of these, tlie tdiild suddenly 8i)ring8 up in gr<!at alarm, the eyes
stand ont like thosoof one in strangulation, the nostrils are dilated, and
the respiratory muscles tense with the violent effort at inspiration; in
a few sccondii tho countenance becomes livid and tho child almost ceases
its efforts to breathe; bui finally tho spasm relaxes, air ugai:! enters the
lungii, lividity diiiappfurs, and respiration becomes outx- more normal, so
that cxeepting for iUv hoartjene^a it wutilJ hardly be known Lliut the
child was ill. One such attack uiiually Lists two ur threo minntus, and
may bo renewed after a sliort interval of rest. Recurrence in this man-
ner piay take place several times; but usually after the first tliree or
four paroxysms the chilil falls into a restless sleep that may last for sev-
eral hours. If the larynx can be examined, we find it congested, with
iiorc and tiiere patelies of thin, yellowish white membrane upon the
surface. In this stage the child is extremely restlo&'if throwing itself
about the bod, or every few moments asknig to be taken up or laid
down in its fruitless search for comfort and tho oxygen it needs. Th<f
face and gcneml surface arc nsby p:ile, with lividity of tho lips and
finger naiU; the skin, which has l>een hot in the first and set^ond
atages, remains so iu the e:trIioi' part of this the third stiige, but latei
hecoiiu's c'dd and in ImtliLHl in u clammy perspiration. The pulse is
<jui(!k and small, llie voire weak or lo^t, and the cough fticbto or sup-
pressed. The tongue usually is coated, and there ia much thirst, but
no desire for food.
In the first stage of tho disease the respiration may be accelerated, as
in other catarrhal atTcctions of the mucous membnine, 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 tho chest. This is most
marked at the lower end of the t-ternum and ovur ihe fidse ribs, but it
is also noted iu the interclavicular notch and just above the elavlcles.
PiAUXosis. — True croup may be mistaken for catarrhal laryn-
gitis, laryngismus stridulus, or for diphtheria. The essential points
MEyrSRANOUS CROVI*.
417
practirablo. A steam atomizer may bo kept oonstantlj nrnnicg in the
room for the purpose of siitiirating the air with moisture, and the
patient should be induced to inhale from it directly two or three times
an hour, for fire or ten rainntcn. For inhitlation by means of this instrn*
mont, solntions of sodium bicarbonate gr, v. to x. ad 3 i., the saturated
solution of lime water, lactic acid gr. xx. ad 31. to dissolve the membranei,
or potassium bromide gr. xx. to xxx. ad f i., or the aqueous extract of
cpium or belladonna gr. i. to ij. ad ^ i. may be employed to prevent the
paroxysmal dyspnoea. Emetics are employed for the puq)06e of me-
chanically dislodging mncns and false memhnine from the larynx, and
relaxing the muscular system so as to prevent spiiama of the glottis.
For this purpose tartiirized antimony in the form of the compound
syrup of squills is probably the agent most frequently employed. It
should be given in doses of m xx. to xxx. repeated every fifteen minutes
until vomiting occurs, or until its depressing effects are noticed; but the
doso uhould not subsequently be repeated for severul hours. Ipecac iu
some form Is used for the same purpose, nud it has the advantage over
tartiirized antimony of causing no subsequent depression. Zinc sul-
phate, alum, and tnrpeth 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 doses of grs. i. to iij.
Emesis usually follows its administration, in from five to twenty minutes,
rulverized ulum, gr. 11. ad 3 i., mixed with honey is a prompt, safe, and
not unpleasant emetic iu these cases. Mercurial prcparulions have been
recommended for the purpose of limiting the formation of false mem-
brane, and within the List few years mercury bichloride has been much
employed in comparatively large and fret^ueut dose^ I prefer the mild
chloride, wliich is more easily managed and quite as effirient. Tnrpeth
mineral is also used by some physicians in smtUl and repeated doses for
the same purpose. In children one or two years of age, I frequently
order one graiu of calomel to be given every hour nntil it acts upon the
bowels, and subsequently every two hours for ten or fifteen doses. A.
healthy child of this age will usually be sjreedily purged hy one grain of
calomel, hut- in croup about twenty grains iiill generally be taken
before the effects of the remedy are noticed upon the bowels, and then
it does not act -rigorously. Thus, these patients often take from thirty
to forty grains of calomel within thirty-six or forty-eight hours, and
I havo never seen any deleterious effects from its use, but have fre-
quently witnessed the moat gratifying results in (ho relief of the laryn-
l^eal symptoms, tlnfortunately, however, in the majority of oases, no
matter what external applications we employ, or what internal remedies
are adminiBtered, the dise:ise goes steadily on from bad to wo^e; the
glottis becomes narrower until finally suffocation is imminent, and then
we must resort to surgical measures or the child is lost.
Maokensie recommended a croup brush in which the hairs run toward
27
41K
DfSKASES OF THE LAItVNX.
tho hrtndlc, ilesigned to bo introdaoed llirougli tlie glottis and withdrawn
80 lis to iiielotige tho false membmnp. I do iiot know how efHoient this
Ijus pruvod, lull it has not become popular with the profpssion. In a
few iustnuccs an ordinury CAtheter has beon parsed through the glottic
by wliich the putienl hus been enabled to obtain sufficient iiir to support
life. In thia uxtroinity we should not temporize, biH alioiild roaort nt ouct*
to O'Dwyer's iutnbation, or to tracheotomy, either of which, if performed
early, vill save many lives. In children nnder fire years of age intnba>
tion seeniB to offer better eliances for recovery than traebootomy: there-
fore it should be advised, and because of the eu»e of its perfommncc, the
readiness with which the consent of pureiits is obtained, the sjieedj re-
lief uffurded, and the urotdunce of an uniesthetic, it nuiy be recunimended
in all cases, for it is no bar to the subse<|uent performance of trache-
otomy if that operation xhould seem necessiiry. The best ciises for
either of tlicso operations are those in which the menbrane is confined
to a small portion of the larynx and where the Ciirbonic acid poi«oiuiig
I
1
Tta. IIS.-
I'DwTKR'a iVTi'UTiox iNaTiwuEATs 1I4 aiM!). H, AppHMlor; .^t Obturator;
H, B, Tubt<H of rnriouii iIum: C, C, actual cntllbiv<if tuboa.
18 not very pronounced ; when the ditllcultj of respiration has continued
for several hours, giving rise to pulmonary atalectasis, or (pdetna, nr to
heart failure, little can be hoped from either. When the glottis bconmes
BO obstructed that there \a falling in of the soft jiarts of the rheat witli
each iiispiratian, and respiration is long and labored, the lips blue and
the skin pale, there ahoubl Iw no delay in Jidojiting surgical meamres,
for every hour then will materially lesson the chances of recovery.
Intvhtifion is performed by imaina of the instrument (Fig. 113)
devised by Joseph O'Dwyer, of New York. His set of instruments cou-
eists of six tubes gmduated for children less than ten years of age. It
contains a gauge for measuring the tiilies to determine the proper size
for any given age. an applientor for introducing the tube, an extnctor
for withdniwing it, and a mouth gag: the latter, however, is not as satis-
factory as some others, bocjiuse the chiM it> somelimcs able to displace it
fnim between tho jiiws and may bite the operator. But the other Jn-
stniments, which were the outcome of long itnd pjiiienL exjierinienlH-
tioD, are so nearly perfect that it has been difficult in any way to im-
MEifBJUNOVa CUOUP.
410
prove npon them. Heiirotiw'B, Waxh»m'H. or AIlinglKim^s gHgs (Figs.
\\'^, 114, l]r>) ai-e jirpfpniblo. In prtparing for the operution, the child's
iige having Ihwii iiBrcrtTiin&il. the propi^r tnho i« stOpct^?*! :in(I n strong
threail jihiiut thrpp Toct. in length is jmsiif^ii through Ihi- rvrlor in its hertd
and the ends are tied together; the a]>plloiiior is then screwed into the
ohtnratnr, nnd tliis passed tliroiigh tliu luhe ready for the npcratjon.
The head of the tnim is bevelled eo that one gido is niindi t^hufter than
the other, and this sliort side should hu jfla^'i^l toward the hahdle of the
^^-A-
f\
Tto. lis.— RmnoTiM's Oau (^ sl>6).
Fk». lie— Waxbam'b Qui (MUu),
instrument, bo that when introduced into the larynx it will cnuform to
the poBition of the epiglottis. The child, wrapped in a blanket or slieet,
which is pinned <!loiio]y abont the neck so that itii arms are ]iinioned,
Bhonld he held in the arms of the nurse, with its head agatTist her left
shoulder. The gag is then insertfd between the teeth upon the left
side, and intrusted to the assistant who x^ to hohl the bead. The o])i-ra-
tor's forefinger of the left hand should he oiled or smeared with vaseline
to preveut iuoeulution through any ubrusions upon the surface iu casa
Flo. lift.— AujMOSAH'a Mcnrm Oxa m stsei.
the diMttse shoald prove to be diphtheria, and a broad nietftltic ring or
a rubber finger cot the end of which has been cut ofT, should be slipped
orer the finger to prevent the jtatient from biting it in case the gag
ahonid l)eoome displaced; or in the nltaenre of these, the finger may fie
wound with a strip of idoth, which will answer the purpose fairly well.
The tnbe with the applicator, having been dipped into warm water to
bring it to blood bent, i? re;i<iy for introihiction. The ciiild's he;id being
thrown sligiitly baf-kwiird and held firmly by the assistiint. the operator
introduces the forefinger of the left hand over the base of the tongue,
IHSKASJiS OF THIS LARXNX.
dowu bohind the epiglottis, until he feele the arytenoid cartilage, upon the
upper edge of which the finger is rested. The tnlw is now gnided down
along the palmar surface of the finger until it reaches the hirjnx wheu,
the handle of the applicator being elevated bo as to turn the end of the
tub© further forward, it is passed into the glotlia and crowdwl down-
word about half an inch. At the fianie time the end of the finger which
is reeling on the arytenoid is brought upward and pUc«d npon the
upper end of the tube, which is forced downward as far 00 possible
The slide upon the applicator is then shoved forward, the obturator dis-
cn'niged and the applicator removed, while with tho finger of the left
hand the operator crowds tho he:id of the tube faiHy into the vestibule
of the larynx. Not more than ten seconds shouhl be consumed in this
operation- if in this time the operator does not succeed in introducing
the tube it is better to withdniw it and allow the child to breathe for
a moment before making another effort. As soon as the tnbe is intro-
duced the child usuailv coughs, and the regpiratioii gouorally has a
neculiiir tubular sound, whioli indicates tlut the tube has been placed in
^ . , . if this sound is not heard, the opemtor should feel
tho air iiassiige; '* tuto »"• i
• f tho lube to ascertain whether or not it has been passed into
FIft. 116,— O'DwTi™** GxTRACToa (M BUe).
.. fpgophagns instead of tho larynx. If not in proper position it must
'iJViLhdrawri by the string and another effort made to introduce it.
If in proper pofiition. It should bo allowed to remain with the string
ttnchcd for a few ininutPB until respiration tiecomes thoroughly estab-
lahed 8"*i ^^^ child luis finished coughing. One of tho threads should
theu bo oat near the lips, tlie operators forefinger carried down to
the bead of tho tuba to hold it in position and tho string withdrawn.
The tube is left in the larynx, where it should remain for from two to
alx days, unless it should become partially stopped by dried mucus,
as indicated by diflliciilt breathing, or unless subsidence of the symp-
toms leads us to believe that the swelling has gono down and the false
membrane disapjtcared. In many cases the lube will bo coughed out as
BOon as the necessity for its further use ceasee. When it beoomee neo-
esFJiry to remove it, the child is phiced 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 bo felt to
strike against tho end of the tube. It is tlicn moved about gently,
DO force being used, until it drops into the opening of the tuba : the
blades should then be separated and firmly held while the instrument
tho tube are being withdrawn, especial care being ubeerved not to
MEJtfBRAirOU8 CROUP.
431
relax tho pressure juat as the tube is being turned out of the pharynx,
fur, if tins is done, the instrument will slip, and the tube may cither fall
back into the larynx or be swallowed. It is well to have at hand n pair
of forcepB for the purpose of seizing the tube in case the instrument
should slip at this stage of its withdrawal. Special care should bo takcu
thut uo pressure is mude upon the licad of the tube iu attempting to
introduce the extractor^ for the tube might possibly be pushed belov
the Tocal cords, an accident which has happened in a few cases. After
intubation, meronriala should be given freely for twenty-four or forty-
eight honrs> as already ndvised, and care should be taken that when
the pationt takes fluid uono of it passes iato the trachea, an accident
liable to set up pui'umonia, and one whlclt is probably responsible
for many of th« deaths which occurred iu the early days of intubation.
When fluid of any kind is taken while the child is in a sitting
position, u cough almost immediately follows, indicating that «iome
of it has po.ssed into tho air pasaages. To avoid this, the most effec-
tive plan is that recommended by Frank Cary, of Chicago, and in-
troduceil by \Vm. E. Casselberry, which consists of placing the pa-
tient supine with the head much lower than tho body, aud feeding
it from a nursiug-bottle or through a tube. In this position flu.d can-
nut run into the traclioa, but will be forced up the oesophagus into
the stomach. Soft eolids 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.
Tho child may suck small pieces of ice if it wishes, to quench thirst, or
it may bo gi^'Cn 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 tho false membrane is forced below
it iu thO' trachea, aud sutfocatiou becomes imminent. If tliis uccura, the
tube should be ut once withdrawn, wl)cn it usually either brings the
membrane with it or tho latter will be speedily coughed out. If this
sliould not occur, tracheotomy should be done at once. Because of the
liability to this acciflont, 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
bo satisfactorj-; but there are, all told, many cases among these older
patients, especially in diphtheritic laryngitis, where tracheotomy would
be advisable.
Trndtcolomij k so thoroughly described in all works on general sur-
gery thut I need only mention the essential points as they have im-
prened themselrea upon me. The instruments which are liable to be
needed are: a sharp pointed bistoury, a scalpel tho handle of which
should be flat and thin so that it may be used iu teariug through the
connective tissno, a blunt pointed scalpel which may be used in enlarg-
IflSEASMS or TBS LAHYSX.
i^Tnnr i» ^^ niches thfw t«jmctila.a ftrong groored director,
if "* y!"^^,ji* wrenl *rt«nr fon*ep« and spoogc holders, aevend
«■ """'"T njailea. and * niitoble dctoble tracbeotomj Guiala> which
|gi^ <«nwi I— ggtu in it, for such hu opcuiiig fftTora the furmu-
■fc**'* t_^-,^ tiane *l ibe apper eyd of the inctsion in. the trachea,
*>••*■'**.. jiro retrnctorg are also needed for holding mpjirt
.-a»BO( needed.
like Tcrv much & pair of rat-toothed
for taking ap and tearing through the eonnectire tlssac.
**Sr!l^i^t"ehoald be placed upon a table before a good light, and,
J^l^iaed, a rolling pin wrappt-d ■about with a loirel (or some
'■■'* f^™— Hi ahonld be placed under the shoulders and neck, in order
0"** the head backward and raise into prominence the anlenur
*" - mcheal region, aud give a gwwl field for the operation. Ether
■nP"^ -nJorm mav *» used us u general anaiithetir fur tliia ojwration;
^ i!** I tter is generally preferred c*i=p*'rially for children. In miult*
^^^ ' rta roav be sufficiently amwthetisteil by the hypodermic injection
the f» Hropp of a fo'ir per cent whitiun of rocaine along the line of
■ -^ thraeor four minutes before ^leoperutiuu (Form. 1*0). The
'^'^'"tor stands at the patient** right, with his right hand toward the
****** t as he faces the head, the patient being between him and the
I* The first cut is made by pinching up a transverse fold of the
^f r*r the trachea, transfixing it with the sharp pointed bistoury and
t' a out so ii« to niake an iucieion about two inches in length, ex-
^^ ^inc froni a hitle above the inter-clavicular notch to the cricoid car-
laffe. Ky this the Buperfiqial fuse ia and adipoce tissue are cTposed,
IjSi ihould be worked through with the back of the scalpel or with
th aid of the rat-toothed forceps and grooved director, ftccompanie«i by
little cutting ns posaiblo. We then come down upon the dense fnscia
roveriug the muscles and importjint blood veseels. At this stage of the
Deration 1 hiivo derived great benefit from the rat-toothed forceps, with
which i g"^*!' '^'^ f'**^!* ""d twiet out a einall piece, thus making a hole
into which the director con be iiiscrtod. With the director, and handle
of the scalpel, the fascia cao mostly be torn through, but sometimes
iMirtious of it will have to be cut ujwn the grooved director, in doing
which great cjirc should be taken not to incise a blood vessel which it
foav be diflimilt to detect when stretched over the director. Thus
working throngh the fascia wo come ujwn the muscles and engorged
bloo'i vort(ti?l8, which must he separated, by the handle of the wsilpel,
the director, and the finger, and pUBhcd aside, where the assist^int
should hold them by nienns of the retractors. A thin layer of fusi'ia
covering the trachea itt thus exposed; this should be carefully divided
vrtth the biick of tlie sc^ilpel before the windpipe is opened.
During the operation blood should be carefully mopped away, and if
voiuH or arteries are accidontally cut they fthonld bo ei»ught by the
" forct*!^ ""d turnetl aside. In working onr way through the soft
MBMBHANOVa CROUP.
433
tissues down to the trachea, wq come upon tho isthmus of the thyroid,
somctimcR found considerably enliirged. This nmy be crowded out of
the way upwurd or dowuwiird. In either direction that is most conven-
ient, though upward is usually best. Sometimes it is hu nuir:h in tho
way that it ia uucpssiiry to piisu a double ligature, tie upon eacli tiide, and
cnt between. Tlie ligaturf m:iy be easily passed with the aneurism
uccdlo- If we succeed in rcrtching tlie trachea without much bleeding,
it will be seen aa a round, yellowish tube al the bottom of the wound.
Olid may also bo readily felt by tho Gngor. About this time the putiotit
ia liable to cease breathing, apparently from the elToct of the atmosphere
on the pneumogastric ner^-ea, and it frequently becomes necessary to
complete the opt'nition at once. However, if time is allowed, the wound
should be sponged out and all bleeding checked beforo the trachea is
opened. From the efforts at respiration, the tracheii. often moves up
and down convulsively, and it must bo seized and held firmly before an
incisiou c:in bo made. Tho best way to uccomplish this is to pass a
tenaculum ju^t below the cricoid cartilage, or first ring of the trachea,
and draw it upward and fi»rward. The point of a snilpel should then
be passed between tho rings of ihe trachea at the lower portion of the
-wound, and a cut made upward, dividing three or four rings. 1 prefer
to divide the third, fourth, and fifth rings of the trachea rather than to
make either the high or the very low operation, tis the high incision comt-s
too near tho hirynx, and tlio very low ts rnurc diflicolt becanse of tho
det'p situation of the trachea. Care should be taken that the point of
the scalpel does not jmss far enough through to injure tho posterior wall
of the trBche:i. As soon as the cnt hns l^een made, air will he heard
hissing in and out nf tho trachea, and tho knife should ho turned sidewiiya
to separate the edges, and held a few ficcouds until tho patient obtains a
little air; but aa soon aa possible the i.-ut edges of tlie trachea should
bo caught with tcnacuhi and the wound drawn ojien. 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 tu
be drawn back into the opening. As soon as the patient bticomea
cjuiet, the large bent needles, which hnvo been previously threaded witli
strong ligatures, arc passed, one through each side of the edges of the
trachea, the needle is removed, and tho threads arc tied together so us to
form two loops by which the trachea may be held open. These are often
found exceedingly useful during the ueit two or throe days, providing
the tnlto happens to be displaced, for they relieve us from tho neceasity
of holding the trachea open, with tenacnia or with special instruments
devised for the purpose, during thercintrodnction of the tube; further-
more, il at any time the tube should be accidentally displaced, tho nurse,
liy 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 ns can be eonvenieiitly worn by the patient, never less than
4S4
msSASBS OF THE LARYNX.
tk quarter of an inch in dinnieter, may now be introduced, it having Snrt
been dipped into warm water to bring it to the tempcrutore of the bodj.
Tliis is a part of tho operation frequently found difiioult. apparently
eitlier from tho surgeon's luiving imperfect means of liuMing the iro-
cheal wound open, or from having only cut two rings where an opening
through threo ia necessary. I liave never experienned any difficnitf
in introducing tho tube, a good fortune whjcli 1 attribnto to the use of
the ligatures for holding the cut edges of the trachea apart and to
making a suiticieutly Urge opening. Ueforo the operation is b^gun,
la]>es about eightc-ea iuchea in length should bo sewed to the tnidioil
tube; when it has been placed in the trachea, thesu ure puased about
tho neck and tied upon one side so us to huld it firmly in place. In
oaae tho wound is too small, it will not do to try to crowd the tube
into the trachea, a procedure very npt to force it into the cellular tissue
in front; but tho soft tissues should be drawn away from the lower end
of tho wound and another ring cut^ if necessary, to introduce the lube
easily.
A probe-pointed scalpel ia generally used for enlarging the wound
and may be employed for mnking the main cut after a slight puncture
with an ordinary scalpel; in this way all diiriger of cutting tho pos-
terior wall and opening through into the u?sophagiis maybe a\*oided.
If the false membrane has extended below tlie opening, before the tube
is inserted an effort should bo made to rcniove all of it thjit ia possible
with Trousseau's tracheai forceps, or hy ]K»8sing down into the trachea
a feather, or with tho forceps a strip of linen one end of which is held
fay the hand, thus causing i\w imtient to cuugh and remove the blood
and false membmne. The tuW Imving boon inserted, the wound aboTo
and below it nniy hv dmwn toir»Mlier by uno or two stitches and covered
with a strip of Hiiticeplii' (iwuio drawn under the rim of tho collar
of tho tube to pn'vent U fr^^m irriUling the neck. A atrip of doth
may then ho tio^l hM*dy ftl»i«»l iho nei*k and a large piece of gauze folded
over it and allofl-«l li> full ''"wu over the opening of the tube, thus pre-
venting the iwtient fnm» coughing out blood or mucus upon the bed-
ding and attond(Uit#. After the opemtion is eomplptiMl, the inner of
tho two tracheal tuho* •hoiild bo removed and carefully cleaned every
half-hour, for the flwt twenty-four hours, in order to prevent it from
filling with iiitplMa*eil mucus. Subsequently it may be cleaned
lees froquenll.v. hat it should always be borne in mind tbat it muet be
kept free. After the opemtion, the temperature of the room should be
kept at about HO " K. and the air moist. If the accretions show a tendency
tti ilry, tho patient may inhale from time to time steam impregnated
with lime, soda, or tho various other remedies already mcntionefl. In-
ternal iLdministmtion of medicine calculated to prevent extension of the
fjilan membrnne should be continued as before. The patients, oven
*hoii the operation haa been done for diphtheria, usually do exceedingly
I
I
JIEJlJiHANOUS CROUP,
425
well for twenty-fonr or thirty-six hours, and breathe so easily and rest
BO comfortnbly that the friends think a euro has boon effected; bat at
the end of this time the development of bronchitis or pneumonia or the
extonsion of false nicmbranu will oftt-u «viuo« Itself to tbu physician by
increased fever, quickened respiration, and renewed signs of impurfect
aeration of the blood. When tii«sp Bymptonia occur, the diaeaae usually
goes on from bad to worse until death comes ut the end of fifty to
seventy hours after the operation. If the ea^e 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 bo
worn some hours before an attempt is made to remove the ranul».
When this is removed, the sides of the wound, as a rule, readily fall to-
gether, and within a few hour« 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 eilver nitrate. Sometimes, after
tho tracheal canula lins been worn for months, it is found on attempting
\i& removal that the patient cannot breathe, by reason of spasm of tho
gloitia or an obstruction from new growths at the u]»per part of the
wound. If gRinulution tissue is found in the trachea, it must be
removed beforo a cure cnn be effeetod, hut to overcome tho tendency to
spasm, no metiiod has yet been found so satisfactory as the introduction
of an O'Dwyer tube, which will generally be coughed out, or may be
removed wilhia forty-eight hours, and may not be needed afterward.
Wlien a tmcheal canula haa been worn long, it often becomes necessary,
espeeiallv in a Ihin 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
dmwing thoni forward and stitching the edges together. In performing
tracheotomy, chloroform is preferable to ether as an onasthetic, because
of the profuse secretion excited by the latter, and it is probable that in
these cases it is quite as safe. When carbonic acid poisoning is pro<
nounced, no anicsthetio is needed, but at other times una^sthcsia is im-
portant, not alone for prevention of pain, but to kttcp the patient quiet.
In adult-s who are not timid, and in some children, loc^l nrifpsthesia,
qnite sudioicnt, may be obtained by injecting under tiie skin along the
line of incision a {qvt drops of a wewk solution of cocaine (Form. 140).
Kapid Trachkotomy.— In extreme cases it sometimes becomes im»
perative to open the trachea at once; for this purpose various instru-
ments h:ive been devised. Somo surgeons recommend that the child
bo placed upon its face at the tiide of the table, tiic trachea steadied
with the thumb and finger of tho left hand, and the akin, fascia, muscles,
blood vessels, and tracheal walls divided with a single cat. This proced-
ure has also been rec"^m mended for ordinary cases in place of the care-
ful dissection generalSy practised, but the danger of hemorrhage renders
it extremely objectionable except in those very rare cases where not a
436
DTHEASES OF TUB LAUYNX.
k
second can bo lost, and an intubation 6«t is not nt hnnd. Hook^like
trucfacotoniL's (?un8isting ot Mu<lc8 that niiiy be opened iifter the tmrhea
hns been iier/oraUnl. iitid which will 'lius cut a siiMiL-iently large opening
tu inlrodiioc thi> tracbeiil tube, have also bot^tn recuntmendetl, but thej
do not niiiiil with fiivor among HuigeuuH. An ingenioiu trucar which
enables the operator to loare the canula in tho trachea lias been derived,
but tho oannlu is too snmll, and I consider it a dangerous instmment,
which is Hkely to canse 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 grmtest care, serious hcmorrbagu
will sometimes be encountered, and unavoidable accidents may so deUy
the opei-ation that breathing ceases before it is complcteil, and it may
become necesflary to open the trachea hastily before the superficisl tis-
sues hiive been clearuil away. For the avoidaiurc of hemorrhage, great
csire should bo exercised in tearing inettMid of cutting through the super-
iicial tissues, and if by accident n hlood vessel is opened it shonid be
caught immediately with artery fnnjeps, and if large it should aubw-
qnently be tied and the Ii>;atiire cut sliurt; if small, it may bo twisted
sufficiently to prevent hemorrhage. If during the operation the patient
stops lireathtng, at least fivv or ten seeond;^ may be eafely consumed in
opening the ti-ai'hea. providing artiiioial ret^fiiration is tlipu established:
therefuro tho surgeon should not bo precipitate in his incision. In these
cases the surgeon will sonietimes be able, by keeping np artiticial rei«pi-
ration, to restore a ohild apj)arently dead for lifieeu or twenty minutea
There is dangor from gradual oozing of blood into the tracheal wound
aflwr tho tube has been introduced, but usually this is stopped by
the introduction of a tracheal canula. Secondary hemorrhage sorao*
tinit'H otrurs; if it takes place, ilio canula must be remove<l and the
bbtMling vessels tied or twisted. The danger from the extension of the
diReiiJio to tho lower air i)aB8agei«, and the development of bronchitis or
ptumnionitis, cannot always bo anticipated, but it is bestguarde*! against
by earo to prevent the entrance of blood or other foreign tiubstanoe
into the air passages, by keeping tho atmosphere of tho room warm and
moist and by tho judicious administration of intern.il remedies. The
tracheal canula is not infrequently conghedont; this is best proventfld
by having a long tube which will pawt into tho trachea three-quarters of
an inch beyond the cut. Many patients hnro been lost because of seere*
lions collecting and drving in the tube; this can only be obviated by
airefnlly and frequently cleansing the inner tube. A traclieotomixeil
patient must be left in the care of the best possible nurse, and every
detiiil should be carefully watched by tho physiciiin until all danger is
piisst'd. The prognosis should always be guarded until convalescence ia
iuUy established.
CnAPTER XXY.
DISEASES OF THE LARYNX— CoK/miW.
PHLEGMONOCS LARYNGITIS.
fiifnoi
-Sub I
of the
hscesB
ptiruknitu.
arynx,
luryiigitui
mt/nis. — MI timiicoiiH laryngitiB, diffuso ab;
iHryiigitis ^^'''^t}""'"^^* laryngitis KuhmucoBa
8ero-piirii)enta.
IMilogmoiious Inryngitie is a nire affection, in which infljiinmiH.ion
ftttitcks tlio submiicons tissues^ causing suppuration and iieerosi^, with
the formation of diffused or circumscribed abscesses which are geuomlly
located in the upper portion of the Iiirynx :it the base of the epiglottis,
or in the Jirytpno-epiglottidBJiu fohla. The affection Hometinien involvea
the ventricular bunds, and rarely the vocal conls.
Etioi^gy. — The disease may either originate in the larynx or extend
to it from the surrouiiditig parts, especially from the pharynx, in which
c&se it is nearly ulwaya due to blood poisoning. lu many iuatiinces the
infliimmitttou begins in the cartilages or perichondrium, nsnatir resuit-
ing in stich cases from typhoid fever or syphilis, or occusioually from
other diseases.
SYUPTOHAToLoctr. — At first the patient often complains of a sousa-
tion as of some foreign substance in the purt, soon folluwed by actual puin,
especially upon deglutition. The voice becomes weak or hoarse and
may finally bo lost, and, as the swelling advances, dyspnoea occurs, which
in severe cases gradually increases, causing stridulous respiratlou, or
orlhupnieu, cyanosis, and all the symptoms of stniugiiliitiou. There nre
frequent violent efforts to clear tlio throjit, but usuuHy no cough. Dys-
pht^^ia is more or less prominent in proportion to the swelling of the
epiglottis which may often be detected by palpation, but thia should be
practised carefully as there is danger v{ exciting suffocative spasm of
the conls. Upon inepet'tion, the parts are fonnd deeply congested and
much swollen, and often the tracheal mucous membrane is invulveil.
]n some cases swi^lling and tluctuation are present
DiAGNusis. — In adults this may be easy from the history of ante-
cedent disease, with gradually increasing dyspuiea, and from the appear-
ance of the parts on liirjTigoscojnc examination. But in children when
the larynx atunot be inspected there is some danger of confounding it
with laryngismus stridulus, laryngeal polypus, rctro-pharyngeal abs<'esB,
foreign bo<Iies in the larynx, or diphtheritic laryngitis. Wemay oxcludo
-UB
laSEAaMS OP TBE LARTSX.
%
rtirit fkmrymgml afaeiM bj inipeciin^ tbe fmooM and bj lifting tbe
laiynXr vbich wHl reUere the drspncBa in moat eaMS of abooesA of
pfaaiju, bot DoC in pfalegmoinoos UiTngitis.
A hiitocT' of Kbeir entnoott and abtesce of ftnteccdent diaaa«o
readUr dtctingntfrh/omyw kviiM, Compared vith [rtd^^onoufi larjn
gili^ ftiffu* derelopa much more slovtr, and t&rfnfi$mms striduliu
much nM>re qateklr, and neither of th«m id attended bj the ■jinptoou
of inflammation.
Paoo50Sl& — The disease nsnallT mns a rapid eonne and t«fmuutc«
iilaDy in about KTentT-fiTc per cent of the eaaesy from either sufloca-
tioB <ir exhaoatSoft.
TRBATUirT. — Earlr In the ilJif ir the beii reiMdiee are leeches aad
varm applications to the neck, vith steam inhalatiom, or, instead of
thflM^ coostaat cncfciBg^ of biu of ioe. As aooo as there b ledewa or a
esOeetio« of pas, scarifieation shoold be emploTed. Qntntno and ^trjA-
Bsne ta medxom doeee and potassium chlorate in foQ doees are indicated,
together with lumrishing diet and the (nenaeolstuaBknta. Bonediea
and feed shoold be given by eneoM if the pati^t oaanot evaDov.
Crgent djapnon demands intabalioa or traeheotoeny, the latter gcner
■Ify faemc most efficient in tlus diseeea.
KR\SJPELATOrS UlRTNGITlS.
4
uU; ,
Kijaipelatona larTBgitis is an ipflam— tinn of the 1w7tix» nauail;
with errsipelas of the toa^ike aad pahrte. Vost oa
fhTrrr r— 1 — r or epidemic It wnMimei nsaUs tem mileai
CMlaaeeiu eryaipeb% or from ita exieiuien doog the mtoM mm
«i the noeSb noath. or ear. The iatimwafiew aooa termiBBtea in ex-
tmmt* aapparatieit and dooghtag of the iatraJarnigeal or peri-IaiTii
CMlti».e6.
Sno&eai:— Tha phaijm is anaeWy Ant inTetred, the diseaee
ma felly mtiaitiiit iato the knax.
STVPTOOiATOtjiMT.— The II J mpUimi are fcnr, kical pain and raeH-
^^vith diifcally la ^eala^^ dfefmmi^ aad greek pieetialiun. In
CaaDr br deGiiam. Bathr ia the iBsiain the tam^amfae a^iearaneaa
*n ■■fIt Aaae «f larragitia; eabeeqaeatlr doaghe «r eiUiiiaiii nloen
wfflheibamuL
DtAfisosia.— The diagaerii wait be based apen the sTrnptaans and
the fffUeaee ef iafcm^ftWB e( tfe MM ^pa aflMiag the Axa or tba
PBottxosis.— The temetm aaae&T raas a npid caane^ temtnatiBi;
btefljia^em^sffikyefaMBK. A«eee«agfeaCaKaa (JraUcw^nW^whr
df JKWkur. Puii^ iflO) dheat etfafth U thase came die ia vhich
the ialammniiai flnt b^iM ia the farj^x. vhenH e( thnv in ahicb
ABSCSS8 OF THE LAJtYlVS.
429
the inflammation extends from the jihftrrnx to the larynx nbont three*
fourths (He. This resuH is apparently due to an increase in the consti-
tutional disease markod by extension of the inAammatiou from the
pharynx downward.
Treatment. — The general treatment should be the surae as for ery-
sipelas oi other localitius, Quinine and tincture of iron arc most useful
medicines, Nourishing diet is essential, and stimulants are iudiciited
early. In view of the more recent Iwicteriological knowledge concern-
ing the matories morbi of erysipelas, agents opposing the development
of micro-organisms are indicated; therefore a satnrated boric acid
spray, and salol and lutphthnlin internally, are recommended. Slioe-
maker, in his late work, praiecs pilocarpine highly,' regarding it as almottt
a apeclGc in the cutaneous erysipelas. In hopes uf aborting the attack,
ice may bo sucked constantly for the first few hours. Gibb reports a
case in which applications of a strong solution of silver nitrate, pr. Ixxx.
ad ^ i., every six hours cut short the disease. Steam inlialations and
anodynes will be useful in relieving pnin. Tnicheotomy will naturally
suggest itsell, but it is of doubtful vulue. Intubation may be tried.
ABSCESS OP THE LARYNX.
Absoees of the larynx consists of a ciroumBcrib;ed collection of pns
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-
Fio. 117.— PxHtouoxDiiiTia Aso AsacKRs or LaudtX.
chondrium following typhoid fever or pysemia, or dependent upon
tuberculosis, syphilis, or local injuries. Abscesses occurring as the re-
sult of typlioid fever are generally found during the second or third
week of the fever. The smaller cf these iippeur just beneath the
mucous membrane, and the larger ones beneath the perichondrium.
SYMpTOMATOLOOT.^The symptoms of absceai of the larynx are:
pain whicli is aggravated by pressure, cough, dysphonia or aphonia,
difticuUy in swaUuwing, and dyspna'a. Upon laryngosoopic examina-
tion, the abscess uppeurit us u glistening swelling, red at its base, and
«ither red or yellowish at its upcx. It is usually located on the inner
DISEASE!^ OF THE LAJiY^'X.
surface of the larynx^, either tit tlic base of the epiglottis, upon the uyt^l
euoid or suprii-urvtonoid curtilngos. or in t}ie iirvtoiio-epigloUide-.iii folds.
DiAKXosis. — Jn <'hiii]r(.'n Ihc ditiearie may be iiiitttukeu for croup or
rotro-pharyngeul ahHctt^ii. uiul the duigiioHifl is Kumetimes utmn«]cd vith
great difficulty. In adulta tlie liiryngoHcopi*; ii^jpearances aro ehflntcl^r-
istic if the ahsceas points; ctherwise it is not always poBsible lo distiu-
guiab it from tiiniple intinmniatory swelling.
It iH diHtit)guishe*i from rmup by tliP history, pain, iiiid difDotilty in
deghitition; from retnt-pharifngrnl ahucfn^ l)y inspection and palpation
of the jtharynx; from acute catarrhal injlammatinn by the history. loottl-
izod in6jimmation and swelling: from tfthma by the history, eymptomi,
and signs; oedenm follows remd or rurdiac disense inst^^id of infiuiumu-
^ion of the curtiliiges and perichondrium, and it is chamcterized by a
pale, translucent color, and the absence of puiu and dysphagia,
Puooxosis. — The iifTertion oaually terniinuleri in from three days to
two weeks and if seen in time and properly treatetl, most caws reoover.
Fh. I1&— limu-OM/rnc Ahcsm ow LAsm.
Fia. 1I«.— TbkSaur anFio. llfl.TVcLTvHofFMaj
Arrma orBximn or kmtctm.
Sometimes fistulous ojKniugs remain after opening of the absceas into
the uesophag'is or externally; and iu the former caac lirjuids or soft food
are apt to pass Into the larynx during deglutition, causing dangerous
spasms or pneumonia. In some eases 8nl)outjineous emphysema has
resulted. When the affection prores fatal, death may occur from suffo-
cation or the exhaustion attending prolonged i^uppuration.
Tbeatment. — When the ubecees can be reached, the pus should be
evacuated by mean a of the larjiigeal lancet. When this cannot beao*
joniplished, the patient must be carefully watched, and if dyspncps
threatens, tracheotomy must be performed. Subsequently, with the
Iraohea completely stopped by a large canula, renewed efforts should be
made to open the abscess.
CEDEMA OP THE LARYNX.
i?yKOrty»w.— (Ederaatons laryngitis, snb-macous laryngitis,
glottic or infrn-glottio dropsy, ledema glottidis.
(Edema of the luryux consists of a serous or sero-sanguinoleuc
tnttion into the areolar tissue beneath the mucous membrane, which,
owing to the formation of the parts, at once dinttnishes the size of the
snpm- I
It infil- "
(KDEMA OF THE LARYNX.
431
air tube, causing dyspnoea, und uules^ the proccas is checked or promptly
roliewd, speedily inducing suSocation,
Whoa tlie inriUralion is of a sero piirulrnt clmractor. tlic affection would
more jn'operly nuiiie imd^r tlie head of plilogmonouH larvngitis.
A Bpasmodic element frequently coexists with the mechanical inter-
ference to respiration, and thus odds greatly to the gravity of the case.
KtioLouy. — The trouble may result from simple acute eatarrh:il iti-
fiutnniatiou, but must frui|UfUtIy from tuhi-rcnUosis, syphilis, or Hri^bt'a
disfusc. It is sumetinies iuduced by c*sposure to impure atmospbere,
BOfTer gHi!, and tbe like, or by iuhalutifm oi extremely oold ulr: ii rmiy
follow injuries from foreign bodies auvl oi)enitivi* procedures or scalds
and burns. It occasionally follows small-pox, typhoid fever, and scaria-
♦ana, or rvsults from suhniucoiis hernorrhiigc, from erysipelas, or from
.jbronic inflamnitition of the cervical tissues, and sometimes from the
jpressure of aneurisms of the larger arteries.
Symptomatology.— There is usually a history of extreme fatigup,
exposure lo ext-essive hejit or cold, an injury to the larynx, or of some of
the diseases already mentioned. Tho acute attjiek not infrequently
vomes on i^uddenty during the night, the patient awaking with a sense
of discomfort in the throat, or choking. l"he symptoms increase in s(^-
verity with great rapidity, giving rise to frequent suffocative attacks,
"With inton'als of loss impeded respiration. These intervals grow shorter
and shorter until relief is obtained or death occurs. When i^dema fol-
lows (dironic diseases, the progress of the case is more gradual. At first,
symptoms due to sliglit obalructiou present themselves. These gradu-
ally increase in severity, until finally a sufTocativo paroxysm occurs,
which umnally subsides after a short time, to recur after a few hours and
again und again at shorter iuttirTals, until it proves fatal. The symp-
toms referable to the larynx are slight local tundemess, with a sense of
dryness, heat, and 4-onstnction in the throat, hoarseness, aphonia, dyt^ji-
uoe* with labored an<i sometimes stridulous respinition, and more or
less difficulty in swallowing. The inspimtory act is chiefly obstrncted,
<ixpiration being com pi^ rati vely free; this is an important point in the
diagnosis. Vpon insppction, the fauces are flometimos found to be
uedemalous; and by the aid of the larjnigoscope the epiglottis, or ary teno-
epiglottidean folds, or both, are seen to be greally swollen, and occasion-
ally the ventrirular bunda or vocjil cords are also affet^tod. The affected
parts are translucent, of a pinkisli or yellowish color, and closely resem-
ble, in their genenil appearance, an a*demjitou6 eyelid or jirepuce. The
epiglottis has the appeanince of u roll or ridge, and the arytcno-epiglot-
tidean folds are globular or irregular in form, and u^^ually project upon
both sides; though occasionally only one side is involved, and at other
timee the swelling is greater on one side than on the other. When
cedcma results from catarrhal inflammation, the vocal (M>rdg are ulwavs
DISEASES OF TUB LAUl'NT.
of a bright rod color, and the other parte even more congested, some,
times showing distended veins upon the surface. When resulting from
renal, hepatic, or cnrdlac disease, the nit-uibnint! is iwle and iranalucent.
In hemorrhagic effusion there is localized swelling of a deep red color.
When occurring during scarlet fever, the niUL-ou^ niembrauc is apt to be
congested in putchea of varying shadus. In typhns fever tne wdemu-
tous larynx is usually of a dnaky red iiue. When inflammation has been
excited by irritjiiit poisons, excortatioutj of the epiglottis can fre<)uent!r
be detected; when caused by scalds, patches of thin false mHinbrune
are observed; and when by other traumatic wnises intense cougBation be-
ginning at the seat of injury is generally present.
Prognosis. — Most cases tt-rrainate within five or ten days, but some
are more prolonged. About lifty i>er cent of all those casus prove futaL
Fm. 190.— IKouu or LAxvns (.•.Vhui).
(Edema caused by pharyngeal inflammation nsnally terminates favora-
bly, but when resulting from inflammation of the cen*ical tissiiea it id
generally fatal. In icdema 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 bluod poisoning
arc nearly always fatal.
Treatment. — Prompt and complete relief is sometimes given by the
iidniiuistnition of pilociirpino hydrochlorate which may bo nsod hvpo-
derniically in doses of gr. J. It will uausc profuse salivation or dia-
phoresis, or l>oth, in about twenty niinutoj. Larger doseu cause a pro*
fuse and prostrating diaphoresis. Its depreasant effect upon the cardiac
mnsclc should always be borne in mind; and wlieu ipdema of the larvnx
attends heart disease, or when the heart is weakened from other onuses,
this remedy should bo exhibited with much care. It often causes vomit-
ing after two or thrett hours, but this action is also faronible tn cedeoia
of the larynx. If wo fail with the remedy, scarifiwilion of Iho larynx is
the best treatment; when this does not afford relief, tracheotomy or in-
tubation must be performed.
CHOlfDUtTlS AND PBRWHONDHXTIS.
An
Chronic oedunm of the laryux should be treated by scarif cation^ fol-
lowed by the stronger stiinuUting or Hstriitgont pigments, as zinc chlor-
ide or silver nitrate. When the oHlema is hjcateii below the vocnl cords,
v*ry little can be acromplislied by topieal applications. Schrutter's
method of diluting the liirynx by means of hard rubber tubes of gradn-
jiUy increjising size, which are introduced every d:iy or second Jiiv, and
kept in position several aeconiU or ns nuK'h longer iia the patient can
tolerate them, has been snccefi^tfnlly employed in eases of this kind; bat
from the limited experience of the past few years, dilatntion by O'Dwyor's
Jan*ngeal tubes seems the most eatisfaetory for the majority of cases.
If dvEpnu-M cannot be relieved by these methods tracheotomy must bi
performed.
CHONDRITIS A^^) PERICH0>'DR1T19 OF THE LARl'XGEAL
CARTILAOES.
An iuflammntiou of the hiryngeal cartilages or perichondrinni Rphlnm
occurs as a primary iiflectiun. The acute diae;i8e is seldom found except
in persons of a>ilvanced life. The inllammatton soon resulta in more or
less caries of the uartilages and thickening of the remaining portions.
In severe cases the whole wirtilnge may be destroyed and thrown off.
Etiowjoy. — The disease, sometimes primary, is usually the result of
tuberculosis, syphilie, tvphoid fever, or of trauma. It has been produced
hy injury done in laryngoul operations, by external wounds, and in rare
instanoes when the cricoid cartilage is ossified, by introduction of the
ccsophagoal sound.
SYMiToMATOi.or.Y. — Excepting in traumatio cases, the patient usu-
ally first complains of tenderness and pain in the larynx, soon followed
by hoarseness and more or less dyspna>a and diEBcuIty in swallowing.
The cri CO -arytenoid articulations are early affected, and iis a result thero
is partial or complete innnobility of the vocal cords. Finally, especially
after typhoid fever, the consolidation and contnictiou of the inflammii-
tory lymph may cause permanent anchylosis of this joint. Occosiouallj
a grating or crepitating sensation mny be detected on palpation. Until
an abscess forms, laryugoscopic exaniiaation will often reveal nothing
except slight hyporasmia, with very trifling swelling of the parts.
Indummation of the thyroid cartilage causes some tumef;tclion of the
ventricular bands and of the arytenoid or crico-arytenoid articulations,
impairment of the movement of the vocal cords and occ-asioniilly subglottic
swelling. Infl;i,mmfttion of the cricoid cartilage causes swelling below
the vocal cords, whioh may not bo detecto*! at first, bnt us the disease
goes on to suppuration the tumefaction becomes more prominout and
sometimes a yellowish spot may be seen as the abscess is about to open.
Abscesses of the arvtenoiOs present above and those of the cricoid just
below the glottis. Abscesses of the thyroid cartilage usually point belov
38
434
DISEASES OF THE LARYNX.
the glottis, but aomcttmes externully. ^Vlien the nITnotion is eccondarr,
tilcemtion of the mncons membmim nuiy sometiraea bo first JctocUn],
extension of vhicU fiuully oauses inflammatiuD of tlio cartilage or peri-
chondrium.
DiAOSOsift. — Primary perichondritis miiy bo suspoctcd when the pa-
tient complains of dull aching or boring i>iun, nud lurynijoseopic tixam-
iuation reveiiU enhirgenit^nt of eome of the cartilages wtthuut much
oongcstion of tho ]}arts. Secouditry {>eri chondritis may escape notice
owing to evrclling of the parts. Txitc in tho affection absceesM are
formed, tho niovomcnts of the tocjiI cords bocomo imp:iirfd, distortion
of the hrynx may occur without tho presence of cicatricial tissue, an4
often a fetid discharge takes place. From a consideration of thi^e i-on-
ditious and tho history, the affection cuu generally bo easily ditdia-
guishcd from other laryngeal didcaees.
PitooN'oais. — The majority of cases prove fatal. Cases have oecnrred,
however, in which the whole arytenoid or even cricoid cartilages hare
been thrown off, and recovery h.is taken place. Usually gradual exteo-
sion of the disease produces progressive dyspnoea, or tho rapid formation.
of an. abscess may cause sudden suffocation unless tracheotomy ii per-
formed. When an ubscess ruptures, pua may escape externally or into
the a'sophagus or larynx, and tho continued discharge may finally ex-
haust the patient'a Klrenglli. Tracheotomy may be performed to avert
Buffncation ; but if recovery takes phife, it U probable that the patient
will hiivc to wear the tracheal cantila during tho ronmindcr of life.
»en after tracheotomy there are but few who live longer than twelve
or eighteen months, but those in whom tho disease is not of speciilG or
tubercular origin may live many years.
Trbatmext. — When the disoa«e is slowly progressing, tho patient's
general condition denuinds our flnit attention. In specific cases the
imlides in large doses are of t)ie nio^t importjmce, and in all casce tonics
and nutritious diet are usually nec«ss{iry. Tracheotomy must be pei^
formed when dyspnoea becomes marked, and the lower operation will ba
most likely to prolong life. If the patient recovers, subse<)Uont attempts
at dUatatioii of the larynx, either by Schrtitter'a dilators or by O'Dvyer's
tubes, should be mode, 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 bco-
ployed.
TUBERCULAR LARYNGITIS.
Synonyms. — Laryngeal phthisis, throat consumption, heleosls laryn-
gis, laryngeal tuberculosis.
Tubercular laryngitis is a chronic uffoction of tho throat attended by
dy8pncF>a, dysphagia, emaciation, and hectic fever. It is characterised
by moderate congestion and swelling of various portions of the larynx
TUBERCULAR LARYHfOITIS.
435
foUowe<1 by iileemtion an<! eavere pain on itttempts at swallowing, and
usually by a peculiar pyriform awelling of oue or both arytenoida or
Hry-epiglottic foMej which is often pathognomonic.
Anatomical axd Pathological CHAUACTKKisTirs.— The charac-
toristies vary considerably in different cases and at different times ia
thc> eame ciise. Early in the attack there is sometimes simple conges-
tion, but more frequently anaemia. Ere long in moat cases swelling of
ISI.— TcBSRCVl^K Labtkoitm.
Fio. t22.— Tt-BERi-i-L4n L^itsuinm miowtmi
PmtronK Swcixua or Lirr AkyEpiolottio
Fold ako Farmsih or Lett \ocai. Cord.
the soft tissaefl 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 ulso be much swollen or, in rare in-
sttuices, 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 rontriculur bands, and they may
subsequently bo found iu the upper portions of the larynx. Ulcera^
tion iu this disease Dearly always begins in the lower part of the
'a^r^
Tia. 123.— TiiBSBctnan Larvxoitu. raovcro Fto. 1^— Ti;KBCTn.*K LABnroiTta.
pnurou 8WKU.I1IIO or Botb AnT-KpioLomc
Fouw akd TsKuutBiixe or KnaLorru.
larynx, subsequently extending upward to involve the arytenoids, the
posterior cummiasure and tlie epiglottis. The ulcers are superficial and
nt 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 tiken 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 ho detected, but they arc
sometimes found in groups. It is probjible that in most cases these
immediately precede the ulceration. Warty growths are sometimes
found about the edges of the ulcer or upou its surface; these arc soft,
43G
DISEASES OF TJfE LARYNX
easily broken down, Bnd hare somewhnt the appearance of p»]nll
matu (Figs. 125, 1'^tJ). lto6worth dosoribes ob one of the pimsea of 1
the (litti-itsu an tiuute follicular inflammation of the epi^lottiK which tna;
exteiiil to other porlioiia of thy liiryiix. This is chtiraeterixod by co
gostion and swelling of the mucous membnine, with numerous jiearl;
ivhitc or gray gninulalinii^ upon its Burfucc, which at fiiisL apjicar like
Iho folliclcfi ill follicular tonsillitis, uxct-pt that they arc- smaller. Mlvit
short timo they niptnrc, coalesce, and form superficial ulcers. In thi
way the entire epi>flottis may become impliealed. lu such cnscs th
patient is uliin)j>l unable tu swiillow on account of tlie severe pain.niii
us u reiiult he declined nipiiUy. and may die within two or three weelu.
Tubercular depoiiit and ulceration frefjuently nffect the perichondriDm
or the cartilages. If the latter are iiffecled, nef-rosis and exteiisire bu|^
puration are liiible to ensue. Paresis of the laryngeal nniecles is commi>iif,
due to atro]thy of the Hbres or pressure upon the nerve trnuke. Tbi
t I
I
vy
/
Fu. las.— ntctriUT Tf»EEiLn.*L«B LtftYXome.
Fio. 138.— TrwncPijiR Laitkoitu. Gnan-
Intlnir llcniv rtwanbtliig pajilltary tumor.
I
may occur early in the diBenee when it is indicated only by weakness of
the voice and loss of tonicity of the vocal cords.
Ktiolooy. — The causes of this disease are the same as those of pul-
monary tubcrculosia, whicli generally precedes the throat affection.
SisnTiiMAToi.om. — The jKitient usually comidains of first harinj'
taken a cold^ M'hich lasted for some time and was followed by a haokJDj^ ■
cough, that may have continued for several months, or in exceptional
cases for two or three years. As soon as th& disease hiis made much _
progress, nutrition is disturbed, and there is gradnul emaciation with,
fever and nigiit sweats. The patieut gradually loses strength, the voice
is we:tk, and lutur wheu ulceration takes place, and sometimes even
before this, deglutition becomos difficult, and even phonation may
painful. The paiu on swallowing is liable to grow steadily worse, and
finally to become exceedingly distressing.
Indeed, I know of no disease in which the jiatient suffers more than
in the later stage of laryngeal tuberculosis, though in the beginning he
may notice only prickiug or tickling sensations in the larynx, ^lien
the disease is fairly established, tlie patient has the appeanmce of one
with pulmonary tuberculojiia. The akin is sallow, hot, and dry or bathetl
with profuse sweat, fever of tliree or four degrees occurs at some part of
TUBER*:VLAR LAJiYJVOITia.
437
the day, and the piilso, which is soft and small, ningcs from 100" to 120^ F.,
or higher. Hoarseness is present in ubout nine-tentlis of tlio cases, and
in some there is complete tiphoniu. Most cases soon exhibit more or
less dyspnwn, cspcciully upon exertiou, due partly to weakuesit and
partly to obstructed rcspiratiou. It is said that hiryngeal obsiruction
occurs in about two ami two-tenths per cent of all cases of tuberculosis
ftnd becomes so grove as to demand tracheotomy in Dearly a third uf
these. Cough may not annoy the patient much, but usually it is very
troublesome. The amount of expectonttion is not very great unless the
broneliial tubes ur pulmonary fmronchynia are also iuvoWed, but in the
latter pJirt of the disease the thick Recretions 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 patohes 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
Fl0. ]9T.-TrDKi(cit.«n Imrthoitu.
Tt». ICS.— Ti-hebctlar LAarmrtu.
the ulceration; in some cases there may be considerable ulceration with-
out diflicuUy In swalluwing; in others a small ulcer will give great paia
and prevent talking of food.
When the epiglottis or ary-epiglottic folds are so swollen that the
orifice of the larynx cunuot be properly closed, fluids find their way into
the trachea and excite spasms of cuugli attended by such distress that
the patient prefers to PufTer from thirst and hunger rather than to swal-
low. Auurexia is geuerally but not always present. Ujjou 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 bo slow, bnt cases
where anamia is pronounced generally advance rapidly. The peculiar
pyriform swelling (Figs. 121, 132, I'iS) of the ary-epiglottic folds is
present in a large number of cases; it maybe confined to one side or
may be found on both, and the epiglottis nuiy or tuny not be involved.
Ulceration of the conis ^Figs. 127, 128) or ventricular bands (Figa,
129, 130) is common early in the disease. The vocal cords act slug*
gishly (Fig. ni) in many cases oven before swelling or ulceration, and
their movements afterward are often very much restricted.
DlAaxosis.— The affection is to be distinguished from anaemia.
438
DISEASES OF THE LARYNX.
1
cedemA of Ibe larynx, caiarrlml laryogitia, and from syphilis. Tbe
eesentiiil pointB in the dingiimia are tho pain, the pecaliar awcUing,
the character of the ulceration, nnd tho pbyBicol sigiu wbioh nsy be
found by examining tlie lungs.
'Inborcular laryngitig is diBtinguiahed from rhronic vatnrrhni Jaryn-
ffih'g by the history and by the physical appearance. In simple chronic
laryngitis there is usually diffused congestion with but little swelling.
Fie. 12P.— TmiKTLAR LmYKaiTu. Ulceratloo
lit Timtrlcttlar buids.
Tio. 180.— Ti'»«iiciL4ii Li
of vMitrkntUr InumLi u.
In the tnbercular disease, while there may be congestion, more c<im-
mouly the parts ai-u anwmic, and sooner or later there is the penulinr
pyriform BwcUing {Figs. 1*^1, 12^, 123). In the early st:ige of hiryii-
gcal tiihcTcnloRis when attended by rongesliun instead of anicmia, the
appearance of the ports may not enable na to make a diagnosis; then
we must rely u|H)n tlie jmlmonary eigns and tbe discovery uf lulM;r-
cle bacilli iu the gj>utum. Ulcvratioii is uncomiuon in catarrba], but
is tbe rule iu tubercnlar, laryngitis; yet there are raru cases of biryngitis
with ulceration, in which it is (lifTlenU to determine whether the pit-
Ueut bos tuberculosis or not; and in such instances, should we Hud bnt
no. 1«.— TniraPTn.ia Lutvottw. PBr«Bliorn)iiaclMprw«xlInK(*(]''mAan(liiU!(>mlloo.
little change iu the physical signs over tho apex of one Inng, it will be
•specially difficult to determine whether we have an instance of laryn-
geial tuberculouia or one of c:it.irrbal laryngitis. 1 recall two or threu
obfitutate laryngeal cases in which the condition of tbe apex of one lung
aroused my tiuapicions, though I oonld not bo cortjiin of u deposit, and
in whom the ulceration linolly compU-ti-Iy healed, and the patients
remained well for u nttmlMT of years; apparently indicating that there
no pulmonary tuberculosis. If ulceration ocjm upon the vocal
TUBERCULAR LAJiYNQlTia.
430
I
cords in front of the vocaI process, or upon the ventricular bands, we
may generally safely conclude that it is notu caao of ('nturrhul Inryngitia;
and if the ulccmtion extends to blio upper part of tliu luryiix (Fig. I<'i2),
and there is a peculiur (mllid or light piiik appetiriuicf of the tisituee, with
more ur lest; swelling, we ure tlieu certain of our rliiigiioijig.
The dieeiise can be differentia ted from chronic uiuirrhal laryngitis
by the following characteristics:
Lartkobal tuberculosis.
Usually very alight conRosdon.
PartKpjnerally palt*, cbangeuf contour
by pyriroriu sweUiny or uk-eration.
Pain. Iiec-tic. rapid puUc, s&Uow skin.
Enim/iatlon.
Aptionift and dysphagia.
Suinetiini'R iitiocpxia
Short duration.
Usually tubercles elsewhere.
CHBOmC CATARRHAL LARTNOITIS.
CoDgestioti of membrane. Usimlly
norniid t-utituur of parts. Rarely ul-
cumliuo. No pain, no faver.
No prua(.*iation.
Bo&i¥«nL-8s, but uo dysphagia.
Ko anorexia.
Lon;; dui-ation.
No pulmonary eomplkation.
The essential points in mhma of (he fari/tixnro: eemi-transparency of
the swoUeu tissues, and the absence of ulceration luid pnin.
The distinguishing features are indicated in the following table:
LaRYHUKAI. TUBERCtn^OiSIS.
May l>e slight conscstion of pai-ts.
Early chunsQ of coutour slight.
W Fain, rov»?r.
I Eniafiation,
I Beepimtion commonly normal,
I Loog dumlion.
(BoeUA OF THB LARYNX.
Usuiilly no conyestion, of parts.
Great chanfie nf contour liy marked
swelling-, wktb parts (tale and semi-
transparent.
Abseucp of pain and fever.
Nu L'nii)(.-iiUioii.
Labored respiration.
Short durution.
"We maybe able to distinguish laryngeiil tuben-'ulosita {roxn 9J/phiH/t ot
the larj'nx, in the first place, by tbc history, though it is frequently difficult
to obtain tins satisfactorily. The majority of people who have had syphilis
flatly deny it, no matter how much ii affects the condition under which
they are laboring. In syphilis the larynx is occasionally involvud early bat
usually not until the tertiary stage; although ulceration may occur at
the upper part of the Iiirynx in the secondnry stage. The margin of a
syphilitic ulcer is sharply defined and has an iireula of roddoned and
slightly thickened tissue about it. On the other hand, the tubercular
ulcer has a grayish, worm eaten appoaranfie, the border is not rognliir
and well defined, but liere and there runs into the sound tissnc, and
Commonly numerous small ulcers are visible about the larger one. In
syphilis, ulceration is apt to occur lirst upon the epiglottis; in tuber*
culosis, on the rocal cords or ventricular bands. This is not an absolute
rule, but holds iu a largo uumbor of caiics. The ulcer iu tertiary syph-
440
DISEASES OF THE LAltYJfT.
ills ia deep,and its ghurply cut edge is frequently undermined; in tnlwr-
culosis tho ulcer ia shallow excppt in rare cases where the process hoi
existed for a long time, but these hav« not tho sharp cut, nuderminM.
edges of the syphilitic ulcer. Very often in the latter affection cic»-
triccfl may be sc<^ti in tho upper purt of the pharynx or about the fanci"*
and on. tho soft pulatu, bigniSeant of former ulecnttiou. lu the syph-
ilitic affection the pain is not nearly as marked ns in the tnb^rcalar;
many oases of pronounced syphilitic ulceration of tho throat occur in
which there is no pain, and in others it is slight; while the tubercnlar
ulcer is attended hy Revere pain, especially on attempts at de£;lutiti<ni.
There are, unfortnnately, not a few cases in which the tubercular infec-
tion has occurred in syphilitif subjects (Fig. 133); giving rise to an
■itypic nlcoTfttion. General evidence of tuberculosis and marked laryn-
fical pain may be ossociatcii wjiii an ulcer uf the syphilitic type, and in
ruch cases particularly, tho results of treatment must often clear up the
Fie. ISS.— TvBKiKVLAX LAxryaiTiH. SM^Kdl-
dol utcrra And riincnii gmniilmUoDiL
Fro. 138.— TusncD-AR L^rvxktu Oooca«s»
IS pATiKfT irfTii BritnriP Hiirn>«r. Ukmtkm
couUuu'sl for t^htetiQ monUu.
doubtful points of a diagnosis. If upon the free administration of
antisyphilltic remedies such as potassium or sodium iodide the ulcera-
tion begins tu heal and the patient to iD]prove, wo may be at once sat-
istie<i of the chanietcr of the disease. There are some cases, however^ in
which there is undoubted cTitlence of jivpliilis, where the patient will
not improve c(uickly, but only recovers after proiotiged use of antisypb-
ilitic remedies; therefore, exceptionally, a diagnosis cannot be made un
til the course of the ilisease has boon watched for some weeks.
Between laryngeal tuberculosis and syphilitic larj'ngitis the following
are the chief points of diSeronco:
LaBYVGEaL TL-BEB0UL061S.
Oener^lly in u'IuUh.
Ulcemtiun mu;i]ly su))erf)cial, n-itU
groyi»h worai-eaU'ii appeai-ance; usu-
uUy steailily progi-p-ises for three or
(our niooUiB to a fatal issue.
Comparutiveljr short duration.
SYruiLJTic i^RYNums.
Syphilitic history,
Sometimes H€en in diiMreD, If hvnsd
ilary.
Ulcur sharp cut witli indurftted aw
coiig'i'sted horJf>r, iwnietimes under-
miniil. May attain a large Bizi>withia.
two tir three weeks, hut is apt lo p
gress but slowly aftcrwan] or may
checkeil or completely healed.
Loi)^ duralioo.
Prognosis. — Tnborcnlftr Wyngitis usntillTrnnsarapid coorsc, many
cases tcrmiiiuting within six months. It is clniinod that sixtj*six per
cent die within from eix to twenty-four months. lu moet instiuices
the curlier stages nm on. gmduuUy, und it is some time before ule^nktion
tukes place; when this occurs luid is accompuiiicd by difTtcuIty in swal-
lowing, we may expect the diseuue to run :i nipid course, mainly beauise
of deficient nutriment. When extensive ulceration of the litn'tix is
found, wo mrty safely predict th:it tlic patient will not live mure than
eight or twelve weeks. A few Ciisus die within six Mucks of the begin-
ning uf thedi»e:ise. It i^ not now the belief, a.^ formerly, that all of these
cjiacs lire futjil,fur Iheri' is ample proof th:it u fuw recorer. We nearly nl-
waya find accompanying puhnonary tiilHirculosIs; and it is probably safe
to say that where laryngeal tnberculogis is so complicjitwl, nine-tentlis
of the patients die. Finally, while the local reparative process dopemls
largely upon the ability to better the general nntrition, the hope of cnro,
as well snggested by Jarvis, should be also based upon the extent of
ulceration ( Tra n sat- 1 ions American Laryngologioal Association, 1883).
Trti;.\TMF.NT. — ^C'oustitntional Lreatmetit is of the iirst impartance,
and should bo similar to that for pulmonary taberculosis. Local sooth-
ing applications, in tlio form of inhalatinns, apniya, and powders nro
of more or less benefit. Tlie jtrinuipul inhalations which are rocom--
mended are: the compound tincture of benxom, camphorated tincture of
opitini, or solutions of opium or bellndonno with or without carbolic
acid, or eucidyptol (Forms. 5tJ to 50). These give soniu rclit'f, 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 patieut is able to be out of doors, as the warm inhalation:? prC'
dispose to acute colds. Early, before much swell/ug has taken place,
mild astringents snch as carbulic acid gr. ij., and rj'nc sulphate gr, ij.,.
ttd 5 i., or similar preparations are often helpful. Thebe BhouH he 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 foi only five or
ten minutes. Menthul ha8 also been highly recommended as a Rpiny or
inhalation in the strength of a dmclim to the ounce of liquid albulene.
Wm. T. Belfield has recently communicated to tlie Xew Vorl- Medi-
cal Jifroni a prnliminary paper on the use of iodine trichloride in sur-
gery; from whirh I am Iwl to hope for good effects in the local treat-
ment of tubercular laryngitis; and also in. the general treatment of
pulmonary phthisis.
The dcmonstntions by W. S. Raines, revealed to him that when
brought in contact with saliva, blood, pns. and other animal matter, iodine
trichloride is tpiickly 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
■fcdknc** ytM»Ty tali iiiiiliwi ier SkmOfni
poderauaDf tt ■■? be wed is ntotieB m fijbBBd
The jmmUa hsfc heeB fOTsnUc. nd jmtlfj sto
of tahrralnMi «tf the air faMget nd plenxm.
Pwden are oftcB better than ^ib;^ hecHMepatitBtB geoermJIj
them to the throat aaece eaaOy. The aaat aii linelihi powJcie ere:
fona, morphine^ WiMiith, taam, iadei. and gam henmre. in lariowa ■
hiDAiumM vrhh each cCfaer aftd m^x of BtUk, atar^ or acacia (P<
ICI-IG^ ITif 177); an exeeflent eeothhis powder u t— poeed of eqaal
parU of gam hfflranin aad hwiath. with two parts of iodoform. The
btier, bowerer, k ao axeeedin^y nnplramnt to naanj patients that it u
better to fobatjtate iodol, wl^ch hat neaiij, if not qaite, aa good
effect an'l, ham bat alight odor. When there is mnch pain, nnloaB oon-
trm-indica^ bj id ioajmeraaj, morphine nuj be adruitageoaslr oonbiaed
irith may of these poirdcrs in the proportion of aboat five per cent, ao
iHttt the patient vilj receire one-tenth of a grain with each insufflation.
For the aame porpoae ooeaine has been highly recommended, bat I have
found that it afforda the patient rerj little relief and often prorea to ha
exceedingly nn comfortable. Morphine, iodol, and bismuth, in proper
proporttona (Form, 1R5), gire more relief tlum other coiiibiimtions, in
iny cx]>cricDce; tbongh n Rmall amoant of tannin or gum benzoin mnjr
be advautagconitly ad']e«1. if not too irritating. If the epiglottis be>
cortiet destroyed by ulccmtioti, the patient may need to be fed vith
an (BMphageal tabe, which if of snmll bIzc mar be paased with-
ont mnrh discomfort. The patients sometimes fiwalloa' more Oftsily
with tlie bead low in the manner recommended for patieutts who are
wuaring tlic laryngeal tube. They often suffer greatly from thirst and
hunger, rutbcr tlmn endure the agony caused by swuUowing. For miti-
gating the torture under these circumstauces, I Imvc had great satisfac-
tion from tho n^c.by pvrah or ntumizer, of u pigment of morphine, carboUe
Kcid. and tannic iicid with glycerin iind water (Form. 139). This applied
to the larynx in full strength usually cansca intense smarting for a
few monicnttt and subsequently so benumbs the parts that the putiont
may hwuIIow readily, Ibe ana'sthosta continuing for some hours. In one
eosn whflro I frequently used it, ansesthesia would often coutinne for
tliirty-«ix botirn. I often give this preparation diluted with an eqnnl
t|iiantily of water, for tbo patient to use by the atomizer two or three
tintuH ditily, Tlicro is now and then n case, in which it only causes
■nfft^ring. K. 1>. Owsley, of Chicago, informs me that he bos been able
to givi' great relief in tliese rases by Imving the patient spray into the
larynx, boforoeuting, a satuniti^d solution of oil of cloresf J of one percent!
In water. Trnohontoniy biw biron recommendo<l in these cases, rflt
only lu prevent dyspnu'tt, but also to give the larynx rest. With the
SYPUiUTic LAJtyyoiTxa.
443
latter enil in riev, it hoB beeu ttdviaed compamtively early in tubercu-
lar liiryiigilis, but there ia no proof tlmt it improves the putient's
cbancGiS for recoTery, and I think it imjustirmbk', excepting, of course,
Thon there ia marked obstrnntion of the glottis, in which case it luiiy be
the means of prolonging life for several months.
The question of artinciul fpeiling in these cas^a Js ably discuuMd ia n paper
by Bevortey Kobiu^on. to be touad in t)iu Ti-aoSactioas of ttio American Lury ago-
log'ical AssociutioD, 18SS.
KYPIilLlTlC LAHYXGITIS.
The local laryngeal phenomena of syphilis rary at different stages
of the disease. Syphilitic laryngitis, although frequent, is proecut in
only a coniparativoly small portion of eases of all Tarietics of throat
disease. Primary syi>hllitic laryngitis is extremely nirc. Thu synij^-
tonis of sccondury syphilitic laryngitis make their ajfpeiLr.inee with-
in from six to twc-nty-four ninulhs after inft-'ction, and are charac-
terized by hyperajmia witli aUenition of the voice and frequt'ntly condy-
lomatous formations. The tertiary manifestations do not usually appear
until throe or four yenrs or much longer after the primary affection,
and it is not uncommon to observe cases in which tliey are dekyed fif-
teen ortweuty years. This stage is indicated by gummatous lunionj, deep
ulccnitions, and vicious cicutriecs, with consequent dyttpnua and altera-
tion of the \oice. Syphilitic patients are niort} subjt'ct than ulliers to
acute inflammations of the larynx, which aro usually slow to rooorer.
The disease is more froqnont in men than in women, and the tertiary
symptoms are about twice as frequent as the secondary. In i^eoondary
syphilis of the larynx, chronic hyi)erffimia and superficial ulcers are
found, but Mackenzie thinks that smooth, yellow, round or oval condy-
lomata are most charactoriatic (T)isease« cif the Throat .iiid No?^, Vol.
I, p. 355). These are from five to teu millinietrw in diameter, hut may
be twice as large, and are most frequently found upon the epiglottiB or
posterior conimissnro.
Lennox Browne states that ho has &vvu »overul cases in which these
formations were essentially like warty growths (Diseases of the Throat,
second edition). There is usually nothing characteristic about the
persistent hyperajmia, but, as Browne observes, in many c-ases there
is a well defined, muLtled discolorutiou, apjijireiitly less snpertUial, and
not 80 vivid in color as in simple chronic indnmmation. This is most
distinct on the voo^l cords. Sm:in siiperllciid uleers or mucous patches
are occasionally seen on the ventricular bunds, edge of the ejiiglotlia or
posterior part of the larynx. These arc described by Oottetein as round
or elougntcd. grayish white spots of thickened epithelium, 'slightly
raiscil above the congesteil 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 tliickcrj'ng
(Fig. 137) are characteristic. The gummuta may occur singly or in
■
444
PISEASSS OF THE LAHYNX.
groups, and are most frequent upon the posterior c-nmmissnrc or nr/t-
enoid cariiluges. Thoy are uanuUy observed us rounds smooth eleta-
tioiifi of tho sjinie color ati tlie surrounding- lissiip, or of » slig^htly yellow-
ifili tint; Iml ns lirpiiking flown occurs they tisimlly heconio vellowish at
the centre. The ulocnition may he superfirin] nt first, but ere long it
becomes deep und destruntive. It may of^our in any portion of the
larynx, but tlie epiglottis is the most Tnhieruble point, ami frerniontJy
Fnt. ISI.— OoKUTLciHA ax TMR UcrKM StmrAOK
Fio. laS.— til
M ^--KEXXUI).
it is destroyed by the progress of tlie disease. When tho ulcetf
heal, resulting ricatrires may seriously interfere with ciwnllowing nr
respiration. Thesa ulcers are often, though not alnraye, the result of
softening of the gummatous tumors. C'hronic thickening of the wnJla
of the larj'nx or of the vooal eortU, with anchylosis of the curtiluginou5
articulations, are timcmg tho common results of the disease.
Etiolooy.— Tho affection is due to constitutional sypliilis, either in-
heritod or acquired. It sometimes gnidually extends from the pharynx,
hut more frequently occurs after it hits disappeared from that locality.
SYMtTOMATOLOOY.—Hy careful inquiry, a history of somo of the
ruonifcstations of hereditarj' or acquired syphilis may generally be ob-
Fio. IM.— Hn-nrLK OtniKATA CfUxntX
PlO, I87.-8TPRIl.niC LARTROnMl
tained, though the greiit majority of patients, if the question is nakMi
them directly, will positively deny ever having been affectod. The
eymptomi will necessarily vary grejitly in proportion to the amount of
tissue involved aud the jwirts immediately affect^hi. There may ho only
the symptoms of a slight laryngitis, or, in the advanced disease, diffi-
culty in swallowing, aphonia, or dangerous dyspnwa. Superficial ulcere
nsaally occur in front six to twelve months after primary infectiun.
The condylomata are sehlom truuhlcsome excepting as regards the
LToice, and they often spontaneously disikppear. The symptoms of the sec-
ondary disease, as in other parts, rapidly decline nuder appropriate Lro:it*
ment, but show a peculiar teiideiiL-y to recurrence. The turtiiiry fiymptonia
may not occur until lusiny yeiirB :ifter iiuK'nlalioii : Mackenzie stiites
that in horeditary «i»es ho has never seen tlie Jiaeaae hcfure tho seventh
year of age. In these unfortunate cnses I have seldom soon the disease
develop before the person was fifteen yearsof age; though eoyenil iu-
stantres have heen reported of its occurrouoe iu vouug iufauta. Kveu
when there is extensive uh:eratioQ, patients are peculiarly exempt from
pain except on deglutition and oocaaionally on using the voice, and even
then it may be absent if ilie perichondrium is not involvtKL
Fever is often present in severe cases, and colliquative sweating may
occur in those who are ranch dehilituted. Specific eruptions upon tiie skin
are said to be infrequent in these patients. Tlio voice is ojisily alfticted
by exposure or vocal exertion, and the singing voice is commonly de-
atroyed. Hoarseness is usual early in the disenso, and in many casea
theru is a pi^culiiir huskiness of the tune siiiil to be quite characteristir.
Impairment of the voice may gradually progress until there is complete
aphonia; if, however, tho disoaso is limited to the epiglottis, the voice
may be but little influenced, and even after complete destruction of
this portion of the larynx the voice is sometimps quite restored. Kcspi-
ratiou is seldom affected iu tho secondary disesise; but in tho tertiary,
marked and even dangerous dyspna'a may result from thickening of the
parts; or from n«w growths, Jinchylosis of the cartilages, or contraction
of cicatricial tissues. The dyspntpa may only be noticed on exertion
or on the oecnrrence of acute inflammation, but U(>ually it gradually
increases, with frequent cxncerbatinns until eventually life is threat-
ened by exhanstion, by spasm of the glottis, or by siifFocative attacks duo
to collection of tenacions secretions upou tho porta. Cough is often
preeent, but it is not usually a prominent symptom in either secondary
or tertiiiry forms of tho diseaiic. Karly it is occasioned simply by efforts
to remove the secretions, and is not peculiar; but when the larynx be-
comes constricted the cough often acquires tho characteristic stridor and
«pa8m of true croup, antl when the trachea is obstructed it may closely
resemble the congh of pertussis. Couatitutioual symptoms are usuiilly
«light unless the disease iu the larynx seriously interferes with degluti-
tion or respiration. The appetite renmins good and digestion normal in
the majority of cases, but obstinate dysjwpsia may bo c^tused by accom-
panying syphilitic disease of the stomach. In the e;irly stages there is
«eldom dilficulty in swallowing, but in the tertiary form dysphagia is
often present, especially where the pharyngeal border of the posterior
wall of the larynx is ulcerated. Thickening of the epiglottis docs not
«eem to interfere greatly with tho act of swallowing, and sonietimea
Tilceration or even extensive destruction of this valvi- (Fig. 138) has little
«ffect upon deglutition. U]>on laryngoscupic exuminutiun, congestion
or other chaugua already mentioned are discovered. The snperficiU
■
44G
DISEASES OF THE LARYNX.
nicoretion of the lecondnnr stage most frequently occurs npoa the reu.
triculjir biiiid*. tlio epiglottis, or jioeterior wiOIb nf thrs laryiii. Condylo*
niiita, if fouml, iiro ti*miilly iit tho posterior commissure, or on, the epi*
glollitt. ■ III tho lcrti;iry ulTection tht* general surfticeof the larynx isusa*
iilly of II iluep pink or light rod color. Giimmuta have ibo appenrance
(ilrwifly (K'Hcribod. Thi' superficijil ulcer of this stugu hiw sharply
(]('f]iK<l hi)i-(h<rri. whic:h ilir^tiiiguiHti it from tuheroubir ulceriitiou. The
doop alour bus boon well described by Turck, as more or less circular in
4
y YM
Fte. )3S.— BrpBiLmo LARTWitm. Fvttal dMtructJott of cpUIotCls.
form, with shiirp miirgins Rometimes elpvnted :iTid surroiinded liy an ra-
lliimmiilory ;ircolu. The floor is covered by ti dirty yellowish white
coiiting. When tho ulcers hoal, the resulting cicatrices are deugo, fibrons,
and niiviohling, and exceedingly prone to return if divided. There is
nsually no external swelling uf the biryux, excepting when thera is ex-
teufiivu poriuhondritis, but enlarge uieutuf the conical glands is common.
LllAOXOBls, — The disease u to bo distinguished from simple chrouio
calarrhnl inllammatiou from tubercular laryugitis, and from benign and
malignaut tumors. IMie essential points in the diagnosis are: the history
Fto IW, -SvmiutK- ru-BakTiii.i or £piati)V> Pm. Hfl,— SmitufTn* l*u:nu,Ti(»r mncs).
fBk Uypcttrophr ot tirft vwtilculAr baod *ad o. 6. c; R«nnMita at «iilglaak.
and abeence of grave constitutional symptoms, the presence of acarv in
tho pharynx or upon other parts of the body and of one or more deep
ulcers of the Lvrynx. After the surgeon has satisfied himself of the
nature of tho disease by the appearance of the parts and « cantious ia-
quir)' about former symptoms, such as prolonged sore throat, loss of hair,
and eniplious u|h>u the body, he should ask the patient. Uov long since
yon had syphilis ? Put in this way the question is ncau-ly always on-
■vered honestly. While there is simply hy|)enemia without Dlcermtioa
^ is impossible to orrtTe at on oocnrate diognueie from the exmrninatiim
SYPHILITIC LARYKOITIS.
of the parts iilone, bat the diseovery of mucons pittchcs or lertkry
ulcers, together with the appearance of the pharynx and of the ftiucea,
and the patient's history, with the iibsence in meet ciises of constitu-
tional symptoius, will nearly always enable ns to make an accurate diag-
nosis. Sometimes, however, we are obliged to g^tvc anlisyphilitic treat-
ment for Bonie time before we can bo certain of the (rase.
Between typiciil cases of fuberruhtr hiryntjitix ami sypliilitic Liryngitis
there is little diflicnliy in making a diagnosis; but whenihc two diseases
are combined, or when the patient 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 s}'philitic affection,
while all of these are present in the tubercular disease. lu the eurly
Btages of both there may be simjile hypencmin of the jwirts, but ver)*
soon there is a peculi:ir, [Kile red swelling iu tuberculosis, having a semi-
solid appearance mueh like cedema, instead of the darker red color and
dense appearance of syphilitic swelling. The ulcers in tubercnloBls are usu-
ally comparatively numerous; they are superficial with irregular, poorly
defined borders; uuJ are attended by much (>ain. This is not tlio casein
syphilis. The ulceration is usually rapid in syphilitic laryngitis, slow iu
tnherpular. It Is more apt to bejijiiiat the upper i)art of the larynx in the
former, and at the lovver in the latter. In syphilitic laryngitis, adminis-
tration of tho iodides usually causes speedy improvement, whereas in tn-
bercnlosis it is likely to work an injurj'to the patient, and tho jtymjttoms
grow worse. Tnberonlar larj-ngitis is nearly always attended by distinct
signs of pulmonary phthisis.
The rapid growth of comlylomata, their location, and, under appro-
priate treatment, their speedy disuppeunmce, together with other evi-
dences of specific disease, will usually enable us to onsily distinguish
them from (lapillomata w other Utryn^al tumors. The gummata are
not likely to be mistaken for any other growths in tho larynx. The
fungous growths which sometimes occur about tho edges of syphilitic
ulcers are not likely to be mistaken for any of the benign tumors of tho
larynx, but are not unlike those which may be observed in some cartes
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 tho larynx, it
maybe impossible to distinguish catwer ivom 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 |)roeedes
the ulceration, whereas in syphilis the ulceration is often tirst. In
syphilis the ulceration is more rapid, tliough there is less infiammation
about It, and the ulcers are usu;illy 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 ditficntty in making the diagnosis, Iu
DISEASES OF TUE LARVyX.
run' cii8e« wlioro there has been much tliickeuing of the larj-nx, with
ulcoraliun and cicatrizalion so that purtioiig uf the (irgan are mnch. db-
tortorl, it i« sometimeB impOBSible at first to tell with whioh diticuEie we
urt* dealing. In these cases, as suggested by Lennox Hrovne, much,
rbliaiice may be phiced upon the evidence obtained by frefjuently weigh*
iiiH^the patient while he i« tAking the iodides. Although nuderantiiiyph-
ilitic: la'Jituienl, porHong auHering from cancer of t)ie larynx sometimes
dii well for a short tiniD; irnprorenient soon ceases, and Iher lose weight;
whereas in tho syphilitic disoiise there id generally stciidy increase in
wi ight for A considerable time while this treatnient is pursued.
pROONosiH, — In the secondary stage of the disease iipproprlale treat
in<>nl iiHunlly efTecls a spcody cure, though the singing rotoe may b*-
pi-rmani'iitly lost. However, there is a peculiar predispositiou to re
la]>m'fl nndiT i-x|M»surc to the onuses of cjtarrhal inflammation. In tb*
t<>rtiury variety a fuvorablu prognosis may be given where the case come*
nniler ohitervatioii sudiciently early; but if the pertuhondrium or tht*
oiirliliigi'H iin'i'XtPnaivfly involved, there is great danger to life. In either
t'njiii n-Hlorntion to the larynx of iu perfect functions is impossible,
thniigh Iniprovomont may be expected under appropriate treatment.
'I'liH iileeralions will usually heal within two or three weeks, but the
Ihiukettihg or cicatrices remaining may interfere with deglutition, res-
pinillou. or i>honation. Death may result from acute cedema, and
liHH occurred from hemorrhage though this is not a likely termina-
lion. (.-hnniic thickening or distortion of the larym is liable to remain
pcrinaiionl in all cases where there 1ms been extensiTe 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-
IlloltiH may for a short time iulerfere with deglutition, but the patient
joun learns to swallow without this valve.
TiiKATWENT.— In the secondary diecuse, local stimulating applica*
tions, similar to those recommended for simple chronic larjTigitis. are
indicated and arc peculiarly beneficial. For this purpose solutions of
rinc chloride or copper sulphato have been found most useful. .\
mild mercurial course is also indicated; and whenever condylomata or
ulcerations ap{>cur, potassium or soiiium iodide should bo given. Bitter
and ferruginous tonics are indicated if the appetite is fitful. The use
of tobacco iu any form should be interdicted, and alcoholic stimulants
are generally hurtful. In the tertiarj- form of the disease the greatest
reliance is ]daced upon the internal administration of potosfiinm or
sodium iodide. If for any reason these cannot be borne, the patient may
be given a meroiirittl course; gold and ^idiuni chloride sometimes act«
equally well. It is sonietimeii found necessary to use the iodides in
Very large doses; for example, I have aocn a patient in whom twenty
grains of potassium iodide taken four limes daily had no effect ; where<a«,
— ^n he was given much Lirger doses the condition of the larynx im-
' mediately improTed. The remedy shonld always be given freely diluted
with water, and it U beet to begin with small dosed, which can be eteiidUy
increased. I usually begin with seven and oue-Iialf grains sJtor eacli
meal and at bedtime, aiid the dose is iucrcmed euL-li dny two and
a half grains until fifteen or twenty grains uk taktii at a df>se. If
with this treatment the patient does not improvB, uud Ihe eymptomB of
iodidism do not oecur, the dose Its incronsed each day five grains until
thirty, forty, or sixty grains, and in extreme oiises oven one hundred
and twenty grains are taken at a dose four times daily. The maxio
mum dose having l>een reached, it is <:ontinucd for two or three days,
and then the patient again begins with tiie niintniuni dose and IncreaBes
the quantity daily as in the first instance. This plan has seemed to
me much more satisfactory than the continned administration of largo
doses. Usually it is well to direct the imtient to drink nearly half a
pint of wat«r with each dose of the medicine. Locally, IjCIiuox llruwue
(DiseaaoB of the Throat, third edition), especially recommends tlie solid
ailver nitrate, or, when the ppigloltia is ukcralKd, the gnlvaii<>-<:anlery. '
I prefer at first tho tincture af iodine fnll strength, thoroughly and
accurately applied to ths nlcers daily for five or six days, and subse-
quently less often until healing hiis occurred. In c:ise the tincture of
iodine falls, 1 rt-sort to copper sulpbiite in solution of from gr. x. to
XX. ad 3 i., or to zinc chloride in solutions of from gr. x\. to xxx. ad ? i.
Under this coursf, even large ukers will ut-ntilly heal within two or
three weeks. After ricatrizjitton of the uh-ers hits taken i>lafe, if sten-
osis of the larynx oi^nrs, it muHt be dilated by means of Schrotter's
bougies or O'Dwyer's laryngeal tubes, as described in tlic treating of sten-
osis of the larynx. At times the sjwcitic medication should be discon-
tinued and tonics substituted. Where ihe patient is mnch run down, it
is best to administer nuK vomica and quinine while the specific course is
continued.
SYPHILITIC LARTNOITIS IN INFANTS.
The attention of the profession was first directed to congenital syph-
ilis of the larynx by John N. Mackenzie, of Baltiuiore, uccording to
whom it is not very iufrequeut, and occurs mostly within the first year
of life (Ameruan Journal vf Meihcal Sciencrs, 1880), It is charactor-
lEed by cough, dysphonia, dysphagia, dyspntva, and deep, destructive
ulceration. The voice of the child may pass through all stages from
flight huskiness to aphonia. Paroxysmal cough is frequent, and res*
pirutiun is more or less entlmrrassed accorditig to the condition of tho
part. Laryngismus Hlriduliis is also spoken of by John N. Mackenzie
ai a not iufrequeut symptom in these eases. Deglutition is often diffi-
cult, and cutaneous eruptions may be present.
DiAONosis. — The diagnosis must be made from the symptoms, and
personal and horeditjiry history j from the signs as manifested upon
29
450 DISEASES OF THE LARYNX.
the skin or the fiiuces; and from the appearance of the lurynx, when
tapyugoscopic inspection ia possible.
Prognosis.— The prognosis is always anfaTorable. The yonnger
the child, the more rapid will be the course and the greater the certainty
of a futal termination. Some cases recover under proper treatment,
but there is a strong predisposition to recurrence.
Treathent. — 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 tim^ 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'Dwyer'a method.
CHAPTER XXVI.
DISEASES OF THE LAHY ^X.—C'otUinued,
LDPUS OP TUB LAUY.NJt.
Luprs of the larynx is a r&ro affcotion said to occur with aiboDt eight
per cent of nil cases of lupua iu other parts of the body. It is usually
Becoiidnry to lupu^ uf tlit* face, is moix- frequent in women thaii in
men, and i» most common in the lower idu!):>et) of suc-tcty.
For a history of this diaeaaa we are indebted Itrgely to G, il.
LefiTcrts, of New York { Atmr if au Journal of the Mcdictil Sciences, Ajtrit,
1S7S). The literuture hue been ntiicii enriched by C'hiari and Riuhl
(Lupus vulgaris Laryn^is, VifirielJ/ihreJifirkii/t fiir Derm, unj Si/ph.,
1882) i Morris Asch, of New York ; F. I. Kuight, of Boslou {Archives 0/
'- ; ii
Tk0. in.— Ltrrot o-r Lunoc (Zumheh). Fio. ttt.— Lrpn or Laryitx (Times), a. b. Epiglotdi.
Laryngology, 1881), and hy uumeroua other writera. Although tho vari-
ous inveatigatorti liave observed numerous cusee, it is not yet possible
to point out any diagiiuHtlc chamcituriKticrit of tlie disuusd.
Anatomhal and Pathoi.ouic al (^iiAKAfrrKRiyTics. — According to
I^ffertR, the essential pathological chunurteriBtic in hyptTtrophy 0/ tissue.
This is followed hy slow but very destructive ulceration, and when heal-
ing occurs the cicatricial tissue is very hard and of low vitality. Aboul
tbuae scars congested uoduleis are usually seen.
Etioloov. — The causes of the disease are not known. It has gener-
ally been considered as an evidenoo of it scrofulons taint. By some it ie
believed to bf tubercular. The cxporimentg of Koch, in dis<vivering
tutiercle Imcilli in the lupus nodules, and from them obtaining pure rul-
tures, while not furnishing conclusive evidence of the tubercular charac-
453
D2SBASSS OF TUB LABYXX.
i«r of the dlKOie, m&ke this the most pUorible hrpotliesu, tfaoofh tWl
difference in the clinical aspect of the two affections faa» not m jrtj
lNx.'n gatisfactorilr explained. Whatever the ultimate caiue of lh«4i»-|
cuse> it is eTideiitlj the same as that which caosea hi|nia on other por-
tions of the body. According to Ilarrica and Campbell, th« diMtarj
requires for liA development a caitablesoil (" Lnpas/'etc, Loadoa,]BSffl|
—possibly allied to tuberculosis and scrofnla; a predi^posiiig en
particnlarly traumatism; and an exciting cause, probabl/ a aicfo-j
organism.
Stmptovatoloot.— At first the patient ma; oomplaia of miUMn'
throat, but the symptoms arc not marked and are entireljr out of propw^
tion to the physical signa. There is often neither pain nor discoaifoet,
and the patient is usnally ignorant of larvngcil disturbance; bntaitb*
disease progresses, the Toice is often affected and in manv cascAdj^nKia
is derolopcd. In some there is distressing cough and a sense uf ohttne-
tion ill the throat, and occasionally there is nomplaint of dyspbigk
Ifo oharscteristic physical appearances are observed upon brrngoscopK
examination, but in many eases congested nodules will be seem mi tbc
epiglottis or anterior i>iirface of the arytenoids, Tlieso nodoles srt
irregular or may be almost splierical. Ulcers or cieatriccis may slse W
seen, similar to those observed when the disease affects the face. Baraon
de III Sota fipoaks of marked ahsentieof bleeding from the ulcers (Tmni-
actiona of the American Loryngologienl Association, IKSO).
Diagnosis. — The disease is to bo distinguished from tubercnlooit
Bvphilis, or cancer of the larynx. The most important points in tlw
dilTercntiation are lh« liistory and the presence of lupus exttfruiillT.
■Wlien the latter uxists the diagnosis is nut usually difficult, nud in jooog
subjects lupus can scarcely be confounded with any diaonse exreplj&f
hereditary syphilis. lu coses n-horc the disease is confined to iht
larynx a diagnosis can only be reached by a carefnl exclnsion of other
diseases.
Lupus is to be distingniahcd from tuberoular laryngitis by the eha^
aotci'istics 2>re8untc(] in tho following table:
Lmjs or the ulrvmx.
Generally in voting; iidiilts.
Udiiiilly Assuciuloi) witli (1isea)>e of
Um faoH, and uosfgosof pulmonary dis.
«•■».
Abftonce of ronsUtutlODul dtsturb-
anrp.
Iilltlt*. it liny. |iRtn.
Pntttitwi alow utid may be arrested.
UKvrB deeply deutrucUve,
Commonly m mjilrtlr ngafl pina
Nearly always sigus of pubnooary
disease.
Marked oonsUtutiona] dUUiruwice.
Severe local pain.
Progress rapid and seldom amsie^
Ulcer gcQerally superfldaL
Lnpns of the larynx is to be distinguished from syphilis as follom:
LUPUS OF THE LARYNX.
4AS
LCPUa OF THE LARVITX.
Most apt to occur in youog adults.
No »>'pliililic lustory.
No cuiutitutJODal sj'iuptomH; absence
of pain.
Prepress slow; ajrgravnted Ijy anli-
sj'pliiiilJc Ireatnioiit, (DtHiwii. in tUo
third edilioii of'liis work, |>, 430, rc-
iiarlis tli.it tnoiviii'ial trvfttinent does
not ng^r.ival4* tviie liipnft, but ]t<) ap-
pears to contnulict this statement
on p. 487 of the sattie.)
Syphilitic larvsoitis.
If of lier^Jitury oiigin, it nmy occur
in children: oihernliu-' it is muf^t apt to
occur in niidtllt) life, Uvf^ or lt>u yeara
lat^i' than tlio advent of lupus.
Sypliihtic historj".
May bi; marked unnHt jtutionni symp.
tomn. Frequently no pain, but ttiis
syniptom niay be sovBre.
Progress may be i-upid, but beneHt
or cure follows auli -syphilitic tt-eat-
nient.
Between lapua and cnncer of the Inrjrux the following are the chief
points of difference:
Lupus op the larynx.
Presence of Uio difieOKe or the ncara
whiob follow it upon llie face.
Usually occui-s in early life.
Slow prog^reai, and may be arrested.
Apt to extend over neveral yeattk
But slight pain,
light caoalitutional disturbance.
Cavcer of the lartsx.
No lesions upnn the fat^e.
Appeai-s usually after Ute age of
forty.
Comparatively rapid progress, sel-
dom or never arrested, and usually ter-
mitiatt!tt fatally within fram twelve to
eighteen months, but sometimes ex*
tends over four or five years.
Frequently severe pain.
Marked cachexia, rapid emaciatioo
and exliauHtion.
Pbooxosib. — The disease progresses very slowly and may last indefi-
nitely, without materially shurteuiug the patient's exiatence. It is
certainly not dangerous to life, but sometimes npw formations so ob-
stnict respiration us to demand tracheotomy. Any interference with
cidttrices by incision is liable to result in renewed ulceration. The dis-
ease niuy sometimes be arrested.
Treatment. — Ferroginous and bitter touica and cod-liver oil are
reconinicnded intL-rnullv.. thougli their cffuetd are not very apparent.
Chemical caustics, of wiiieh. the solid silver nitrate is preferable, have
been used, but not very satisfactorily. The gulvano-c^utui^ is reoom-
mcndei] by Lennox Browne as the best means of destroying the diseased
tissne and promoting u healthy conilition of the parts. Thorough
ecraping and the application of lactic acid, us specially recommended by
Ramon de la Sola {loc. cit.) are worthy of fair trial. This author also
lays stress upon strict liygteiitc and tonic LreaLuieut, arseniouti ai;id
giving especially good results. Koch's tuberculiue has not been found
4Si
J>JS£A8Ji::i OF THE LARYNX,
moro valoablo than other Tomcdiea, and its use is not inXreqaesUj
followed by disastrous conacquciicos.
LEPRA OP THE LARY>X.
I^epra of the larynx \a an alTectlou which attends some cases of gen-
enU Ivprtwy or elvpli2ititi:itiii<, mid ih charactttrized by inflnmmiition Altd
the forinutton of nodular miwtsos eimilar to those seen npon the skio.
Theae usually ulcerate and are a cuiisu often of dyspncea or hoarBeneiu.
Anatomical asd Patuolocjical CHAiiAcTEitisTu.s.— The diuMM
is atttMuUnl by congestion uf the uiimons nienibranu, wi;th uniform (if
nodular swelling, and oongiderahle deforuiity. In advanced ciises vi-
tensive nlt'enition may have occurred. In »ome nasets the vocal cordi
have been found thickened and of a yellovith
red color, vliilo the mucous membrane of the
ary-cpiglottic folds and ventricular hand^ hii
been much cuiigestcd, and has the apjiciir.iorc
iu some cuses of having b^^eu louaened from Uis
tissue beneath. In llie only cose which has '*oine
undtT my observation, the mucous membmnu
w!is of a reddish yellow color, the vocid cords
had a grayish appcaratice, and the opigluttiaaud
supra-arytenoid cartihiges wore thickened, and
several nodules appeared on the ventricular
hands, epiglottis, and vocal cords.
There is a tendency uf these nodules to
uluerutiou, but, owing to the slow progreu of
the disease, this stage in many cases U not
reached. In some instances great thickening occurs, and very oon*
giderahic stouosis results.
Etiulooy. — The causes are the same aa those of external lepT*,
which iu nearly^ if not quite, all atses precedes the disease of the larynx.
SYMPTOMATOLonv. — There arc no characteristic symptoms, but the
patient may become hoarse or suffer from dyspnaia, at^cording to the
thickening of the laryngeal walls or vocal conls. Pain in swallowing
was only observed in one out of twontj'-fivo cases reported by MureJl
Mackenzie (.hurnal of Laryngology, London, 1887 88). As iiotwl by
I^unox Browne, dyspuooa is commonly an uniniportunt symploni, even
in cases of marked stenofiis {"' Diseases of the Tliroat," third edition).
T)[A(1X0SIS. — The rli.ignosiit is based npon the presence of external
lepra and the abnormal appejiranco 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 tlie infre(]uency of alceraiiou.
PR0O50SIS. — 'llie prognosis is unfiivurable.
Trbatment. — Trachvotoiny is mruly indioaUMl, but it may be n«ct*>
BOry if oBduma of the glottis dovelups. No irualment has yet 1>o«a
l-i" I l.l.fl-.< .!»' I.AItVXX-
irrvKuIrir t)>icketiUut
I iMTlUtiUil ary-pplKlni-
Uo lokls, live (IJBtinct tiiberelm
CAD be le^n od ibe tockI conb
aai] venlricular twud. aivJ ouer is
IlKUsUOCUy KcD Dii Ibe uiWrlor
aurfkue oT the lufrft^kiUio |igr-
tloo of Um Iftrrnx.
LARYNGITIS OF SCARLET FEVER.
455-
'fflw^ered which will snrely relieve lepra, bnt the interual tidmiuistni*
tion of chaulmoogra oil, five to sixty drops dnily in an emulsion, has ap-
juirently henefiUKl fiomo cases. At the sumo time un Inuiictiou of an
ointment prepared from the same oil with Hvcor si.\ paruof lard sliuuld
be used. In the single ciise whifh I have observed, J. Xevina Hyde, of
Chicago, employed thia remedy witli iipparently muoh benellt to the
patient.
HYPBRTROPHY OP THE T.ARY?(X.
In his work on " Diseases of the Throat and Nose," J, Solis Cohen
cites one instance in which alt of tlic tissues were thickened an(l hypor-
trophied, but witJiout congestion of the parts; the obstruction of tho
j^lottis became so great that tmchootomy Wds necessary. No cause was
known for the disease.
LARYNGITIS DUE TO SMALI.-POX.
Tjaryngitis due to sniall-pox is always secondary to the eruption upon
the skin, and may be oither mild, or severe. In the latter case, the ex-
ndate interferes with respiration in the same way as diphtheritic mem-*
brane in the same locality, and sliould be treated in a similar manner,
uUnbfttion or tnicheotomy being performed if dyspnota becomes nrgent.
LARYNGITIS OP MEA8LE8.
Host caaee of measles ore attended by inflammation of the larynx,
either mild or severe. Usimlly there is simple ctitarrhal inHiinimii-
tion in llie uarlier part of the iittouk, which graduully jjitssoti .tway as
the disease ]>rogri'Sse8 ; but in some casoe, jusi us the eruption uu the
skin is disappearing the larynx Iwcomes involved. This form of iu-
flamumtion is gcucrally very obstinate nnd may permanently impair the
voice. In some epidemics of measles there is a peculiar prouenew to a
deposit of false membrane in the larynjc, occurring, as a rulu, from the
third to thu sixth day. It causes the same symptoms n.s diphtheritio
laryngitis and caIIs for the same treatment, but unfortunately the ma-
jority of these patients die; so great, indeed, is the mortality that
some authors Iwve stated that none of them recover even after intuba-
tion or tracheotomy. Intubation has seemed to be followed by mora
favorable results in this particular disease than tracheotomy.
LARYNGITIS OF SCARLET FEVER,
Laryngitis of scarlet fever is a compi natively rare affection which
may be simple in chai-acter, but is sometimes coroplic;ited with ledema
of the glottis or with a diphtheritic exndnte. In tlie latter case it
ahonld receive the same treatment as diphtheritic laryngitis,
450
DISEASES Oil' THE LARYNX.
CHRONIC STENOSIS OP THE LARYNX.
Chronic etenosis of tlie larynx usually occurs in eyphilitic subjocts,
or iu persons who Imve suffered from chondritis or perichondritis result-
ing from tyjilioid fever or tutwrenlosis. It is oharacterized by more or
Icsd iiUenition of the voicre, itud dyspnoea in proportion to the narroving
of the glottis.
Akatomicai. akd Patholooical CHARAOTERiSTioa — The obRinic-
tiou uuually oeuurs from vicious, adhesions or fruni iho uoutractiuu of
large ciciitrices. The chink of the glottis nijiy liave various fomis, and
in eize may vary from the narmul Ln a miunte opening scarcely large
enough to permit the piLHiuige of sufficient titr to support life; the ports
are usually thickeneil, hard, and distorted in various ways. The vocftl
oords, ventriuiilar handf, or the arytenoid cartilages may he more or leae
adherent to each other.
Tut. IMl— STratuno LAnryomi'. AdbA-
•louur aJile<rli>r ^mrtloii ut vmriU (»iriU. uud
Fm. 146.— arrBiLmc Stkjkbm or T^m
AiUu!«kin of KT««tvr poitioa oC voo«t cords.
Etiolooy.— The disease usually results from syphilis, bnt it may fol-
low inrtaminations of the C4irtilago or perichondrium (caused by wounds,
typhoid fever, or tubercnlosis; in exceptional instani:ea it has been
cansed hy chronic cittiirrhal laryngitis. The obstruction may be cauited
•hy anhrnucous intiltrations or hyporchondrosis, or two or more of theee
conditions may be combined.
Hymi'TOMAtoloov. — In connection with the history of one of tho
insee already mentioned wo may find that the larynx has become in-
volved and that the clisease has gradually or rapidly progressed until
there is great dithculty in respiration. Sometimes there has boon a sud-
den amelioration of the uitlammatory syuiptoms and apparent improve*
ment of the coudition, but the dilhculty in rt.'Spin(tion has gnidualJy in-
oreased owing to the contraction of the cicatricial tissue which h;is bceu
formed. The voice will be impaired, and respinition obstructed, accord-
ing to the part of tho larynx Involved or to the narrowing of the glottis
present. Distortion or thickening of the larynx and narrowing ot tho
glottis may be seen upon a laryngo&copio examination.
DiAGNusiB. — Chronic stenosia of the larynx is to be distinguishcti
CHRONW STRNOSfH OF THS LARYNX.
from asthma, compression of the trachea or larynx by tumors or othor
caoses, foreign bodies ia the nir pasanges, and panilysis of the abductors
of the vociil conU. Tbti diitguusis must umiiilly be based upon the his-
tory and the liiryngos«opic ajipwiranccs.
In asthma^ there is a history of sudden and repeated paroxysms of
dyspnoai with more or less complete intermissions or remissions of the
attack, iusteiid of the gniduully increasing ubatruutiuu found in hiryu-
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, bofiien in the larynx.
We are to diagnosticate fumorg preying on the tarynx or trachsa
by a careful physical examination of the neck and chest. When this
does not succeod. an inspection of the larynx enables us to distinguish
between this condition and stenosis.
DyspUL&a, often as prououueed as that of stenosis, is caused by pU'
rahisirt of fke aMuc/urs. Here again the history must be carefully con-
sidered, and upon inspection the position of the cords near the median
line, their slight moTements with respiration, and the absence of thick-
ening or cicatrices, will indicate the true nature of the morbid process.
pRor.Nosis. — The voice is usually permanently lost, and the disease
progresses gradunlly to a fatU termination unless appropriate treatment
is adupted. By proper surgical procedures, however, Ufa may be indefi-
nitely prolonged, though the patient uften ha» tu wear a tracheal canula
during the rest of his days.
Treatmkxt. — Whatever the cinise of chronic stenosis, medicinal
treatment alone is of little, if any, aTnil in most cases, for oven when of
syphilitic origin the disease usually progresses so rapidly that surgical
interference betromes impenitive. If dyspncBa is great, it is essential
that it should be promptly relieved by intubation or tracheotomy, and
it is highly advisalOti that these ojverationn should be recommended
early. The anarathesia for tracheotomy in these caaes is best obtained
by the hypodermic injection of a few drops of a four jier cent solution
of cocuiuL* (F'priii. 140) aloug the line of incision. If the dysjnuL-a is not
pronounced, SchrOltcr's laryngeal Iwugicjt may be employed for gradual
dilatation, but otherwise tracheotomy should be ]>crformcd unless one of
O'UftTcr's laryngeid tuU's of sufficient size to give the patient relief can
be intro<iuoed. After tracheotomy, or when there is no immediate dan-
ger to life, dilatation of the parts should be practised by some of the
rariouB methods reconiniended in standard works. The repeated and
persistent use of .Schrotter's bougies, gra'inally increasing sizes of which
T«hould be iutroduced twu or three times a week, will Bometimes prove
vnccessful, but the treatment is neroesarily tedious, and there is much
liability to recurrence of the atrirtiire. .Schrfitter's, Mackenzie's, or
Kavratil's dilators may be employed with sutisfactiou in sonic coses
458
DISEASES OF THS LARYNT.
(Morell Mackenzie's Diseases of the Throat and Nose), but when adhe-
sions of the ventricular bands or vocal cords have occurred, Whistier'i
cutting dilator will often be found more satisfactorr. 0'Dwyer*8 method
of intultaiiou furnish^ an admintble means of treating chrv>nic stenosis
of the larvnx. The larynjeal tulv?: f<>r tbU purpose are similar to ihoee
tisev! f«*r orv^ap. Thev are tea in nnn'.ber, vary;:-.^ in >:ie jnst Wow the
head from six so ten milMnierres in lateral diameter bv nine to nineteen
ttlW$i\«Kt Hiuci si;i&-Ac::';n. an i I j.»-- :7\s--'\ : *- ^^.tJiii.^IIrnt
* It »W t.*^vn:*^^ ct •zk ^-o":* j? • -r- ^■r^ i... : - i :e silar^l
niltlifrV v-tt»i3^ Zi'jVr. f.-;:- »i;-i ;> ;j- ..vrv-;^-:a: :-:'?e. A nV
W «ku*v in^rwl-.vd *ii'-til'i i
■K »;rn :,;: i Zz-v lar* xi ZTSt^
FiQ. lia-Tt'U£ ml Lurryao-nucniL ^nxosiB. A. Tub«a [upo«itiMi: B. outM- tube wbk^
posars up u> iXve Uuyax: C. uiiddlu tub* vbich poaaes throui^i iba fADeatnw in tkeouur tube, inio
the tnebea: D, ftrncr Uibu of mJllcbenl leagth to ral[«ivit stuiosl* low down ibe cmohva: E, vnlve
wtaicb opnwoD inspimUnu uid oloaM oa pboitatton ur explnaJoD.
Open. Wiatevor treatment isadopted, the voice isapt to be permanently
inipuired. It bad seemecl to me that continual wearing of an O'Dwyer's
tube 16 more liable to injure thn voice than iutprmittent dilatation.
Poaaibly these tilth's might bt' usctl for much ahortt'r pprioilawith eijually
good results in keeping the glottis open, and without ao much injury to
the voice, but tliiii U a matter tu hn deteruiiued by future experience.
After tracheotomy when the lower portion of the lar^mx or upper
part of the trachea become obatnirtcd by vegetationa cr cicatricial con-
tractions above the c-annla, thcase ninst be removed. The operation will
be facilitated by the punch forceps spoken of vhea treating of post-tra-
chootomio vegetations (Fig. 178). The air passage may then be kept
open by the combination tiihc shown in Fig. 1-18. This tube allows tbo
patient to talk, and may be worn as long as neoeasary.
Sometimes the constant t«ndenc%' to contraction will necessitate ita
retention during the romaindor of the patient's life.
]
n\o
DfSEASSS OF THE LARYNX.
STENOSIS OF THE TRACHEA.
Tho close rclutiou of the luryux aud the tnichea iu sotno sense com*
pels ibo dUcussion of tmcheal discuses with those of the hiryiix.
Stricture of the trachea is a condition frequently, though not con-
stantly imsociiitcd wiili stricture of the hirjnx. It is chu meter ized l-v
piiroxysinal cough and dyHpna>a^ aggravated from time to time bj
congestion and swelling of the parts or the collection of mucus. Tlie
obstruction, which may oceur at nny part of the trachea^ usually results
from cicatrizations of syphilitic ulcers or from compression by intrs-
thoracic tumors. Tho diagnosis uau only bo made after careful physi-
cal exploration uf the throat and chest, and a paiusULklng laryugoiicupic
exaniitutliou whereby ub^lructions abore the vocal cords are tliiuiimleil.
The prognosis is always unfavorable when the leeion is too low to be
relieved by tracheotomy. Id syphilitic cases, vtgnmns use of the iodide«
has sometimes given gn>at relit-'f. Dilatation through tho larynx bv
loans uf long tlexlble catheU>rs has been reuominendeil. Tiie beat results
to be ex{>ected from Iniclieotoniy with aubitequent dilatation aud tlie
iring of a long, tlexible tradu'otoniy tube.
TRACHEITIS.
Tracheitis ia an inflammation of the mueoas membrane of the tTAche*.
which may be either acute or clironic. It sometimes occnra indepen*
denily. but is usually associated with laryngitis or bronchitis. The d.i»*
OBM is generiiliy uiild. but severe cases sometimes occur.
ANATOMICAL AXD PATHOLOGICAL CHARACTERISTICS. — In the acntft
ones the mucous niembrano may be red aud swollen, so tlxat the iut«r-
■piocs iK'twi^iMi the cartihiges cannot be seen. In chronic cues the
mombrune is usually slightly swollen and of a deep pink color, and the
in terra rtilagi nous spaces are not very distinct or may be iurisible; there
are e^ome cases, however, in which post-mortem examination revonis no
ragestion. In chronic cases masses of mucus may often be seen ad-
lering Ut the snrfare, and rarely, ulcers ant prescuL A peculittr form
of this disease is sumt'times met with in which the mucous membrane
it cori>n*d by desiccatetl and dccaj'od sucrctious similar to those found
kit the nusol citvitT in nzip$in.
EnOLOOT. — The causes of tracheitis are the same as those of larj'n-
giti^ "hitis. Chronic Ciises are frequently due to rheumatism,
^■i _ _ .lOLoiiY. — In neu/0 cases the patient genemlly oomphuns
of a souse of soreness or rawnea in the superior sternal region or at the
npiK'r pnitinii of the imrhfa, with tickling or itching of the part and
{reiju^Dt cough. r»uruig the Bret few days the expectoration ia scanty,
thick, and trnAcious; but as the disease progrcjisea toward recovery, it
booi>mv4 muoHpuralent at in ordinary oacw of subaimte bronchitis.
In the chrunic diseMe there is eomotimes locnlised pain over a small
portion of the trachea, but usually simply a sense of discomfort due to
swelling of tho miioous membrane, dryness, or a collection uf mucus
ujMjn its surface. Sometimes the tickling sensation h vcr)" iinuoyiug.
These symptoms are associuted with u hacking or henimiiig cough and
espcctoration of small quantities of mucus usually discolored by dnst,
Ipccaaionally th« rough is paroxysmal. In many cases there is slight
rseness, or eimply a low of control over the voice on attempting to
ng. The general heuUh is not impaired.
Upon examination of the chest, mucous or sonorous rdles are some-
times found over the trachea alone, or tmnsinitted over the entire
thorax. When the mucous mcmbruno is dry and the secretions are de-
composing, the patient is greatly ajinoyedby conatant efforts to clear the
trachea, and by an ofTeusivc odor similar to that of ozi^na. In some of
these cases the crusts collect just h^neath the glottis and may give rise
to spasm of the larynx; in others the symptoms are very similar to those
of asthnta. Ijaryngoacopic inspection will reveal the condition already
entioucd.
DiAGXOBid. — The disease is readily distinguished from hiryngtlis
and bronchitis by laryngoscopic examination, and physical exploration
i tho chest.
Progkosiis. — Acute tmoheitis nsnally subsides in from five to fonr-
n days. The chronic form may last for several months or even years,
he variety attended by drying of the secretions is peculiarly obstinal*.
cither form of the disease is considered serious: and the common fear
of patients tlmt it may extend to the luugs, causing phthisis, is appar*
ently without foundation. There are some cases, associated with con-
Buniption, but this ap|>oar8 to be accidental.
Treatment. — The acute Gises may he given the same local treat-
ment as acute laryngitis, and the internal remedies suited to acute
bronchitis. At the same time, cold compresses over tho chest in the
earlier part of the attack, and hot compresses later, M'ill often be found
bencliciul. The patient »hou1d be kept in as equable temperature as
passible, and should avoid exposure. In the ordinary chronir cases
treatment similar to tliat employed in chronic brouclutis is applicable,
but the grcjitest 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 lirst attention. The local appli-
cations which have been f<nind most boucficia! consist of inhulatious
of ammonium chloride with oil of tar or eucalyptol, and the apjflicution
of various astringent sprays, and stimulating jiowders. It is difficult to
apply a spray to the trachea because the glottis will close as soon as the
application touches tho larynx, but it may sometimes bo accomplished
by directing the patient to cough while the spray is being thrown in
^
4fJ2
VIHEASES OF THE LAHYNX.
quite forcibly. The sprays which I oenally employ consist of solationt
of aiuG su1phtit« or cliloriUc gr. ii to x. nd 3 i^ the strouger of the»
being conlra-lndicatei] uiilesti the larynx iaiiUo involved. In any ciu-i* the
patient ehould not experiijuce unpleaiuint sunriatioiiB for nioru ihun half
an hour or at most an hour after the application.
Some phvBiciana favor iiijaetingBtimulating Bolutions with a ftyringe.
Powders have given me the most satisfaction in the treatment of Im-
cheitis, as they can be applied accurately and vill remain in coutact
with the parts longer thun j^olutiuui. These are UKed two or threo tiraes-
a week, beginning with mild applieatiuns, und gnuJually increasing th»
strength as fonnd necessary to produee sufficient stimulation. They ar©
ajiplicd while the glottis is wide oix-n by meiinsof a bent g1as<« tnbe and
un ordinnry insufflntor, loilol nsuiilly lisis a Siilutary Inflnenco iipun
the infiaired mticoiis mcmbruue, iind many patienU experience speedy
relief; from half a grain to twu grains may be Uf^cd at each sitting. A
slightly more stimulating powder, und one that answers a good purpo?(»
in Home cases, consials of eipial parts of iodol and boric acid. Where
Still more stimulation of the putts is desired, I usually combine with
the imlol or the boric acid from five to fifteen per cent of alam
thoroughly triturated with su^^ar of milk. Uisinuth. gum benzoin, and
other powders arc occasioiuilly used, but the three already mentioned
generally work sittiafactorily. Menthol may bo used in the same man-
jier. but il has no sitecially benofici:d effect.
Treatment of the fetid form is eminently unsatisfactory. Where
the crusts collect close beneath the glottis so as to cause Bpasm of the
larynx, inhalations of ammonium chloride or carbonate, or sodium car-
bonate, with glycerin ant] water by means of the steam atomizer, have
jtroved brnellcial, the strength being regulated by the eeusatioue of the
patient. I have employed a great Viiriety of substanciea and liave haJ
the patient ust^ many ditlcreiit rfmeUies at htime, but most drugs
seem to have no inllnence in separating the incrustations or in limiting
iheir formation. The most satisfactory results have been obtained
from the frequent inhalation of oil of mustard in combination with
Hh-ohol in proportion of about Tflv. ad-i.; a small quantity of this
two or three times daily is poured upon the handkerchief and in-
haled by the itatient, with the result of enabling him more readily to '
clear the tmche:i and finnlly of greatly decreasing the collection of secre-
tioua and the offensive odor.
XtARYNOKAi. tumom include seveml VArietiea of ninrbid gronrthe sim-
ilar to those found in iiiunv other porCioiict of the body. They are
commonlr benign, nnd of these the ptiplUiiry furm constitutes'iihout
ecveiity-fire jier cent. Next in onler of ficqHonc}-, rpspectively, come tib-
Tous tumors iind fibro-oeMulitr growtlie, the hitter constituting ouly
about five 2)cr cent of the vhole ninnber of intrflrhiryugual tumors.
Following these we find cvBtie, lipuiimtouH, and malignant ejjithelial
and sareomiitoui! growths; ciirtihiginoue tumors iire among tlie most
infrequent. Intra-hiryngtail tumors aire u»;uHlly characterized by dyg-
phonin or cnnipiete loss of voice, often by dyspnoea jind oocsisionHlly by
dysphagia. They occur most frequently in laiibile nged men, but they
occ-isionally appear in udvunced age, und are seen in children, ftomctinius
being of congenital origin. Previous to tho devolopment of laryngos-
topy in 1857, onlv seventy hiryngeal luinora hai] been recorded. Suli-
aequently, up to the yojir 1.S71, about three hundred were observed, ac-
cording to Morell Mackenzie; but since then the number has run
rapidly into the thonaiTids, and many of these hare been cured by intra-
lar)'ngeal operations.
ANATOMin.iL AND pATiioLooif-'Ai. CHARACTERISTICS. — The laryui is
tiBually more nr lean congested, and the tumor may spring from any por-
tion of the orgjin, though cerUiiii parts are esperially liable to certain
varieties of morbiil growth. The appotrance of the tumor and its path-
ological peculiarities depend upon its character, size, an<l location. Thfir
microscopical appearance is not unlike that of similar neoplasms in
other parte of the body, but it frequently happens that it is impossible
by fiuofa examination to detcrnnne the truu ehtiracter of the growth.
EtioLoot. — Benign tumors nearly alwayn have their origiu in con-
tinued local bypcriemia: their cjiusation is therefore oft^^n the same as
that of chronic luryngitis, f!ohen beliores that they are not infre-
quently caused by catarrhal inflammation, duo to the oxantbenmta, or to
that resulting from croup, diphtheria, pertussis, or the inhul-tion of
irritatine substances; lie also shows that they sometimes occur in per-
sons sufTeriug from syphilis or Inherciilofiis (Uiseascs of the Tliroat
and Nftsal Passage^). Morell Mackenzie, on tlie other hand, state:! Uiut
434
PI.SEA8ES OF TBS LARYNX.
neither syphilis nor p]itliiai« is u proilispoaing chubc, ihongli lie atlmite
that both limy give rl^o to false cxoresceuces or outgrowthi! (DiacaMS of
the Throat aDd Noac, Vol. 1). He attrihiitcs laryngeal neoplusus in
muny cjises to the professional use of the voice.
Stuptomatology. — The symptoiim of » tumor in the larynx depend
upon its eize aud position, and are esBentlally the same whether tt it
benign or malignant. The asual symptoms, which vary, of couree, with
the size of the growth and the part of the larynx involved, are; cougbf
dyspnu'ii, dysphonia or itphuuiu, dysphagia, and occasionally pain.
Cough is not apt to be truublcsuiuo unless the gniwth is large or in*
voWes the glottis, or unless it is attended by bleeding; that which does
occur is often paroxysmal and may be
of u cronpy character.
Dysphonia or aphonia, hoarecneaB, or
even complete loss of the voice occur
wheu the growth is located ou the vocal
cords, or when its position or the con-
current inflammation interferes with
their vibration. It is surprising how
small a growth located ou the edge of
the cord will cause hoarseness while
large tumors differently situated aoinft'
times but slightly interfere with phona-
tiou. Sometimes the aphonia is inter*
mittenl aud it may disappear or change
w^itli altenition of the jiatient's position.
I>yspnii!a occurs whenever the neo-
plasm is sufficiently large to materially
obstruct the respiratory passages.
Dysphagia is not a common symp-
tom, but it nuiy occur when the tumor
inrolves the epiglottis or posterior laryngeal wall, or when by its size it
encroaches on the pharynx. This symptom is more likely to be present I
in malignant growths.
fain is not a common symptom in benign growths* although patients
frcqnently complain of a sense of aching or discomfort, or the sensation |
oa of a foreign body in the throat. Occasionally, even with small tumors i
on the vocal cords, patients experience slight pain, especially upon deg<
lutition. Severe paroxysms of pain are not uncommon in malignant
growths, thongh even with these it is fre<piently absent. In adnlu a
laryngoscopic examination will usually at once reveal the presence of a
morbid growth, but laryngoscopy is frequently difficult, aud soraetimet
impouible, in young rhildren. eii[K*c-i.i]ly in those less than six years of
ag«. By forcibly pressing the tongue downward and forward wtlhi
s tongue deprenor simttmr to Lh&* aho-vn in Fig. 149, a good viei
rw, 1«.— M«WT Blbtkh'* ToHorB
Xtmrtuumon i^ UUfl.
4
i
BBNION TDM0H8 OF THS LARYNX.
40A
mny commonly bo obtained oven in rebellioiiB children. In young
subjects tho larynx can be reiulily reached by the finger, and it is often
easy to feel the growth, provided it is looated above llie corde. It ia im-
possible to be certain of the true cbaracttr uf a tuinur tiutil it bns been
subjected to a mitToscopie exaiiiinulion, and even tbon the diagnosia
may remain doubtful, tor aotnetiuiea laryiitreid grovvtlid of malignant
histological appearance possees a n on- 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.
BENIOK TUUORS OF THE LABTKX.
Symptomatologt. — The most common symptom of these growths
consists of alteration of the voice, though this is not invariably present
A growth npon the vocal cord usually causes hoarseni'ss or aphonia,
sometimes more marked from sinall tumors than from large oubb.
Orowtbs below the cords usually affect the voice by being forced upward
Tuk. 190.— rANLLOMA or Riarr Vocal Coeo. ru. IBl.— Pakixoha or Lartkx. Supm-glotUa
daring expiration. Those upon the veutricnlar bands usually cause no
alteration iu the intonation. Tumors npon tlie epiglottis and ary-epiglot-
tic folds do not nsnally alter the voice unless they become very large.
Cough is not a common symptom, but it sometimes becomes very an-
noying. Dyspncpa is preseni in only o small pruportion uf cases, usually
being inspiratory and sometimes paroxysmal. According to Morell
Mackenzie, these paroxysmal attiicks are due to sudden swelling of tho
mucous membrane in muj^t cusce, but octrusionally to an unusual posi-
tion of the growth. According to hewin, if the inspiration is noisy aud
stridulona the growth is probably above the cords {Deutsche Klinikt
1862). If interference with expiratioii occurs, the tumor is usually bo-
low the cords. Dysphagia is much leas frequent than dyspno-a.
Papillouata are usually located on the upper surface or on the free
margin of the vocal cord, but tliey may occur in other portions of the
larynx. They are genendly of a light pink color but may be white or
even red. They usually have an irregular, oauliflower or raspberry like
snrfacc, and vary in si/^ from a few millimetres in diameter to a mass
large enough to completely occlude the larynx. They iire sometimes
pedunculated, but most commonly they spring from a broad base; they
30
peduucuh
U
46«
HIS BASES OF THE LARYNX.
we generally single but not infrecjuontly ninltiple (Figs. 153, 154).
These tumors are nsaally soft and mny l)« readily crashed or torn off
with forceps, but sometirnetj they are quite firm.
FiDitoMATA ftrc uaually observed as amull, round or oval pedunculated
growths (Fig. \hb) of a grayish or re<ldtah color, und nrcmost frequently
attftohed near the (interior extremity i>f the vorail cords. Thty vary in
size from a x>iu'a bead, to ten or tiftccD millimetres in dinmotcr, thongb
Fta. IH.— PArau>iu or Vocu. Ooitwt.
Fia. 153.— Pafiuoiu or Vooal Ocoom. ,
they seldom exceed the size of large pea. The surface of these tumors
is usually smooth, but it nuiy be rough and irregular; they arc firm und
reiiistitig when touched with the probe. They uro generally, though
not iiivuriubly, single and pedunculated.
FiBKo-CK].M"i.AR Ti'Mints conslst of moro or loss perfectly devel-
oped fibrous growths, having a uerous like fluid diffused through their
substance (Fig. 15(3). They arc small, pyriform or globular growths hav-
3
Tn. IM.— Papillomi ur Larikx.
FlQ. US.— FiaROMA or txrt Vocal
ing a smooth or slightly irregnlar surface of a pale pink or reddish hno.
They arc usually pedunculated, but may be sessilti, and arc generally
tittached to the vocd eonls or Ijiryngoil surface of the epiglottis.
Mtxouata, or true mncous polypi, are seldom found in the larynx.
Thoy are gonenilly of :i light gniy or pinkish color, cunimonly tnui»>
Incent; the surfiice may ap{>ear smuuth or irregulur, and they are soft
to the touch.
Cystic orowths, whon found in the larynx, vary in color from ft
light yellow to a red, and lirc u&uallv surrounded by a zone of congested
mucous membrane. They arc round or oval in form, and generally ariso
ffbm tho ppiglottis ur ventricle t>( Morgugni. They varj' in size from
three to fifteen milUmelresiii diftmetcr. They are orUiuiirily filled with
11 seirii-fluid, sebaceous like material.
Tib. W.— Fiiii.ti CriJ^XAB Ttmoi
ox BtoBT Vocal Ooiu>-
no. 197.— Ctwric Tinaa jirmcmNe Bam Od^
Lbpt Bioc or CrioLonu.
Fascicvlated Bv^bcomata, adenouata and lipouata possess do
chanicteriatic appeaninces, and are extremely mre. They may spring
fruiD the epiglultiH or nuicotiR niemliraiic uver tho arytenoid cartilugei
or other parls outside the Urynx, but not nsually from within it.
Pio. 159.— Crsnc Okowtii ik Kiobt
VorrfUocLAa R*m>.
Fio. jafc— Ctbt of EpioLomi
(Hack ■!(»■).
CAKTiLAiiiNors TUMoRa are extremely rare. Fig. 162 illnstratev
one of this variety growing from the lower p«rt of the thyroid cartibige.
It liad a Bmnoth mucous covering, was of a yellowish color and oartl-
lagiuons consistence.
V^ 149.- Aoxxoio TvHUH or tuk LahyHx.
Flo. Dll.— Adckdii) Ti^uoH iiF luftirHX,
IMVul.VI.\a V EXTKIVL^ or MoHOAQSa.
An'OIOMata or vaseulur tumors are also very rare. They are dark,
tlackberry-Iikt* in color Jind iippearance. They are «oft, and bleed easily
When tout'hed, and may give rii<e to aovere hemorrhage if removed.
Diagnosis. — Gmnulation tissne ench as is frequently found in tu-
bercular laryngitis might closely resemble papillary growths, but it is
468
DISEASES OF THE LARYKX.
nsnally lighter in oolor and softer in consistence, and more or less cot-
ereil by the sumo socrotions which are seeu upon the neighboring ulcer-
atPi] Burfaces. The nffectloiis most likely to bo mistaken for benign
growthii of the laryux are syphilitic or tuberoiUar lur^iigitis, lepra, lupus,
v
Fie. IfliL — CAmTLAGiNors
TntonorLAtiTM. Sltukted
Just Mow Uu! vtK-jil c>jnl
Fin, nW - V*«-ii_»»iToitonoi'
Larvxx. orv'oLvi.vo Sukfack or
RiiiBT Vocal 0>bd.
FlO. 1W.- Nam 1 taw Ti'»>« cv
LaRtiOC. Of a. lir^p llvul cAof
and naphrrrj like Mirf»ct>.
fibrous, carlilagiuous, or lymphoid outgrowths, eversiou of the ventricles
of the larynx, and malignant tumors,
Benign growths of the larynx are distinguished from syphilitic con-
dylomata as folloH's:
Bekiqn oBowrns of the LAn\To:.
ComraoDl^' in middle aud odvuuoed
life; occasionally in children.
History' of cx>Dtiuiied local hypera:-
mia.
Usually found upon the toc«1 conlii
or veulrii'iitar handt).
Distinct line-of deinarcatioo betTveea
growth and Burroundta^s.
Usually DO iik-cruUoii preseat.
Operative measures usually neces-
aar>-.
S^THIUnc COXnYl^MATA OF THE
LAB^-SX.
CoiDiiioaly in early aod ratddle Utt,
Hi^tury u( mfcction; appearance Hvc
or six wfwkti lifter inocnlatiaa.
Uoiially ntuated at back part of Uw
larynx.
No distinct line of demarcation.
Ultvratioi) frequently present.
Rapid disapp«araacfl under aittj-
syphilitic troatment and use of local
aslriagi'Uta.
Benign growths of tlie larynx are distinguished from tttberoaltTj
Iar}'ngitis as follows:
Bbnign orowths or the larvn^x.
Ko cachexia or iHilmonarj' (]i!>cas«.
Absence of pain,
Hypencmia or normal color of mu-
coas membmae: DO ulceration or |)e-
culiar i( welling.
Benig-n pnpillniT tumont Icutt iietstte
than tuberttiiUr graDulaUons; no pu-
rulent secretion.
TUVERCtrLAX LARVyORIS.
Usually grave constitutional symp-
toms and signs of associated pulmo-
nar\' affection.
UituBlly jNiin/ul.
Pallor of the inuoous roemlmnet
with pectihar sn-elling of Ihe aiyte-
ouulh ami ii|(-i>fat.ion,
Tubercular fun^'oun Kninuiationtkar* '
of li>;lit ixilor; appt'ur as tbivtieoiii}^
ralbur tlinn outgrowths: and ore as
sociutdl with iiKvnitiou uud jniridefll
•ecreiion.
BBNWN TVilORS OF 7'HE LAHVyX.
4G9
Lejfra of the larynx is ftsaocinted with eimilur nuinifestAtions npon
the akin. The epiglottis nnd low^r \iarts of the hiryiix are likeljr to
be swollen iiuU nodular, but no distinct tumors arc present.
Thickening and noduUr ouigronths, vhich arc generally soon fol-
lowed by uk-eratiou, are caused by lupus ; und in noiirly, if not quite all
cases the diiienHO in the larynx la preceded by ulceration on the face or
in the fauces, wfaieh will materially aid in the diagnosis.
We can recoguizo oufgrowth.'i of various character as merely thicken-
ing of the tissues, lacking the distinct demarcation of true tumors.
We might possibly mistake evenion of the tvntn'cfe of the larynx for
II tumor, but the condition is so extremely rare that the error is not
likely to occur.
Generally mali(/miiii tumors may he recognized through being more
thoronglily blended with thu surronuding tissues, which become irregu-
larly swollen and thickened so that the tumor does not stand out dis-
tinctly, an appearani*e Tery unlike that of benign growths. In some
oases whore diagnosis by inspection is extremely difficult, the presence
of jHiiu, the cunstitutiounl symptoms apparent in the later stages, the
ulceration of the growth and the microscopic appearances, must all be
considered lu drawing a cunolusion.
pKOUNOiiis. — The growths tend to increase in size slowly or rapidly,
according to their ehanwrter, except in very rare instances of papilloniata
where sponUineous atrophy or expulsion may take place.
Growths in the larynx which cannot bo removed are always danger-
ous, especially in young children, in whom smallness of thu organ and
<li«poBition to spasm enhance the danger. In children, these tumors are
more dangerous than in adults, because of the difilcnlty of cndo-Iaryngeal
operations, and the less favorable results of tracheotomy; an operation
which if succestiful, removes one of the serious dangers by averting
the tendency to suITocntion. This operation, however, is often grave in
yonng children, and is far from being devoid of danger in adults; for
iji cither, a fatal bronchitis not infrequently supervenes. As regards
the voice, the prognosis is favorable where the growth is single and
Jjcduuculated and an en di> laryngeal o|>eratiou can be performed. In
the opi>osite condition the prognosis is necesjiarily less favorable. Some
fonna of papillomata show a strong disposition to reproduction after
femoval. With the exception of sarcomata or carcinomata, other laryn*
geal growths seldom recur.
Treatment.— Small growths in the larj-nx situated above the vocal
oords commonly cause little or no inconvenience, and often, especially
"^bcn fibrous, enlarge but slowly. In such instiuces, active inter-
ference is unnecesaarr, provided the growth can be inspected once or
twice a year. Even when the tumor is aitaaled upon the cords, causing
more or less complete aphonia, it is frequently wise not to interfere,
especially in the aged or in those whose occnpation renders the voice
470
MSEAfiES OF TifK LARYNX.
relntJTply of little imiMirtanco. Kvon the most fikilfnlly p«rformcd
eiKlo-IuryngPtt! ojit-mtions jiro not entirely do^oid of danger, and ooca-
eiunally they i-xeito sufficient inflammmion of the soft i>]trts> caniUj!*
or perichondrium, to render tnichcotomy necessary; and it is poHibl _
though not prohnMe, Ihut the irritation of frequent attempts ot romor>l
may cuiiso a ix'^ign growth to luku ou nialigiiiiucy.
Palliative trejitment consist* in tho iippliuilion of various ostringt'pl'
yenicdies, wiiich soniptimes apparently retard the growth; and wlierc
roepirutioii is seriously impedeti in the perfornwucc of tnichcolomy *'
the introduction of an O'Dwycr's laryngeal lube. Tho lattur » to ^
first reeouiniended in most casus, becuisc tbo pressure which it exer^
may possibly cause atrophy uf ihu growth, and tliy rulicf of dyspiiu'i^ *•
neually coniplutti exoejtt in easeji of largo tumors at the uppor part ^^
tho larynx, which may fall over the opening in the tube.
Itadicid trwilnieiit for the destruction or tho removal of ihegrov**
should in nearly all C!i«es he carried out lhn>agh the natur;il [uw^gr *
the endo-laryiigeal method; but in exceptional instanceti; laryngol'ii*
or a combination of the exo-lar)'ngeal and endo-laryngeal methods :nj
be i'e<|uirod. Tho endo-!aryngo:il removal of ueoplaems may be actoc*"^
pliehed by chemical or mechanical means, or by a combination of if*'
two. Local treatment by ai^tringuuts ur mild caustics is sometimes \ww'
enciiil, especially in removing concomitant inflammation, and so poKsihl
preventing incre^itH'd growth of Die tumor. Mild c-austics have littS
effect ni>on the growth ilaelf, bat nccnmto applications of escharotiw
especially chromic acid, are not infrequently followed by most siiiisfjitT-
tory rest! lis. The same maybe a:»id of tho gjilvano-cautcri- and. wiif
less confidence, of solid silver nitrate. Usually before any etido-larrn
goal npi-ration is commenced for the removal of growths, the parts slioulJ
be thoroughly nnwstbetized by sevenil applications, by spray or swab, «]
a ton per cent to twcnty-ftve percent solution of cocaine or tho solatiurv^
recommended for nme^thclizing the nasal mueona membrane (Fnrm--
14.1). This done, silver nitrate or cbrnmic acid fused upon the end ul
an uluniinium probe» and protected to pTorent contact with othpr poi
tions of tho larynx, should be aocuratoly applied to the growlh with.
tho aid of the hiryngoacope. The skilful laryngologist may sometimefc
apjdy the e8chan>lic without injuring other parts, by means of an ari-
guarded probo, but it is Kifcr to employ some of the various instrument« de-
signed to prevent acridentjil contacts. The simplest, and to me tiiemost
satisfactory injttmment ia n comfMiratively stiff alnminium-wire prolje,
over whicii lias been slippc-d a seetion of small rubber tubing nbont
half an inch in length; about this tubing is ticd.with a ulip-knot, n piece
of silk thread which is then wound about the stem and carried up to the
handle, thus preventing the postiibiHty of the tube slipping olT into ths
tnchea. Tbo tubo is slipped upwarti upon the stem while the caustic
u being fused upon the probe and is pushed Isick to the end of the In-
BEN to N TV MORS OF TUB LARXyX.
471
utnent when it li:i8 eoulod. Whcu it is desired to ciiaterize with the
i of th« probii onl}', tbc rubber lube la pusheiJ dowu far enough to
nplettily protect Ibc c:iustic, for ua the iustruincut is {}rc£sed upon
J growth thf ehiatifity oi tho rubber will hIIow thi* end to protrude
ifioiently. Hj however, it is desired to touch the tumor with the aide
Fro. lU— CoKHox LAsryacAL Foucxm (M sL»). Thtse an inatpiog and cutUoK torae^
t Bt itv proper ongte, and wiUi beak ot Uie m>ed«d lengtli. thai tite larynx maj- be roacti«d
the probe close to its end, u small piece may be cat out of the rubber
)e at this point, which cau then bo turned so as to expose the proper
rt. Thia waa Khuwu uiidor tmehoiuii of the vocal cords (I'^g. 110).
As fioou uH the escharnliu hue been applied, the insiruuieut is quickly
ibdrawn without injury to other tissues. Various other instruments
478
DTHBASKS OF THE LARYJfX.
hftTO beeu devised for thia purpose, tho must BatiBfactory of vhicli an
those recomiiK'udfd by Sajoiis, of Pluhidflj»luii, and Jarvis, of New York.
The giilvaiio-cuutery U ttuumtiinee an exeellont iustrumeni for d^
stroying these growths. It ia important that the electrode employed
abould tui von small platinum point which will heat or cool rapidly, other-
wise much damage may be dono to surrounding tissues. This <ruuter}'iB
nioro diflicult to use than chromic ucid, and is usually less satisbctorj
iu its results, though in some cases it is prefernble. The most satisfnc-
tory handle is one in wliich the circuit is closed by rcmoTiug the finger
from the button (Fig, 111), instead of oue iu which the button muBt
be pressed, as the former causes leas movement of the end of the
electrode. The niecbuiii'.'al treulmeut of thcae tumors is carried out
by friction, evulsiou, and crushiug or cutting, which may be perform*^
by various snares, ecraseurs, forceps, scissors, or knives.
Tva. IM.— Uactkbnsib'b Tcbe FoecKra Oi ordlBATf alie).
Ab a rule, patients cannot be operated upon under general anfestheel
niileaB tracheutuiny has tirst beea performed; but since the discovery o'
the local anavthetiu properties of cocaine, it is seldom necessary to do *
preliminary trachentomy except in young children.
Frktuni — I'olftflim'^ Mefhvd. — The simpleHC and sonietimee the mort
efliciont measure for mechanical destniction of laryngeal tumors is pe^
formcil with a sponge firmly fasteficd to a staff preferably made of nial-
leablo steel. This is pajiscd into the lurjiix, and, with the tinger and
thumb of the left hand holding the organ as firmly as jiossible, it is
rubbed vigorously up and down fur two or three times uud then re*
moved. The openition may bo repealed after a week or ten days. In
case of soft tumors, it will frequently be successful. This operation is
pecniiaily adapted to the lar}"ngeal growths of infants, which arc gen-
erally Ufa papilliiry cliaracter and difficult to remove by forceps. In
tht«e patients it is more easily carrifd out if tracheotomy has first been
performed and a general ana-slhi'tic given. The probsing may then be
carried into the larynx by the aid <»f tho index finger of the left hand,
and tho treatment accomplished without pain. As a rule, an expert
may do this o|>eration without previous ti-acheotomy, but O'Uwyer's tube
or .Schriitier's dilator should bo at hand for use in case of prolonged
spusm of the glottis.
474
DISISASSS OF THE LARYNX.
Cmnhing miiy sometimee be accomplished with stout forceps^ and
is espooiBMy applicjible to firm growths wherp iindne force would be
Ufcetisiiry for their evnlsion. Not infrequently a tumor which has beea
firmly nipped with forceps will be found to atrophy aud completely dis-
ai>pL'ar within two or three weeks.
Cufiijt</of>fr/i/iQ7i8 arc tiiost fret|ueutly accomplifihcd with cutting far*
oeps, »imrc8, or ecraseii ra^ though geisgorktrind kuivesarc sometimes useful.
,\ guiirdod instrument should generally be selected for the purpose, and
none hut experts should use any other. Kor the reniovul of firm growths
fionic form of snare, f^uillotine, or Mackenzie's guarded-wheel ^craseor
iij ]»eculiarly serviceable. It is not well to repeat attempts at reniovid
of thvse tumors mure than three of four tinier ul a sitting, becaase ^
the danger of suttiug up undue intlamnmtiun or possibly ujdoiiia.
FW. IflS.— ToMLp'a LAHYirasAL KxiVM m •(■)}■
After the openition, it ia my custom to have cold applications made
to tlip neck for from twelve to twenty-four hours, and subsequently to
apply lu the larynx oitco u day, or \v&i frequently, some mild astringent
spray fur the purpuse of reducing congestion.
Kxtm-liiryngeal mothode, either by tracheotomy or thyrotomy, are of
■doubtful propriety in most casee— excepting where a growth interferes
with respiration or deglutition — because by these operations the vocal
fnnclion is apt to be entirely destroyed and life is often endangered.
TuYKOTOMV.— It is o<!<:»»Jonidly, though not often, necessary to do a
])reliminary tracheotomy when thyrotomy is to be performed, but then
the liittfT opemtion should Iw delayed for several weeks, and in th©
mean time the surgeon should attempt to remove the growth by cndo-
lantiigoal mcitiis or through the opening in the tmeliou. For division
of the thyroid cjrtiltijfe. the pntient should bo placed with the head
bunging over the end of the tublu, in the lap of the surjieon, who ia
seated at the eud of the table with his back to the window. The pri-
mary incision is made in the median lino from the cricoid cartilage to
the thyroid notch. The thyroid cartilage should then be carefully
dividiHl with a strong knife or, if ossification 1ms taken ptucc, with a
amuil circular or convex saw. If possible, a snuill portion of the upper
part of Uie thyroid cartilage should be left intact, in order that the parts
may be acouratuly approximated afterward, so as to maiutsiu the proper
BBNiajV TUMOHS OF THE LAUY^X.
475
ivlation of the voottl eords to ciioU other. In order to nvoid puroxysius
of cuiighitig, grtutt ciirc should liucxcrcUed lliiit the iiistrurnOMl doL-M not
jieuetrate through the iiiucouii irieiiibniiiu into tlie hirviix before the c:ir-
tilagp h:i8 heeu thoroiiglily divided. Wht-n the divUlou ia eoniplute, tlie
ahe should bo drawn npart by blunt pointtd retriietorn. If this c;innot
be done, the erieo-thyroid niembmno should be divideil along the lower
border of the thyroid cartilage, on one or both sides 119 mur be found nccos-
Kiry. The division of this membniue, however, is cjuilc Jijtt to tnjnr(>
subflerjnent vocalization, owing to tlie direc-t eontinuity of the roeal cords
vith it, ns poiiitcHl ont by Joseph I^eidy (Transactions of the American
liaryngohtgieal AssotTiJition, 1H8(i). If the opening Htill remains too smnll
the thyro-hyoid monibrane shanld l>e divided nlung the upper border of
the thyroid cnrtilnge, but this is not generally necessary, and eliouUI be
avoid od if possible. When a snffieient opening hns been attflinc<l, the
ohe arc held b:iek with retractors, the euvity is carefully eK-iinsed of
blood, and under a bright light the tumor is scizud with hook ur furcops
and torn off or divided with strong curved sciiisurg. After the growth
has been removed, Muekmzie reirnmmends that the huge be thoroughly
cauterized with soliJ Rlircr nitrate, whieh, he stttes, 1.; less liable to
cause a 8nl>g(K}uent laryngitis than the galvano-cnutery, or other cscliu-
rolic, Hn<i seems qnilo as cHicocions on a raw surfaiw (l)ijM*it»c8 of the
Throat ond Xosti). The alai of the thyroid are then earcfully «p-
proxiipul-ed und fustcncd together in tiiclr normal position by two
silver sutures, uud the e'ges of the wound carefully closed. If traehe-
otoniy has been previously done, the tube should be alluwud to rLMuain
until all danger from htryngitis has passed und lliu surgeon is confident
that no other opemtiou will be needed for destruction of the growth.
Sometimes the firmm-s^uf the tumor or iIk exten»ivfattadimQntt* ]>re-
vent perfect removal, so that the operation must be abandoned without
Iwiug completed; in such instances, as much as possible of the tumor
should be removed, and the cut surface thoroughly cauteriKtHl M-ith
silver nitrate. Krishaber (Tail's C'iiuiqnea de Laryngotoinie, Paris,
ISGli) says that divisiou of the cricoid carlihigo is never neccasory for
the rentoval of tumors above the cords, and that those below can he
■Wsily removed through the t-ri co-thyroid membnine or Dh* opening in
tlie trachea. The opuration, though not extremely dilTii-ulL is attended
by some degree of iutmediute or consecutive danger to life from primary
or secondary hemorrhage or inthtmmiition of Lhu air puRHages; therefore
it should not be undertaken without due consideration of the possible
consequences. Mackenzie has shown that in the majority of aises 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.
SuPBA-TUYHoiD LABYNooTOMY 13 accomplished by ft transverse in-
cision through the superficial tissues and thyro-hyoid membrane, either
along the lower border of the byoid bone or the upper border of iho
DISSAHES OF THE LARYNX.
tliyroid cariiUige, II is less dangerous than division of the thyroid c«^
tiliigo, but it lA of very little service, because the growths which couli
be rt'nioved by thid method can usually be equally well removed tbrot::mgh
the moutli.
IsrHA-THYBoii) t.ARYxnoTOWY, that 13, through the crico-thyir~oi<l
menibrAne, acfonling to Mackenzie, has been strongly recommended ht
P»ul liruns for the cxtir^iatiou of growths originating from the ^Ftm
borders or under surface rtf the vocal cords, or below the glottic, provi ^ej
pn>vious endo-laryngoiil oi>eration8 have been unsnccessfiil. Someti "^ea
division of the membrane alone is snfileient, but large or sessile tnic^ors
may require division of the cricoid cartilage or of some rings of the 'ds-
rhoa also. The ojwration i^ done in the manner recommended for cr aoo.
thyroid loryngotomy, hut all soft tissues are cjirefully dissected out f a-oui
tlie crico-th3rroid opening, so that only its cartilaginous borders retn«iio.
A canuta is then inserted and allowed to remain for several days n ntil
acute inflammation has subsided; it is then removed, the head is tfarova
back so as to make the opening us 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 tho inflamnui-
tion has subsided, the edges of the wonnd should be drawn hack and the
attempt made to remove the tumor. The patient shonld wear the
cunulft for a few months afterward, until the surgeon is conTinced that
recurronco will not take place.
SIAUOXAXT TVMOE8 OF THE LARYKX.
Tlie term cancer of the lar^'nx embraces a variety of tumors of vldch
epithelioma is by far the most frequent, and sarcoma next. Fouvel,
Cohen. Uosworth and Gottsteiu also recognize medullary or encephaloiilt
and strirrhous, as possible varieties of cancer in this locality. Sticfa
growths give rise to hoarseness, dyspnwa, pain, sometimes dysphagia, iii»l
finally, in must cases, to that peculiar cachexia which generally attends
malignant tumors.
Anatomical and Patholooical Characteristics.— The growtli
of these tumors is first mantfesteil by localized hypeneraia, with thick-
ening of the parts which gradually increases, progressively involving all
tho Bultjacent tissues in the cancerous process. By a process of cell prv-
Ufemtion a large irregular tumor is formed intimately blended with ili»
surrounding structures and early undergoing ulceration, which ultim»n>ly
causes deep and widespread destruotiou of the jwrtSL. The microscopi-
enl apiMvimnops of these growths, and their canses, are similar to those d
like growths in other localitieB.
Symptomatology. — The symptoms var)- with the siie, location, and
condition of the growth. Pain, usually lauciualing in character, is cwd-
MALIGNANT TUMORS OF THE LSBYNX,
477
ily present. Tliia, at first, is generally coiifiued lo ibe larriu, and is
nyl particularly severe. butaftoruU;erdtion i>ccurs, it becontea intense and
Jrequenlly mdiates to the ears and opfjisioniilly to the Bubmaxillani' nnd
cerrical glantls. Muokcnzio stttes that early externa! evidences of laryn-
geal cancer ore seldom present (Diseases of the Throat and Nose).
VM. Its.— CftKn OF La^na. RNt«loulc.
rio. 170.— CxKcn or Ljuukl
AJ7-t-plK*oltie fukl.
V In most cases after the disease has progressed for a few montlia the
submaxillary or cervical glands, especially those near the cornuaof the
hyoid bone, will be found affected, and undue prominenpe of the thyroid
cartilage may be seen or felt. In rare case.'} nlceration extends to the
surface. Iloartseneas is an early symptom, bnt the voice is seldom en-
tirely lost. Dyspntiea on exertion is frequently an early occarrence^
and later may be constant or subject to severe paroxysms. When ulcera-
tion has taken place, usually the bre:ith had a peculiar fetor which lA
EpiCMOi
Fie. in.— Ojiwsa or Lai
almost diagnostic. Sensations as of a foreign body in the throat canao
freqnent efforts for its expuUion, but cough is not a prominent symp-
tom. The amount of eecretion from the ulcers themselves is not very
large, but there ia profuse salivation which causes the patient great in-
convenience or distress. The sputum consists of mnco-pus, frequently
tinged with blood; sometimes there is profuse beniorrb-ige. Dy8j>hagia
often attended by some pain is an early symiitoni wiili jdiaryugo-
laryngeal epithelioma. When the disease is confined to the interior of
the larynx, this symptom is not experienced »o early, bat later it is
^^ways present.
^H Upon inspection the neoplasm appears at first aa a drcamacribe^
478
DIHBS.SES OF THE LARYNX.
areo of congeetion and submacoua thickening, tlie 'ooniors of trhkli
are not well defined. Usually it is located upon ono of the voutrieuUr
I>anda: but occaeionnny the vocal cords, opij^lotiis, or ary-cpiglottk* lolda
aro liret affected. In color the growtlie vary from light red to scarlet.
Kpithclioumtii uauiiUy have the deeper hue. The most elmracterislic
Pio. ITS.— CiiiCEN or LAsnnL
V«ati H.-ular Uands.
feature of malignant tnmors in the larynx is the great deformity wtiicb
Btt«hd8 their progress. As the process of jtrolifcrat'on and infiltnition
of the surrounding tissues adviinces, the growth whidi at first Hppeored
as u litiiitud area of subiiiueuuij thi(:ki?iiiug without well detined bordere,
presents a raised and irregularly nodular surfact!. These tumors duty
be single or multiple, and usnally attain a targe size — two or more
centimetres in diameter. Laryngeal farconmiw are soft, light in color,
bleed easily, and ulcerate early. In epithelioma this process may be
Fio. 175. FlO. ITS.
Fro. ITS.-Miuu Saiitom.*. This tamorwaa fonntl in a man about flftr feanoC o^n. who
bMO troubled with dj-irhntila for abortttwuj'narK, aiul wUh Bouw djrRium* for a Cvw hmoUb. The
Kmwth wm m flrni m to rmbrt aUempW at t^Tulsion or cnnhlnir- I. K. Datiforth uuilr a niino-
atopic exaiutaMtloii of BoiiMK pontons which I refnored, andprooaiiacnUtaitiixiilmnxmLB
Fio. I7&— Oa-Ickii or tus Luarxx- Vocal Cord. TMi ffrowtb was Rupfx'iw.d lo i«, n Blmpk
pairtUuina, but a mlcnitcopli- exaiiilniitloii >Jtt<Me(l it to be of a wtul-ntaligDant trliiiraiTiiT. Aboat
four trevka af t<*r Its n>niovaJ, tike iUa«a>e appeared In Uie raaUtcular hUKl and at7-cft>|tk)ttte raid,
and raa • ra|4d coureo.
long delayed. In either case, whether occurring early or hite, the ul-
ceration steadily progresses without any attempt at repair. AVliere both
the pharynx and the larynx are involved, ulceration usually first occurs
at tlic free edge of the epiglottis or on the glosso-epiglottic or ary-
epiglolllc folds, and r)uipkly exteinJw to the deeper jiortions of the larynx.
The epiglottis is frequently so much swollen that the lower portions of
MAUO^fAST TVMOSS OF TB£ LARYXS.
4T»
''^ynx ojutnot be Been, but ooeuio«uUj it m dovly dtstrojred willi-
^^*^U tumefuctioD. I'lc -'LalljOMUMUCojU ftiiagle pout,
SH sometimes two or iu<i led tfoU Hajrbft mum in the be-
WlieD the duetw ia wlT%Dced, % hrge farfuv or tbe whofe
>ft ^^ ^^ tumor uppnin in b Male a< fsagDOt aliMiiiiii^ Uitfced in no
^'JisiTti, purulent st«relion.
1 Auxosis. — In the eju^r Bills'^ an aoconl* SmgoaA^ of csDnr of
^ ^O'tix if often diffirnit ttfkd raaj he iMpnowWf, bat m tb« diMnM
KY%«ee« it Lun gpoeraUv be reabdHr noogniaBi W tW experiouod
^J^^Sokgist. C'aDcrr of ibe lairnx is to be dHUDj^akhtid from
^P AiUa^ (tju^Qj j. catarrbiJ inflaminatjan,inpas,tabofenlBr lai7Bgitif,nod
71**'^ grovUu. The ceMtntiAl point* in tlM iTiignwig an: tbe ■«»
th« paiient, the pain, irre^lar ihirfcewing with nnrlcod deiprmitj.
.^^^^uire Bloeniios, gtandnLu* entargeacat, sad the Morcaeopic np-
.. ^«Bcwr of the Urrnx is dictingniibad fraa ijyifltf by tbe hiatory,
^^ nfaaeooe of cicatricial tiaaa«» tbe Bum or lean diitif* twaor fautcad
^' simple tfaickenisg, tli« piogiaaiifa ■leenAaon in spite of traatmcnl,
^1^ ia aene coetr by tbe cuwcniBi mrhnia aad hj tha aSact of tiw
^4idM on the body weighu In tertiBfy irpfailii five adiniiuHiatioa of
^*^ iodidei, u a mle, io speedilf foUcrved bj incnaae of v^bi, «iih
^'^httt aridcMca of fenanl iiapmieincBt; ahcfcai in ■aijgiiaat dlwaif^
^thoogb at int ^ght iaBpswraneftt aaay appnreatly fonov Iha adBin*
^ratioo of these remedies, it i* boob obaenred that the weight ia atsadfljr
O'^nJBJahtnr and the atxcDCth f^jTittr
Graat thicfanfag aeUon, and large nleemttng loaon never, aiiee
fiva dtrtmie tatarrkmi im/immmati^m of the larynx, akho^h aeoaiionallr
QOBiidenUe thickeaiag and dcf»nit^ of the porta la priasal; hot in
theoe iaaUaoea the UatoiTof tiij fininHnarl iaJaMoiaMiw bin! ■bainn
of the pecollar lanriaathif pnia, of deep nlnialjaii^ orttf m i— lig—nt
Cachexia and of the glandalsr mkrgcawnt salaUiih the Jlisgnssii
We hare in impiu a devij pngraaave diMaaa eeearrJng SMot oAbb
in Tonng a«byect4 ; ita dtiilmMtwl in the Unrai is featsdad bf lla ap>
pcanaoe apoa the &ee ar Caaeak It i« rttrnded by tiula or ao pnio
aad cempawtHair ■%>* awrffcg The ■katatiaa piiipaaasi batalewly,
aad npatr aar USkm at aaaw paiac^ Than is aoi the aaffhatia mhiA
is ffttqaaatly ailiiiassil ia th* fatiesfta of aaon adf aaead aga saCsrfaf
Osaev af the hryas ia £iti^pUbad fraaa /aJarvalar JEoryafiifu by
Iha hialaaT, the afcvnoe ai firtaMiij diasaBs a^ aaraia aaa]|iu th»
af aa irrefabr toaer la^sail of iha aeea ar la» aaifona
andthada^diatiaitJM aliarKiiia, with the firafcirfcaM
braoO. IatafacfcalMtovhMlhaap4||lBttiaiiiav«ltad.avdBSaf feacn».
parstirdy naifbna mct the afaale valve, aad arhca the aiyleaesde «r
ary-epigMtie falda ara rf^ad that* is afiiisfiii pyrifona
480
DISEASKS OF THE LARYIfX.
comiDOitlr on both fiidee^ not obeervod in CAnocr. Tho swollen tiwaes
in tnberculosis, eo long as nlceraliou has not taken place, arc usuttllT
lighter in color and less dense thiia in the malignant tumor. The sar-
coniaUi have an irregular surface and the apjieanince uf an abnornutl
growth, quit« di^Ltnet from the more or lesu uniform KwelHng of tub^?^
oulosis. \Vhen ultieration takes place in tuberculosis, it is usually pnper-
ficial, tliougii Bonictinics deep and destructive; but by tlie time the lat-
ter occurs, tho hectic and cough, the cachj.<xia and ]mlmonary signs, will
at once indicate the nature of the disease.
In the early stage or until ulceraliun ot^cnra, it is often rery diCBcnlt
to distinguish malignant growths from l/eniffit tumort. During the
course of cancer, before ulceration has occurred, the ago (past middle
life), tho pain, the irregularly defined tnraor of a dirty gray or bright
red color, with almost constant glandnlar infiltmtion in phuryugo-
liiryngeiil cancer, and tho occasional occurrence in intra-htryngeal cancer
of glandular eulargomont farther down the tr-.tchea at the root of the
neck, renders the ditignosis fairly certain.
Phoonosis. — Cancer of the larynx sometimes terminates fatally
within from three months to a year; but the nrerago duration is about
oigliteen months. Kpitheliomn is snro to terminate fatiilly, though life
in some instances may bo considerably prolonged by operative moMurea.
Sarcoma may probably bo completely eradicated in some cases. Death
is finally ly^nsed by inanition, ai-theniii, af^phyxia,, or hemorrhage.
Tkkatmkxt. — All medicinal means have proved inefficient in check-
ing tho onward progress of the disease. There are certainly no spccificf,
and all dnigs fail in the end; even those which are held in most es-
teem, such as arsonion.-i acid, calcium sulphide, iodoform, carbolic acid,
ergot, mercury, and turpentine. As a palliative rem<'dy to relieve pain,
opium in some form, and belladonna or cocaine are of importance.
Morphine, tannic acid, and carbolic acid locally (Form. 13f, 1-18) ren-
der the nicer less painful and offensive. Continnous heat is especiully
Taluable in relieving the severe cnruche which often attends this disease.
Anti-^rphilitic remedies should be thoroughly tried in all cast-s where
there is any doubt us to the diagnosis, and sometimes they apparently
check the progress of tho disease foi a short time. Surgiad measures
should be adopted in all suitable cases. These are: endodaryngeal at-
tempts at removal; cndo-laryngeal rauterizatiuns; tracheotomy; resets
tion of tho larynx: extirpation of the larynx.
It frequently happens that the true nature of tho laryngeal grovtii
cannot be determinetl at first, nnd under such circumstances it£ n»-
moval by endo-laryiigeid methods should be attempted when there is
any probability of success. In a donbtful cuso portions of the tumor
should be subjected to microsmtnic examination and if cancer is demon,
stnited, all endo-laryngeal operations not oak-ulated to elTert complete
crsdication should be discontinuod, ejccepl In extreme cases where re-
movul of portions of tho growth will prevent suSocation. In cancerj
pariiut upemtiuus upon the tumor ustudlv itccclcratc Ub growth.'
Leiiiio.v liroft'iiL* ('* Discuses of llie Throat," second edition) recom-
mends endu-Liryiigcul cuuterizutioiid in ceriiun coses confiiiud to the epi-
glottis and not susceptible of reuiovul. However, he justly reiiturbH that
he ftmrs the beiieflt of such itieusurea is but tein])orary. Though I huve
never pruclised cauterization of laryngeal cancers, my experience M-ith
it in umccrous growths of the nasal pusgngos lends to tho belief that iu
this ortectiou, as a rule, it would bo productive of more harm than good.
Tracheotomy to prevent suilocjlion is frequently neccssiin.', and may
proloug life fram three to twolvo or even eighteen months. In case
of myxo-sarcoma, I huve known life thus prolonged for four or five years.
Itesection, or p.irti:tl extirpation of tlio larynx, in suitable cases,
hue been attended with very favorable results, where comidete extirpa-
tion of the dise.ise is possible by removal of the epiglottis or tiie lateral
half of the larynx. This operation is indicated in small eiido-Iaryiigcal
epitheliomata confined to one side, and iu aarcomata not yet markedly
infiltrating. It is useless when the larynx is invaded from the phaiynx
and whenever the adjoining structures nnd cervical glands are involved.
Immediately fatal results have follcweil this operation in only a small
percentage of cjiscs, and usnally life has been very considerably pro-
longed; in a few instances tho disease seems to have been completely
eradicated, Tlie folluwlug description of the operation is taken from
the report of a case by Lennox Browne {op. cit.):
The patient bein:? BnGe<ithetizt:ii n liikrh ti-achcotoruy tvos dune, and Haiin'i
tarapOD canutn introilticed lor twenty tniniile^, wliicli tinit> was allowed fur the
cunipi-essed Rpon;^e iibout tlie cunula tu ex|iuii<), A tueiUaji iticisUm uvpr tlie
thyroid was made from just ahovM ihu tracheal opening to tlio liyoUl bone. The
tissues were carefully diviiU'il ilown to llie tliyi-oid ami L'rifoid furlilu^ ; the soft
|iart«. will) the perichoadriuiii, wi-re cai-efiilly lift**!! with a raspatory, the peri-
cliomlriiini bcinj poclinl away fnmi the cartilage, whiJft its rplatinn«i to the soft
parts remaiiiw] undmturbed. Tho heparation was carried back a* far .is the
median line of the boundary b«>i.ween the lar>'DX and phar>'DX, solely by tlie uao
of the ont* metruiuent. Tartor the Ijyoid attachment of the lliyro-hyoid muscle
was divided, but the horizontal inci<iion over the hyoid bone, as reconnncDded by
Hahn, wa.<t unnecessary'. The thyroid curtilai^'e waa then split in the median line
by culting-raix-eps. The attuchiuents to the pharynx were further sei>aruted by
the ras|utlory, knife handle ami flnger nail, and the tbyrO'hyoitl mentbratie t%-as
divided cloftc to its thyroid attaehment, the 8U(>oi'ior cornii of the thyroid carti-
lage cut off by sliarp pliei-s, and tbp cricoid cartilage severed with tlie same inKtni-
men. in the luediun lina in rrr)iit and hahitid. The divideil half of the larynx woa
then ftepoi-ated from the first rin^' of tlw trachea and removed entire. There was
but little hemorrhoj^e, and only two small blood vessels required torsion, the
eomparalive freetlom from heniorrh.-ige bein^ due to the use of the raspatory in
keeping dose to the cat-lilage.
Ijanjngectomyy or ertirpation of fhe tarifnx^ has been recommended
and practised in many iustuuces, yet with but few sncccsBos. Since the
3>
482
DJUSASES OF TNJS LARYNX.
operaiion involves great dauger, and the patient's snbeequent condi-
tion ifi moet wretched, it should nut be atlvised, unless we are conSdent
that the disease is wholly confined to the larynx, and then onljr after
the patient htui buou fully appri^d uf the danger and probable restdts.
The operation is described by Mackenzie as follows:
A TcrticjU incision shoiiUl be made Trom the hyoid bone to the second riogtf
tlie t rachoa, and th<» front and »i(Je« of tlio larynx should be Uioroiighlj frwd
and e-xposed by caroriil diiiseclton, partly with tlie cutlinf; blade of the Snvlpri,
but as far as possible with its handle. Shuuld there be any decided artnntl
hemorrha^, the tiecessury ligatures must be api)lied. The traehea should be
drawn forwunl with u huok, and eut aeru«», care beitifp tulcen to avoid |>enetiii-
ing the u.-sophagu^. A siphuii tube of vulcanite is then tu be iuserteil luto Um
windpipe. Tn onh-r lliat tlie sijiliun muy OtnocurnU-ly, ilis well to have at luwl
sevcml UibeA of di^ervnt Alzesi. The iip]M>r and (Kisteiiur attaL-hnients of the lu-
ynx should next be cut throiig^h, but in disHecting out tlio ericohl t.-arlt)aice tht
riftk of button-holing- the giillet inusi be avoided by keeping the knife clo«e ta
the cartilage ('* Diseasies of the Tliroat ").
Sometimes tlie whole larynx must be removed, but not infreqnoaUj
the superior cornua of the thyroid cartilngo may be left. Hemorrhagt
may be stopped by ligature or torsion, or by some styptic solation.
When the surfaces have liealed »nd the gap in the throat has puniilk
contracted, Oussenbancr's artificial lar)'nx may bo used. Though from
the descriptioa the operation seems very simple, the disease will often
be found more extensive than auticipated, making the procedure inott
formidable. J. Soils Cohen has reeommcudcd a modified form of laryc-
geciomy (Transactions of the American T^iryngological Association,
188T), which appears to oIlLr many advantages over the ordinary oper»-
tiou, when the disease is nut extensive. As cliiimcd, the wound issioall,
the operation may bo done rapidly and with comparative safety to the
jMitieut, the attachments of many of the ligaments and muscles ore
preserved, important functional structures retuiued, and a firm natural
support is left fur an artificial larynx. Uts descriptiuu uf the opcni<-
tioa is as follows:
1st. Make an ineinion from the hyoid bone tu the lower bonier of the cricoid
cnrtiLogpand exactly inthe niediua lino, 3d. Can>fully separate ihvKt«rrno.hvoid
mufK-lBit. ad. Uuld the soft parts aside and insert from above one blmle of a
strong cutting forceps, with narrow blad-'s. b<.'ii><ulh one wioif of Die thyroid car
tilage, Doe-fourth inch from the an^le of j'Mictian with its fellow, and sever tht
carUlik^i vertically its entire length to the cricu-thyroid niembmne. 4Ui. Haka'
a jvimilar cut on the opposite side. 3lh. Hvize the freed angular portion o( the
thyroid ou-Ulage comprising its entire it-spinilory contingent with a %-\i]c«lluni
forc-cps and draw it to either side, the wjft pi»rts being wpanited nieanwhilr,
from the inner surfaces of the utlaelied mugs nf ibe thyroid eartilngtii. %vllh the
liandle of the s'»lp'^l. 6tli. Make a transverse cut to sever tht- ori^-otd cartila|ra
from th<> l^-achea. At this »iep in llio living subject, a sterihzed cotton plu^
atiould be loserlcd into the upiier end of the trachea, prcltmioary tracheatonty
TRACHEAL TUMORS.
403
ha\iagbeen performed previoi»Ir. UMlio crici>iil curt iLaf^e into bcretaiOK). dw>
artic'uluUj the ai'vteiioidx and tliea never ttie »oft parl« above Ihn cricoid Irwtvai)
of below. This modillea the next step in the procedure wjourdingly.) Tlli. f>lfl
Uie cricoid caKila^e forward, uitd carefully separate it with the tdge of liie \in\tt
from ttie iofcrior eoriiua of thi; thyroid luKratljaod fiij|ipriorly, the nfntdi llta
(esophagus posteriorly. 8tli. Insert a fitij^r into the pluu-ynx from Wit/w uad
carry it» tip uver the epijf^luttU tu draw that structure down. Bth. Divide t)i«
thyro-hyoid membrane and the flbroiu tJiauat atill bolitlD|$. lOtfa. Lift out lit*
exsacted respiratory portion of tlie lAryox. Tho arterica likely to re(|tilre llKatloa
will oomprue small bnoches of tbe Hiperior* middle, and laferior Ur7ii(«ttla.
The operation Bhoold be8trict1ja«*ptiCf and vhero practickble should
hare been preceded ftcrcral days by a preliminary tracheotomy. GeorfB
K. Fowler has adopted this operation once for the remoral of an cpithi^
llomatotu laryiuc, vith mo«t mtisfactory re«oIt« {Amerimn Journal
of Metlkal Sciences, October, 1890). Ona«<nbftiier'« artificial larynx «■•
pUced in poeiiton on the forty^fint day, and on th« KTraly-Chird
day after the operation the patient vai dtat^urged. and wa> alfl« lo
speak in a load irhiflper without the aid of the artiflcial laryax. Ser-
enil months later there waa no evideoce of recanvne^ and tbe patieai
remained in good heelth.
EVEBSION OP THE VE5TBICLB OP MOROAONI.
The erernon of tbe rentrtcle of Morga^pl ia a rery rare oeevrPMMtr
I am not swmre that wton than thne mam are oa leeonL Chut ttt thtm
waa diagnoirirtwl beiiagt Jth by OeargeM. tefcrU (.Vew i'wrk MOi^
tai Rtttrd, Jnae^ UffC). bat tbe oibcfs were Doi delected mam Oe
aatopay; Ihatiof we ace enable te give any dWiaatife i%M. The
ooDdhioo ■ Kkely to be mnmwkm tar a morbid growtlu Ift tbe eeae
reported by LafciU tbyrvCoeBy waa perffified, ead tbe c*crt«l wees-
iBBcateft wilb wamoi^
TBJtCH£AL TmOHL
484
DISEASES OF TUB LARYNX.
trnrhea about two iiiclies below thp glottis. Tumors in this situation
may be either boitign or mitlignnnt.
ETioLOfiY. — The pauses are similar to those of corrospondiiig tumor*
in the iflrvnx.
Symitumatoi.ogy.— These neoplasms when small cause no dislino-
ti^-e symptoms, hut as they increase in size dyspnooa results a!iil there is
usually considerable (;ough and sumo expectoration. Upon inspct'ti'Hi
the growth usually pn^senta ii cauliflower or pajjillary appearance, somi'-
times congested, ociTaKionally semi-trausp.irent. It is usually sessiW.
but it may be pedunculated.
DrAGKOsis. — A diugnoRJs c«n only be made by laryngoscopic ex-
aminatiou, and the exclusion of tracheal involution and syphilitic
strictures.
Progsosis. — Tho duration varies greatly aeeording to the uutnre of
the tumor, but tho utfiction is ultimately fuUU iu the majority of cades.
^^.
Vto. 177,— TntM in Vrrat Part or Tnachka. Tlilu tumor oocorreil la a p*>lt about
yeanofie^toiitowlncbtttekrsftilM of bli tr»cb«* It >;av(> him v^ry little IneonTenlencr. Mid
tberafDnlwdecHiKdIolMTeanTBtteraptiiiadaforlU irmoral. TbeBympcomi in Um «»•« vara
boanetieM And uod«rUtt dy^woA.
Sometimes the growth maybe removed, but usnallyit is so deeply seated
that it is reached with difficulty and the patient eventually dies of
Buflocation.
Treatment.— When practicable, tho tumor should be removml
through the mouth by meuus of forceps or the snare, or destroyed with
chromic acid. In either cise the parts should lirst be thoroughly anies-
thetizcd by cocaine, and thu operation performed with great care and
precision. It is quite poitsible that some cases may be relieved by tile
ititrodaction of an O'Dwyer tube, which by continuous pressure may
cause absorption of the growth; but if tho 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 cutliug-forcept^. Otherwise a, long, flexible tniclieul tube should be
introduced and iillowed to remain.
Malignant tumors In the trachea are necessiirily fiitul, aud no fonn of
treatment will be found of vidne, excepting palliative measures some-
times of a general, aud sometimes of a local nature.
INVOLUTION OF THIS TRACHBA. 485
POSTTRArHEOTOMY VEGETATIONS.
Alter tracheotomy, eftpecially whore the tube has been worn for more
tluin two or three weeks, not uifreriiiently gnimilatioiis spring up about
the point of incision iu the irmhua, which more or less occlude its Cftli-
bre, aud, when the ciuuiU is removed, iuterfere witb respimtion. In
some iustftnces true papillary growths iire developed.
ETioLOnY.— Thfsc %x'gcl:ition8 are apparently duo to irritutiou cnnaed
by the tmcheftl ciinula, eepeciJiUy where one with a fenostm luis been used.
Symitomatolooy.— While th« trachpal tube remains iu place, no
difficulty is experienced; but on its removal, respiration is impeded, or
mjiy be completely obsjtrnoted, by rho ahnornuil ^owth.
niAtJNosis.— Tlic symptoms already named will imineih'Mtely sug-
gest the nature of the affeeiion, but an accurate di:igno8is must rest
upon the exclusion of stenosis by a oaroful insjiection of the tracheal
wound and of the Uiryux. It will be necessjiry in some iustuncea to
fw l»— 1jm)*i*" Ptltca Fcj"e»w 'M«l«e). Tlier we-m ihrriw^ tn rvtnnTP jraDDtaHoni tn tba
iracbeft, bol «rr alao •errtcMblu for wruiu cuttlnit oiwfadoiut oa Uw new or limml.
pass a SohrOtter dilator throogh the hirynx to crowd the Tegetntion
downward before it can bo seen at the ojiening in the trachea.
pROuNosirt.— The cases arc usually very dirticult to remedy, and in
a few insUnces it has been impossible to remove the tnvcheal canula.
Theatmest. — Under general auiesthesia, the granulations should be
removed by forceps, and their bases cauterized by silver iiitnite; or they
may be destroyed by chromic ucid 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 (Fig. 178) which I have had made
specially for these cases will he found very serviceable. Sometimes it
will be necessary to crowd the growth down, with .Sehr6tter*8 dilator or
some similar instrument introduced through the larynx, before it con be
reached at the tracheal wound. Two or three such cases have been
cured by wearing for a short time an O'Dwyor tube; but it is not wise
to allow the tracheal wound to heal until wo are certain that the vege-
tations have been completely removed. In &jmo instances the laryngo-
tracheal tube shown in the article on atenosis of the larynx ^Kig. 148)
will be found necessary,
JNVOLrTIOy OP the TUACnEA.
Involution of the trachea consists of bulging inward of its walls re-
sulting from extenml pressure. It is chanioterized by dyspniea pro-
portionate to the obstruction of the tube.
486
DiaSASES OF THE LAUYNX.
Etiology.— It may bo due to preasure upon the trachea by nn en-
largetl thyroid gland, or aiieurismnl tumor, or by eubstemal eyphilitio
grofftliii, »inl rurely by disease of the tierviciil glauda.
Symptom ATOLOQV. — Tlie chief symptom is dyspnoea, increased by
exertion, and soraetimea occurring in Bevero paroxyems dependent upon
swelling of the mucous membrane or partial closure of the opening by
tenacious mucus.
DiAONoais. — The affection is to bo di^linguiKlipd from asthma or
any diseiise causing obstruction of the glottic. It cnn only bo diagnoa-
ticntcd by cxcUision after a careful luryngoBcopic exumination and con-
sideration of the history, physical signs, nnd symptoms. For this in-
spection, a bright light must bo carefully focused upon the piirt« to be
exaniiucd. Unless one is thoroughly familiar witli the appearance
of the region, it is easy to make an error on account of the peculiar re-
flectiuu of the light.
pROQXOSis. — The prognosis depends upon the amount of obetmction
and the nature of the growth causing the pressure, but sooner or later
most cases prove f:ital.
Treatment.— If practicable, the cause of the pressuro should bo re-
moved; if not, tracheotomy and the employment of Konig's long, fley
ible ciinula (ilnx Schiillor, '* Tracheotomie," n. s. w., Deutsche Chirurgiit
1880) will afford the most relief.
I
I
TRACHEOCELE.
Tracheocele consists of a hernial prntrnsion of the mncoai mem-^i
bntno of the trachea between its cartibiginous rings. Several CHH
have been reported by Larry under the title of Atrial (foitre.
Anatokical and P.\TnoLooiCAL CHAi(ArrEiii«Tn;s. — The sac ia
generally lined with mucous membrane and contains some muco-pum-
leut secretion. The walls of the sac vary according as it remains under
the muscles or becomes subcutaneons.
Etiology. — The origin of the disease is usually obscure, though in
most instances it apparently results from accideutiil stmining. Macken-
zie cites two congenital cases (Discuses of the Throat and Nose).
SYMPTOMATor.o«Y.— The voice may bo weak and there Is occasional
dvspncen. During ordinary respiration there m:iy he but slight fuluess
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 t!ic neck, the position corregponding nearly to that
of thp thyroid ghuid — sometimes median, sonictimes upon one or the
other side, occasionally bilateral. By pressure while the patient stops
brenthing or during inspiration, the tumor can usually be m:ulu to dis-
appear almost entirely, ulthuiigh the thickened sue can ordinarily be
felt under the skiu.
I
STPlflLTS OF TUB TUACNHA.
48;
Diagnosis. — Tlio diiiguusis is iniwle by nititiiiig the piitient to expire
forcibly with nose iind nrnutK olosc<], or to cough, which will niiike the
ttimor distinct: Ihon by iirt'ssure during inspinittoii it nrry be rpUiiceti,
The varjing size of the tumor, its incroa^e on (i{>Etriicte(l expiration,
the impulse during cough conveyed on palpation, together with the
other sij^ns just montionod, reuilor the dingnoais rertiiin.
pRoosoais.— When congcnitnl, ihi- afliK-'tion will usually Inst a lifo.
lime: but when due to mrcident, it may diiiapj>ear apontaneuusly, or, if
not, it can usnally be cured by nu uppropriate appliance. -It is not dan-
gerons to life.
Tkkatmkst. — Some meobaiuoid npplinnce to prcTont undue disten-
tion of the sac is indicated and thus its enlargement may bo retarded*
tSurgieal interference ha« not proved advisable in the majority of cases.
8YPHll.ia OP THE TRACHEA.
VarioHR pathological changes are met with in the trachea similar to
those found in tlie secondar)* and tertiary stages of syphilis affecting
mucous membranes elsewhere, but they are comparatively rare.
Fjb. im.— Tra.
:c SpKcina
Anatomical an» Pathouooicai. Characteristics. — Simple con-
geetion or superficial nlcemtion, prnjeciing ridgee, small ulcers, and oc-
caeional ulcere of a hirger size are observed. In the tertiary stage, gum-
matous deposits in the subniucons tissue seem usually to constitute the
first change. These soften, leaving ulcers that onhoalingresnit in dense
cicatricial tissue, aucompanied by contraction and stenosis. Dilatation
may occur above aud below the stricture so formed. Those changes
TiBualty extend over a largo superficial area, and through the whole
thickness of the tracheal wall; even the tissues surrouuding it may bo
involved. Most frequently the lower portion of the trachea is the seat of
the diseiise. The tube itself is sometimes shortened, according to
Mackenzie, but stricture is the most common condition.
ExuiLotn". — The localizt-fl phenomena mentioned may be the result
either of coiigcuit:il or acquired syphilis.
Symitomatolooy. — Tickling sensations in the trachea, a disposition
to cough, anil occasjicuml c.\pcctorftlian of mucus or muco-pus. with more
or less alteration of the voice In cousequouce oi congestion of the cords
488
masASBs OF the larynx.
or the collection of mucus upon them, and othor symptoms of catarrhal
tracheitis liro the common symptoms, except where tliere U obstrnction
from gron-thfl or from stricture. Goiidvlomatu of considerable size or
marked stenofiia of the trticlieji cause dyi^pni»a proportionate to the ob-
struction of the tube; this is iisiuLlly associated with cough, expectoration,
and occaaionully witti paroxysms of gnfTociition due either to acute
swoUing of the parte or to collection of tenacious mncus 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 tho trachea, lesions in its upper part may usually bd
coon, but those farther down often escjipe observation, and can only be
detected by careful physicul exploration of the neck and chest.
DiAososis.— Tho diagnosis must be based upon the results of a care-
ful lar^nQgoscopic examination, and the exclusion of diseases liable to
caoM compression of tho trachea, as, for example, snbeternal tumors or
aneurism.
pROOSOSis. — The jirobable duration of the affection can never be
accurately estimated, for under appropriate treatment some of the
lesions may disiijipear, and the iiatient may remain well for years. When
decided narrowing of thw tnichea has taken place, the result is Hkely to
bo fatal within a few months. Ponth may occur from exhaustion from
apna>a due to swelling, or suddenly from impaction in the stricture of
tenacious mucus.
Tki!atuent. — Constitutional remedies are of prime importance.
Mercurials or moderate doses of potassium or sodium iodide should be
tried thoroughly. Where those fail, largo doses of potJissium or sodium
iodide are often necessary. An excellent method of administering tliem
18 to begin with a doae of gr. xx. three times daily, largely diluted with
water or milk; iucroaso tho dose each day steadily by five to ten grains,
until the maximum dose of from 3 i. to 3 ii. is reached ; this may be con-
tliiued two or three days, and then decreased to twenty grains. After
two or threu days, the do^c should bo again increased us before. Such
largo 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, hut occasionally a case which would improve promptly
under large doges steadily progresses under the smaller quantity. In-
sufflation of iodol or iodoform into tlie trachea, daily or three times
a week, will be found benefictnl in the hyporiemic stage and when
ulceration is present. If the stricture is high, O'Dwyer's laryngeal tube
may lie employed to dilate it; but if low in position, tracheotomy must
foe performed, and a canula which will reach below the obstniction
must be inserted and worn. Kuuig's loug flexible uauula is especially
adapted to this purpose.
I
I
I
I
I
I
CHAPTET^ XXTITI.
DISEASES OF THE LARY'SX.— Continued.
FRACTURE OF THE LARYXX.
Fractcre of the Ljryni is a com]^;r.itively nire accident. ITp to the
year 18€S ouly iifiy-tn'> cases h:;d been recordt'l in medical literature.
In modt instances tin.- thyroid cartilage is the ?eat of fnn-ture, the cri-
coid being broken only by uuuiually extensive and dangerous injuries.
ASATOMICAL ASD PATHOLOGICAL C'HARACTERIriTICa. — 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 predisijosing factor {Ah-
nales des Maladie-f dt VOreOh, March, \t<1^).
Etiology. — A direct cause is usually a blow, fall, or compression.
Ab a result, extravasation of blood, cpdema, or displaced fragments of the
cartilage may so oljscruct 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.
Progs<.i:^is. — The accident is always dangerous, and judging from
the monograph by Henoque, fracture of the cricoid is nearly always fatal
{Gazelf'^ hrhdiniuidniff 1?0S, Xo. 3,0-JO); indeed, there are up to the pres-
ent time but tiiree or four cases of recovery known. If tracheotomy
were promptly jit-rformed, probably the number of recoveries would be
larger. Unfortunately, owing to the vital character of the structures
involved iri ilie injury, manv patients die in ypiteof the operation; or, if
recovery fMlJoiv-:, tliey are .subject for the rest of their days to tronble-
Bome or ■.lanzt-rous deformitv of the parts.
Tkkatment.— Unless the symptoms are very slight, tracheotomy
should be jterformed at rmce, and even if dyspnoea be absent the opera*
tion '\^ :idvis;tbl<:-, since nut infrequently by a slight movement the glottia
becomes siid'h-nly closed :ind suffocation results. If the cartilages are
much cru::lied, it will be best to lay open the whole length of the larynx
>■
490 DLfEASBS OF TUE LARTNX.
and endeavor to replace and fix the fra^incnts in proper position.
Looches and cold appltcatioTis should be applied to the neck to prevent
extensiro inflammation. It is probable that intubation of the larynx by
O'Uwyer's method would work well in some cases.
DIST^OCATIOX OF THE LARYNX.
Attention lias recently been called to luxation of the erico-thyroid
articulation, by H. Bruun, of Konigsborg, according to whom it occurs
uuilnteruUy upon either side, and may take place daily or at intervals
of weeks or months [Berlitter kliniKhe Wuchensrhrift, October, 18U0).
It may occur during deep insjiirntion, but more commonly during tlie
act of yiiwniiig. Probably a loose capsule is the predispoBJng cause,
and the 8terno-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-eleido-
mastoid muscle on a level with the lower border of the thyroid car-
tilage. Keduction miiy be easily ctTected by digital pressure outwud
and biickwurd, or by u few efforts at deglutitioo.
FOKRIGN 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 pntient is
coughing or Uughing during mastication, but sometimes they enter
froin the u-sophagus in consequence of sudden Inspiration during the
act of vomiting, and in rare instiiuces, especially in military service, they
penetrate from without. The objects most frcqueutly found are piecea
of bread, me:it, bone, and other substances taken into llie mouth during
a meal. In children., jK'iis, beans, coins, bnttous, and similur substances
whicli have been put into the mouth in pl:iy, or dniwn in through blow-
guna, are mo^t likely to be found. Pins, fruit-seeds, and coins are som^
times found in adults. Soldiers upon the man^h, in drinkingdirty water,
have occasionally tiiken in leeches which huve become loilged in the
larynx. Artificial teeth, or natural teeth which have become loosened,
have sometimes become lodged in the larynx during sleep: other sub-
stancea which were in the mouth on going to bed ure apt to bo drawn in
iu the same way.
SyMiTOMATOLorjy. — 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 imjiacted in the larynx in
Buch a position as to canse clonic cpasms of the glottis, is apt to oiuse
immediate death; on the other hand, small bodies may remain iude(l>
nitely without very much anuoyauce.
FO&EIoy BODISS AV THS LARVyT.
491
*
^f ODesBavapatieDt twoyeanofojTQ wlialwd dnkwn iniottMWjrnx half •
pcftnut kernel, which urterrviiiuiiiin^ Um* t wo nottlbs w«i couiptMd oul^ Imvuv
caused lo thti nieaa Um« no symjiUtms other than CDttgh aad boorMMW.
Usuftllj, even small and smooth bodies giro rise to much discom-
fort and troublesome congh, while sharp or irregnlnr bodies oxoit«
wverc p-'iroiysius of cough and dvspno^ diic to spn&m of the gloltis,
and in manr ra.^eii pnnluce ht'niorrhagc. Sonii>limi-8 ii bmly wliirh
causes little discomfort in the lurynx :it fin't, upim t'lmnging its posi-
tion gites rise immediiitely to severe svniptoms. Kyph mhcrc irrU«.
tion is not sufficient to excite spnsm of the glottic iit once, the inflnm-
mation which supervenes within from twenty-four to thirty-six hours
may cause extensive swelling, with narrowing of the glottis, whirh
xoay be suddenly occluded by spasm of the laryiigeiil muscles. Tlio
frigbt which attends this uceidenL often tends tu iticix-ust' the dyMpna>a.
DlAOSusm. — The diagnosis will (lepcnd iij>on the histor}* of the c:ibo»
the symptoms alrewly mentioned, nnd the results of laryngoseupio In*
spoetion when this is pnictieahle; bnt rhildren, nn nccount of fright,
eometimcs will not give nn ticcnrate history, and adults nuiy greatly ex-
aggerate their symptoms. In the former, laryngoscopy can leldom bo «c-
coniplislied, and even in adults it is often JilTiciiU l>ecnUBe of irritability
caused by thu foreign bodyj though this may generally be relieved by
spraying the throtit with a solution of cocaine.
pKnuN'osts. — In many cases death or(*urs inini<*diutely from rlosuro
of the ^lottiit ciLlier by the body iCi^elf or by the s]iiu(in wliicli it exeites,
and life is always in danger so long iis the body is in the larynx, fre-
quently the immeiliate efTccts of the uceident ]mss ofT, hut the inflam-
mation wliirii tlu> foreign substance excites caiisrs doijure uf the glottis
in from twenty-four to forty-eight hours by swelling or B{Hisni. 8omo-
times the body suddenly changes ita jiosition with a similar rosult, and
even after its removal there is siill danger until ueutu inllaminatiuu has
subsided.
TicKATMRN'T. — A pnticut seen at the time uf the accident sliould ho
immediutely placed with the head nt leiiiit forty-five di-f^rees UOow the
body, anil should be shipped vigorously upon ihif back in the lm|>o of
causing expulsion uf the foreign body; but if in this position rtiNplmtion
ceases, the bead should bo raised at onco M-bittb possibly may (in cimngo
the }>ogitiun uf the object as tu allow of respinilioii. If Hubitcfjurntly
respiralion should suddenly c<iuse in eonsci|Uun(!o uf change in the posi-
tion, similar measures should be ai]f)pted. If by theso metlxids ros-
piration is not re-cstablislicd, the patient should be placa4l n])(m the
back, jireferably with the head lower than the body, and artificial rBijii*
ntion should be kept up until medical assistance arrives, even if thU 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 expnision of the foreign body. If this does not
b
I
itticcooil, nnleiiB suffooiition is imiulnent, :l 1ar7iigusco[iic examinntion
should be umtU: wheru practicable and an efTurl made to remove th»
object with forcej>ii. If all these methods fail, iinle&s the body u
very small and the symptoms glight, tracheotomy should he done aa Boon
as possible, and another efTort at removal made either throogh the
tracheal opening er through the mouth, whichever is deemed best at
the time.
J:i cases of lingular bodies firmly impiusted, it U oocasionally, though
rarely, necessary to liiy open the whole length of the larynx for their
removal. Sometimes a body which has been firmly fised may be re-
moved by the methods already suggested after the inflnnmiatiou and
swelling have been reduced by external applications. Bodies which
hiivo been impacted in one or both ventricles will not infrequently re-
quire rrnshiiig before they can be extracted. This luis at times been
accomplished through the natural passages. When tnicheotom)' has
l>eon done and the foreign body extracted, the tracheal tube should be
allowed to remain four or five days until 8welling has snbiilded; and it
should not then he taken ont until the physician, by corking the canula
for several honrs, has assured himself that laryngeal respinitiou is easy.
FOREia.N BOUiES IN TIIK TRACHEA.
Foreign bodies enter the tracheii qnite 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 Ijcwio,
in 17A9, though the subject waa not treated exhaustively until the publi-
cation of the late S. I). Oroes' work on Koreign Bodies, in tK54. 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
cbamcter of the body which has been introducod, as well as with the
irritability of the tracheal mucous membrane. Patients have oocaeion*
ally drawn foreign bodies of considerable siie into the trachea withont
causing any symptoms which would suggest-to them that such an acci-
dent had occurred. Ijirge bodies or fluid drawn into the trache.i may
cause immediate death, or severe dyspnoea, which, growing gradually
worse, induces pallor of the general surface with lividity ot the lips and
nails, cold sweating, and all of the symptoms of siifToeation, which be-
come more and more pronounced until do:ith 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 niuy oconr; or, the symptoms of sutTocation soon snbiiding, the
patient may breathe easily agaiu for a variable length of time until the
I
FOREWN BODIES IJH THE TKAVHKA.
493
paroxysm ia reiiewetl, possibly with fatal effect. H the IwiJy Ib small and
Emoo(h» it muy pii«s through the trachea tind drop into tJie hronchiiil
tubes, and unless soon romovoti It trill cro long ^et up intlumnintion.
Coins sometimes nro lodged edgewise in the trachea and give rise to
little or no discomfort, but they may suddenly become turned across
the tube and cause GulTocation. As a rule, bodies of moderate size soon
eet up irritation and intlammution resulting in cough by wliinh the i)l>-
ject may be thrown ont or become lodged in the larynx with disastrous
results; or the inflammation may finally extend to the liing8, natising
pneumonic abscesscR or, eventually, jihthisis. Rjirely, concretions form
about small bodies, greatly increasing the difficulty which they cause.
Kernels of i^^rn, beans, and similar gnbstances may bo greatly enlarged
by swelling, from absorption of moisture, and thoy sometimes germinate.
In cases where severe dyspna-a immediately follows the atKsident, but
suddenly passes off without uxpultiian of the body, we infer that it was
first impacted in the larynx and Hubseffuently drawn into the trachea.
Frequently movable bodicR in the trachea may be felt liy the patient as
they pass up and down during the acts of respiration or cough, and
these movcmeats 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 alight rAle which
may be heanl 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 murmnr 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 nniversally present, even though the
body be lodgetl in the bronchial tube, especially in the case of buttons
or coins turned edgewise.
Vocal fremitus is also diminished over the obstructed lung, and there
may be slight dulncss on percussion, due to collapse of atmie of the air
Tcsicles or to collection uf mucus in the bronchial tubes. By laryngo-
ecopic examination the foreign body can sometimes be detected in the
trachea.
Diagnosis. — TTsually there is a suggestive history, but it is not al-
•mvj% 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 physical Kigns upon the two
Aides of the chest indicates ob^itruction of a bronchus, we may l>e posi-
Htc of our diagnosis. There are frequently cases where it is impos-
sible to diagnosticate the presence of sniall or smooth bwlies which
'ihave been drawn into the trachea; iu these we are obliged to wait for
time to decide.
pRoaKosis. — Where the immediate dangor hua been survived, th^
greatest risk occurs between iLo secoiid day and the end of ibc Qrttf
muiith; during tbo sueeoi'ding month the iiiortalily iiotablv diiittiitsIiM^
but Inter it agiiiii iticrciiHf^. Ait iilreudy indicated, Lb*; jiru^nutitii i.i al-
vnya tti'riuus &o long tie tlii! fureign body remains in the »ir pusKiguit, th4
gravity depending ii]Kiii the size and nature of the body, the nmituiit
dyfipnoia, and the ehangt^s set up m the luug^. When it is ejccti-d <ii
remavi'd. recovery ia nsuully rupid. Foreign gubstunces Imve guutelimc
been coughed up weeks, mouths, or even yeiira after ttio awidwit. tt
putient in the mean time having sulTured more or Ihah from the irritatic
whicU thoy produced.
For the encourage me tit of those io whom the body cannot be Tound, a
mentioned by LJvoss may hn i:\\nd. m which a lK>y three years old drew a piece
bone into tba tnwhea. \vhn-h rtfrnuineil in the luiitf and w;ia fiaally ejwted dunns
a flt ot coug-hiuj; six visirs hilcr. A ciiild was once brout^ht to me who Ii.
drawn a button into tim tt'orhea. I did tnicheotainy, but the button cnidJ w
be obtained. Tlio wounJ waa k*»pt o|wn fi>r Sfvcnd wpwks and IIipm allowed
beol, nod about a nttmth later the button wu» uxpellud duriu^^ u. Ill or i-ou^hmK,
1
TkeaTMEST. — The indicatiotis nro 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 Pudiey's niethad which consists in placing n strong bench
with one end npun a conch, with the other upon tho floor, and causing
the patient to sit on the upper part with his knees tixed over the end,
and while taking a deep breath to lay himself quickly back supinely u|
the bench (F-iOudon Lanretf Vol. U, 1878). The iuspiralion opens
glottis, and the supine position favors the expuUiou of the foreign bod]
If it should happen to lodge in thy larynx, the (wtienL's huld njwn tl
bench with his knees pnablea him qtiickly t<:- regain tho upright |H>8iti<
so that the body will again fall back into the trachea. Children tnaj
be held up by the feet, or the child's body may be ulloweil to hang froi^^
the nnree^s lap, the back being ijlapped in the mean time. When 4^|
tempting either of tho above methods, the surgeon should be ready t^^
<erform traeheotoiuj at once, for sometimes the bf)dy becomes firmly im-
ted iu the glottis and sultucatiou would immediately ensue unless ti^H
vritidpipe wero opened. It ia needless to say that the methods named a^^
onlv likelv to succeed where the body is small and smooth, as iu the caae
of coiui!, buttons, peas, and beiius, und but recently inhaled. The
methods just recommended may sometimes be tried with advantage a(t«^
tracheotomy has been done, providing the body cannot be found and f^M
moved by forcei>3. In most caaee tracheotomy will Itc necessary, and th^^
surgeon should advise it at once when he is sure that a foreign hotly is ia
the trachea, remembering that delay is always dangerous; yot he should
pot fail to inform the friends that some jtalienu recover without opera^
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496
DISEA8E8 OF THE LARYNX.
SPASM OF THE GLOTTIS.
Synonyma, — Laryugismiis stridulus; spasmus glotlidis; sufTocative
laryugiBmos; spasmodic, cerebral or false croup.
8pasm of the glottis is u couditiou iu which there is a temporary,
complete or incomplete, epiitiiiiodic closure of tlie gluLlis or veattbule of
the luryux, preventing free iiispimtiou. It is characterized in the former
case by cessation of the respiratory movements, and in iho latter by
stridulous respiration, almost identical with that of trno croup or that
of whooping-cough.
It is a purely nervous disease, and was formerly belicTcd always to
Tosuk from ccrcbrul disorders. It is now known to be duo ulso to direct
or reflex periphenil irritation from a great variety of cjinses; for exam-
ple, pressure on the rwurreiit laryngeal nerve, the presence of irritating
substances in tlie utim(<iitary canal, or irritation of the gnnis in donti-
tion. Lnbet-Barbon {lievitp: meiixueUe tUs mnUiiliest dr. Vf^n/ance, Paris,
Annual a/ the Unirerml Medieal Scienraty IHl*'i) states that adenoid hy-
pertrophy in the naao-pharynx is nearly always jiresent. The attack is
very likely if> occur during arntn catarrhal intlamniation of the larynx,
and may l>o excited by mental or phyitical irritation of thft 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 iu Uie arms.
Symptdmatolooy. — The great majority of cases occur between the
ages of four and twenty-four months, and very few after the latter. U
is most common in boys, and more frequent in poorly nourished chil-
dren than in those well cared fur. The attack usually cornea on sud-
denly in the night, when the child awakens in fright from great dyspntca
or temporary suapeusion of brcuthiug. After a few respirations it cries
out, and soon falls asleep as though nothing hod occurred. In serere
casee the symptoms uxi'. more violeul; the brcuthiug suddenly becomes
difficult, iuspimliuu is prulongcd and striduluus, and iu a few momenta
the respiratory movements cease in consequence of complete closure of
the glottis; the face, which wa» Hushed, becomes pallid, and this is
speedily followed by lividity; the eyes roll, the veins in the ncok become
turgid; and there are spasmodic contractions of the hands and feet.
General convnlsiona sometimes ensue. In mild cases the attack often
does not recur until the following night. The severer the piiroxyiirost
the greater will bo the rapidity with which they succeed eiich other.
In some severe cases they follow each other in rapid succession, t>r there
muy be an almost endless 6pai;m which does not relax until life is ex-
tinct. In the more common form of the affection the child may appear
perfectly well the following day and there may be no return of the
I>aroxysm. but usually it is repeated the next night or even within a
few hours. As a rule, there Isuo fever, but profuse sweating, especially
of the h«ud, is a common symptom.
Diagnosis. — The disease is nut likely to be mifitakon for ouy other
SPASJf OF THE lARrNX IN ADULT8.
4'jr
ffxccpt true cronp, from whicii it may be Umgiiusticated by the abs4>nce
of fever tuid the inter mi ttcnce of Eymptoms between the parox^'sma.
Prognosis. — The uttackti lust but ti fcft- minutes, but they may recur
after a few hours or the fotlowing night, or in severe cai-es may bo
speedily repeated. In the milder forms, recovery is common, but others
are often fata), and Bometimca during the first paroxvi'm, which may la*t
but one or two minutes. In cases depending upon disturbance of the
digestive urpms or slight irritating causes, the prognosis is favorable,
providing the paroxysms do not lust loo long or follow each other
quit^kly; whereas in those resulting from rerebnil disease, or in thoso
where the intervals between the jiaroxysms are short, tho prognosis is
grave. As a rule, tho greater tho interval between the paroxysms and
the slighter tho individual attacks, tho bettor tho chances of recovery.
Tbeatmrxt.-— During the paroxysm, flugellation, and the dushicg'
of cold water in tho face, nrc tho most comnjou remedies.
To terminate the t-pasni and prevent its recurrence, in the majority
of cases nothing is butter than "l xv. to xxx. of the componnd syrup
of squills, whU'h should ha repeated every fifteen minutes until vomit-
ing occurs. Tickling the fauces with a feather or the 6iiger is some-
times sufficient to excite vomiting, apomorphine in miunto d<j>.es may be
injected subcutaneously, or tur])eth minenil may bi' given for the
eame purpose in doses of gr. ss. to ij. or even more. Teaspoonful
doses of powdered alum act promptly and efficiently. To relieve tho
paroxysm ft hot biUh or a sitz bath at 05" F. may be employed, or chloro-
form may be carefully administered. An enema of tincture of aseafco-
tidu, 11 XX. to XXX., 0*1 3 i. of warm grnel or milk is sometimes a most
useful remedy to prevent recurrence of the attack. Tincture uf castor
and musk are also valuable for the same purpose. The cause of tho
epiisra must be sought and removed. It is most commonly found in
some derangement of the digestive organs associated with slight
catarrhal laryngitis. Tho i^pasm may bo caused by au enlarged tliy-
mus gland, especially in young children. It has been known to arise
from irritation of the prepuce. It Is uot infrequently ciused by hysteria
or cerebral or ccrebro-spinal disease. Subsequent to tho paroxysm, vege-
table tonicsj cod-liver oil, and tho bromides arc generally beneficial.
SPASM OF TUE LARYNX IX ADULTa
Spasm of the lan,'nx is much less freqiient in adults than false croup
in children, and is most commonly observed in nervous women.
Etioloov.— Spasm of the larynx is sometimes a pore ncnrosU, but
may also be produced by irritation of the larynx by foreign bodies, or
by cedcma, or by hiryugenl tumors. Sometimes it results from irritation
of the recurrent laryngeal uerve, and in some cases a puroxysm come«
ou during sloop, without apparent cause.
32
498
J}IS£ASSS OF THE LAHYNX.
Symptomatomot. — The pnroxjsm comes on suddenly. There is
stridiilnuB JiiBpimtion, speedily increHsing dyspiiwa, and in seTere cftsm
temporary arrest of respiration, which may be followed hy expectoration
of a considerable quantity of viscid mucus. On inspection at the time,
the mncous membrane of tlit- larynx '\a usually found slightly cungestcd,
but it may nppeur perfectly healthy, and the vocid cords are seen to sepa-
rate for an iustaut. and then to suddenly draw together.
I)iA{4Xiisis. — The diagnoaia rests upon snddenneiw of onset, the pe-
culiar obstruction of respiration, and the exchision of foreign bodies or
tumors by inspection.
PitOGNosis. — 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 cunium, bL>lladouua, or stramonium,, or inhalations of the amoko
of burning stramonium, are useful In reliuving tlie tendency to sjuism
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, genorul and nerve tonics arc iudieutcd. For this purpose a
pill containing one grain each of zinc valerianate, quinine valonauitte,
and iron, is an excellent combination. Potassium, sodium, or ammonium
bromide may also bu lulministcrod to relieve the irritability of the lar}*nx.
To prevent the spuBni of thu glottis which occurs in some jmtients da>
ing and after applications to the larynx, the patient sliould 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 ia apparently of
nervous origin and not infrequently accompanied by hypertemia of the
mucous membrane. The rellex form may be associated with disorders
of the digestive organs or of the uterus; it is sometimes violent durtn^;
dentition, and it may also result from varix or enlarged glands at the
base of the tongue, enlargement of the tonsil, or elongation of tlie uvuaL
The cough is most freqnont in tho morning, and is usmdly 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 bo given to check the tendency to
cough.
XERVOUS COUGH.
By nervous cougli we refer to a peculiar cough most frequently xiuui-
ifest iu hysterical women, but sonietinies occurring in men. tt ie usu*
Uy characterized by a resemblance to the cry of one or other of the
ANMSTHE^IA OF THE LARYNX.
409
lower aniniAls, mofit freqnentlj the yelping of a dog {Cohen : " Diseases
of the Throat and Nose"). It is apparently purely of u neurotic origin,
the most careful exaiiiiuutiou fulling to detect any definite Icaion.
No very satiBfactory method uf ireutiueut can be suggested, though
electricity htta sometimes proven effectual. Tonics, eB]>ecial)y utrychuine,
arsenioas acid, quinine, and iron, oi'e useful in some caaes.
ANESTHESIA OP THE LARYNX.
Anscsthesia of the larynx consists in more or lees complete loes of
mssibility 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 auiesthesia may be unilateral or
bilateral; it may bo almost complete over the entire surface, even extend-
ing into the trachea, or it nuiy be confined to that portion of the larynx
about tho vocal conie.
Etiolocjt. — TUe affec^tion eeems 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, hcmorrliages, or deposits at
tho base of the bniiu (McBrlde: Edinhurj}h Mtdical Jour/tuf,J\i\y, 1865;
and Srhech : Diiteade!*of tlie Not-e and Throat); it may follow erysi-
pelatous and variolous affections of the throat, and has been observed ia
cholenu
SvMPToMATOLOGY. — The most important symptom is spasmodio
cough on deglutition, caused by liquid or food enlt-riug the trachea and
coming in contact with the sensitive membrane beyond the affected
area. The epiglottis is genemlly found erect, and imperfectly closes the
larynx during deghitition.
DiAONOsia. — A history of diphtheria or bulbar paralysis, with occur*
fence of spasmodic cough nn deglutition, and the absence of obstrnctiona
in the pharynx or cesophagua as determineil by inspection and by the
passage of an a>sophiige»l bougie, are strongly suggestive of this coudi-
tion. Palpation with the larjmgeal probe without causing appreciable
sensations i-endors tlie diagnosis certain.
PnoGNOsls. — Kxoept in eases of bulbar jiaralysis or other cerebral
disease, recovery may generally be expected in from four to six weeks.
, In extreme cat^us, unleiss nunisures are taken to prevent the passage of
food into tho tnichen, it is apt to cause fatal pneumonia. When asso-
ciated with bulbar paralysis, death resnits within a few months.
Treatment.— The employment, three to six times a week, of either
the galvanic or induced ek't'trio current, or of static electricity is to be
recommended. If cither of the first two are used, the electrodes should
be applied six or eight times at etich sitting. Prob:ibly the most im-
portjint treatment conaiats uf tho Internal use of strychnine in large and
increasing doses, until its physlolugical effects are appreciated, as recom-
000
DISEASES OF THE LAR\
mended for paralysis of the vocal cords, AVTien tli
calty in swullowing, tho jwtient sliouM be fed thro
tube, to ]>rerent tho entrance of food into tbo vj
the ana>acbcsiu, special euro is necossar}' to avoid the
atrument into the I&r^1lx.
HYPEIMiSTHESIA, PARJESTHESiA, AND
THE LARVNX.
Increased or perverted Beiisibilltv of the larynx, c
in the orgiin, without strncmnil lesions, is most fre<
preachers and others occutitoined to excessiro use of
Simple neuralgia is ver)* mrc> and most cases wb
have been classed under this bend aro now recognize
ASATOMirAL AND PATHOLOGICAL CUAUACTLUISI
zna; not be congestion of the mucous membrane;
pallor is present, especially when tbc L'ouditiun is iissot
If hyi)erre8thesia rosnits from excessive use of tobat
is usually congestion. Frequently there is diseasi
structure of the pliarynx and larynx, or base of the t
Ktiologv. — llyper^estbesia nsually results fron
tobacco or alcohol, repeated subacute inflammations
trie disturbances, tuberculosis, plmryngilis, or over u
Panesthesia is commonly caused by debility, n
hysteriii, or hypoebondriiisis, and often follows iholo
time of some furuign substiince in tlio throat. It \
the early symptoms o'f phthisis pulmonnlis. It is
enlarged glands or varicose veins at the biieo of tho
is Attributed to similar causes, but is more of tea ^
finil rheuniatiani. H
Symftomatolouy. — In hyperaestlie^ia, the laryn:
sensitive that cough is excited by slight irritatioUjSU
of c<dd uir, smoke, or duet, or the contact of certaiu s
tition. It is frequently attended by various seiisati
prickling, dryness, rawness, and constriction; and oi
modie notion of the muscles of the larynx and pbar
enrring with respiration, the latter with deglutitic
f(uent sensation in puru^jthosia is that of a silverj or (
f, 1- ign body in the throat. Xnmbness and coldj
.■riencod. Tbo so ojillcd tflubus htfutericus is a fa
-'^Dii. fn neuralgia, the pain is ufti-u intermi
-companied by areas or points of U
■i. — The diagnosis must be based n]
<-. I \ CO of physical signs.
^"* ...«mt^ ^^^»xC^ ""^'^ aiiplk-ations. Diseased glanris aud uiliir"
. of Bo\uf * -^Vk ° tongue aro best destroyed with ti
'**^^ed Iretjl ^*^*^^ ^^V^iciitiona to the larynx once or twitre daily, by'
iC ^ -itU e\ *^^ *X ^*^rptiint' or cocaine, though the latter ehould not
^ WliKfo c ^^^^"^^ '^^nibiiiation of morphine, carbolic acid, and tantiio
• and^**^^~»- i '^"'^^^ water (Form. 93. 130), aro often ser'ricoftblo.
ill*** .^^y ^^'i^v ^^^blosomo, troches of lactucarium or of cannabia
cM'^^^^^ V**^^v\\^ '^ (^''orm. 29, 33) or other sedative preparations a
io"^^^* 1 /*■ *^vvv 1 ^**n»etimea the inhalation of a few whiffs of chloro
tel*®, ' ^^^^^X\l *^ carried in a mnall bottlo in the ]iocket, gives great
lO'^^V f) > ^^^^V ^-' ^^*** iodideaandcoU'hicnm aro indiraitod when a rlieu-
(lO^^) .' ^^V«> - '^thesis exists, and camphor monobromide, chloral or
(jcu* . ^^xiY ^'**>ttiidea, gr. x. to xv,, three or four titne« daily »r« es
(fl"''^*^ M.^ . ^or prolonged sedative cffecta. The various bitter and
tio^^* X*i^^. . **lca lire frequently iudtuitod, and good hygienic condl
^"^Uluvly important.
)ia
I
CHOREA LARYJfOlS.
^Tit^'d Y^^ ^*"yTigis is an extremely rare affection of the larjnix. charac-
«ecttVia.Y ^*^gular monotonous recurrence, during waking hours, of a
ffi^ ^*il>^Y ^*id, often resembling a short bark or yelp, associated with,
^ocaV \ia.*. ^it ujiun violent iuco-ordiuate invohintary movements of the
6^*- \iu\ 1- ** '^'"' "'^'^^'"" " accurately duscribed by Ziemstien, but the
M. Vjt.ff ^^^^^'^ uncomplicated case appears to be that reported by Goorge
\^*%y\ ***** (Tiausacliona of the American LaryngoLogica) AsBocinlion,
*T . '* vJaeos havo alsio been reported to the sitme association by F. I,
^^^^\t, of Boston, and E. Uolden, of Newark. N. J. i
-vkatomicaIj and Pathoi.ocecal Charact eristics. — The diseasa
* *^6Urogi3 the scat of wliich appears to be either in the brain or epinal
*^''*'» but the exact lesion has not been determined. The larynx is liable
** lie slightly hypera?mic, but presents no other physical changes.
EtloLiiriY. — In most of the cases reported there has boon no assigu-
aWecausefor the affection, which has come on in pox-sons otherwise per-
»j^ \ fectly well. It is sometimes attributed to hysteria, with which it ia
liable to be confounded.
Symptomatolooy. — The affection may be a part of general rhoroa,
IjiU the term chorda lari/mjis aliouUl bo limited to those oases in which _
yiily the laryngeal muscles aro involved. There aro no constitutional^
symptoms, the patient complaing merely of the frequent recurrence of
^mi' peculiar sound at regular intervals during the waking hours. lu _
some lliis is attended by spasmodic cough, which may be excited by tha^
1
«tt JtlSEASES OF THE J.ARlf^'^
•ct of sTallowing. Upon linrngoscopicexaminiition. ^hwwrrfti-n f.n-T
some coogestion of the luytii, am] in the interV*'^ iH'ltrt-.
daction of the [>ptiiliar sound rhe motions of the con*'' '""J' ' '
natural. or I hey may c^nirer and tremble, and iheflddmlTsaii
may be in constant motion ; bnt. eren then, on phoniilio" tbi
rule sot naturally; sometimes, however, during thia act tli
mente are irrt'gnUir, sjieoch beiug correap«ndiugly altered. A
the peculiar sound is produced, the cords are generally drlti >
and sharply together, iiomrlime^ two or three times in eiiW'
concu^ion probably accounts for the hypenemia, and it is i'l
followed by a long inftpiration after which the parts may remaiii ii»Wr»
until time for the next sound to occur. These peculiar sounJe ftloj
cease during sleep.
rDiAON'osis,— The affection is most likely to be confoundBd »ft*
yateria, from which it is distiiiguiahed by the following points:
■
CHORKA T.ARVN0I8.
May aoconipanj g«aeral cliorea.
Ocx:urs n^ularly during waking*
hours.
Violent, prolonged, ioco<on1iDate,
and involuntary movement*.
lu typiciU caaes, coatined to lar>'ox.
Hystebia.
Abftenoe or geiterul choroa.
Occurs at irregular periotls.
Short spasms; may be voliinb
and iv^iilar: nevur long-conttnirtd.
SelJuri) or never conflneU to Ituryl
Pbogsosis. — Under appropriate ti-eatment most cases recover witbin
a few months.
Treatuest. — Load applications of el*»rtricity have been tried in
many ca8C6, but are of doubtful value. Applications of astringent »pray»,
Bnoh as used in chronic laryngitis, are boneficiul in reducing the hypCN
femiu, 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 wliifh the symptoms immediately subsided upon
the exhibition of full doses of quinine (Trnnsiictions of the American
Laryngological Association, 188;5). Bromides have been found of some
benefit in diminishing the frequency of the paroxysms. Strychnine
hjui rendered little, if any, scnrice.
SPASM OF THE VOCAL COKDS.
Closely akin to chorea laryngis is a spasmodic affection of the vocal
conls most frequently observed in nervous overworked professional mcu
past middle life. In this affection there is commonly congostiou of the
laryni, bnt no other visible change from the normal condition. The eti-
ology and path^^logy are not understood., but the condition appears to !«
Eio functional alteration of the nerve centres. In C4ise8 I have ob-
id the individuals have been able at times to talk in a nataral voice,
FAL.'iK'JTO VOIVK. 503
but Euddenly, viUiout <?ontrol, the vuico rises to a high pitch, iu conse-
queiico of ifpnam of the adductor and tensor muscles, aud is up|>arently
prodm^d with much effort and straining of the liirvngeal nmst^les. In
tliiK latter respect t}u> ^vinptoiiis differ iiiiiteriall>' from thotse attending
pttralyeis of the rrico-thyruid niiiseles, in nliich there is a fiouiewhat sim-'
ilar change in the voice.
The affection is likely to continue for years and is very refractory.
Theatmknt. — The trpatment from whioli moat relief i« to Iw expected
consists ingowl hygienic; surrnundingit, inchiding rest and pleasant travel,
and systematic Tocnl cnltun;.
A( first llin larynx should be given, as nearly as iwasible, pt-rfect rest
for several neeks, the patient talking bul; little and tliat only in a whis-
per. After a time he 6 ould be given vcryBhort but increasing exercises
in reading at regnlar liouii! two or three timed a day, as a sort uf vocal
gymnastics. The reading slionld be in a low unvarying tone and must
be 8tup|)ed a:^ Boou aa the voice breaks.
At fim thc!» lessons may not exceed one or two minutos in duration,
but they may be gradually prolonged a minute or more each day ae the
voice becomes more stable, and after the patient is able to read for half
au hour in monotone, gradual changes may be tried in the pitch and in-
tensity of the voice. During this time the congestion of the loryox may
be removed by the use of weak aetringent i^prays, ae for example zinc sul-
phate gr. i.-iij. iiA i i. At the same time the nervous system should be
fortified by sedatives and tonics conjoined with abundant rest, regular
exercise, and the removal of all sonrcea of direct or reflex irritation.
FALSKTTO VOICE.
Falsetto v<nce is a rare aymptoiri, uetmlly abserved in young men who,
although fully developed in every other rosivect, retain an abnorniallj
high pitched, puerile voice.
It is due to the misuse or nnn-nse of muscles controlling the lower
register, which should Iw brought intu aftivity almnt the age of puberty.
The condition is usually outgrown within a few months, or at most years,
after puberty; but it sometimes persii^ts to niithllc or even iidTanre<i life.
It is purely functional and may genenilly be speedily cured if proper
methods are adopte<l ; but if left to themselves such patients often suffer
for many years from the mortlficatiou eutjiiled by the childish or femi-
nine voice.
Treatment. — The work of the physician consists in demonstrating
to the patient that he huii a chest voice and inducing him to use it.
The method recximmended by J. C. Miilhull, of St. Louii* (Trnnsac-
tions of The ,\inericiiu Larvngological Association, 1388) I have found
perfectly satiafiu-tory in several cases. At lirst a thorough laryngosropio
eiamination is made, and then the {latient is assured that the vocal appa-
ratus ia nonniU and that if he will carefully follow directions he will with
a little training bo completely cured.
£06
DiaSABBH OF THH LAHYNX,
body. Ferruginous and bitter tonics are iiidicaie<l, but Btrychnine la
large doseii an advised for uufeathe&ia of the larynx is of most valne.
PARALYSIS OP THE CKICO-THYROID MUSCLES (kitkbxal
TBNSORS OP THE VOCAL CORD).
Aa a separate nffcction, paralysis of the crieo-thyroid muscles is nire.
It is I'itlier unilateral or bilutontl iu its ocL'urrciiou, and Is characterized
by dyKphonia or aphonia. It ooinnionly n>Hults from diplitheria, ex-
]>i»Kur(f of tliu iicck to cold draughts, or from overstniiniTig the voice iu
aiiigiiig or shouting, psjieci-illy during inflammation of tho larynx. It
lins been ouused by injury to a small bnmcb of the superior hiryngcal
nerve iu ligailng ihe common carotid artery, and it is sometimes assoel-
ated with paralysis of the adductors and internal tensors of the cords.
Complete pjiralysis of these muscles is very rare.
Symptomatology.— Tbo voioe may bo very hoarse and inadequate
to the production of tlie high notes, or altogether KUppre^nd. Some-
times during ordinary convt-raation there is a peculiar sliding rise in
tlie jjitch of the voice, wbieh the patient in un;ible to prevent. Pro-
longed use of the voice may bo fatiguing or even painful. Tliere are
also symptoms of coexistent anaesthesia of the larpjx. Sometimes by
placing the finger over the crieo-thyroid muscle at the lower lateral por-
tion of thf larynx during jibonatiun, iu non<'oiUraction may bo readily
recognized. In some instances there is congcittion, 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 tlie central portion of the cords in
inspiration and a corregpo:idiug elevation iu expiration and vocalijuition;
the vocal process can seldom be seen. When the allcction is unilateral,
the corresponding cord remains on a higher level than its fellow.
DlAOXOSis. — In niotlenite cases the diagnasis must rest largely upon
the symptoms; where the pantlvi^is 18 decided, the subjective synipioms
And the appearance of the glottis, together with lack of tnision of the
crieo-thyroid muscle, leave no doubt.
pRoososis. — Most oases recovpr after a short time, from rest alone,
but the restoration of the voice may be aidctl by appropriato treat-
ment.
Treatment. — In slight cases, wet compresses or mild countor irrita-
tion is all that is nei-eti-ntry. In those mure marked, daily applications
over the mnseles, of the faradic or galvanic currents will bo found bcne-
fieoal. Strychnine and other tonics are also indic-ntcd in some casea.
When nna>sthesia of the larynx coexists, food should be introduced
through an oesophageal tube to prevent its passage into the trachea.
PARALYHia OF THE THrKO-AHyTEiVOID MUSCLEH. 5U7
PARALYSIS OF THE THYROARYTENOID MUSCLES (isTKnKAL
TKN90R8 OK TUK VOCAi< CORDS).
Paralysis of the thyro-arytenoid muscles is a common Affection^ which
may be either unihitoml or hilatenil. It iii often aBsoriiiLeil with \m-
ralysis of the crico- thyroids and the udditulor niUKclea of the cordB. It is
chanicturized by haralmesa and high pilch of the voice, with fntiguo
und sometimes pjtin in its use, nnd is niusL frequent lunong singers.
Anatomical and Pathological Chakacteristics. — The cords
are often congested, sometimes swollen, and the edges are not atTCunitely
approximated but leave an elliptical chink between them in ]>honalion,
which accounts fur the hourseueiis or aphonia.
Etiou)OV. — Tho uffeelion usually results from ovcr-UBC of the voice
when the hirynx is inflamed, or at the period of adolescence when tho
voice is changing, hut it nniy be cunsed by a simple cold, fatigue, or
sttnin of the muscles, and occjsiunally by diphtheria or hysteria.
Symptomatolouy.— There may be fatigue or even jiain ujton ose of
the voice, with dysphouia, or, iu case other muscles arc involved,aphonia.
Tio- 1H) — Bir.ATKitAL HAiui.irata lir raS Pm. IflS,— Aiiti. LAHT>nrnB. PuiilyMtof
CBiix»-Tiiviioii> lMt'8CLEBt)Ucicia<ztK). tlut thyro-uytenotd oiuMltK.
Upon inspectlou during phouation, an elliptical cjiink about a line in
width is U3ujdly observed between the vocid cords (Fig. 182), which, to-
gether with other porliunii <if the lur}-ux, arc liable to be congested.
"Ulien the arytenoid muscle is also paralyzed, the laryngeal picture is
pfculiar, an idliptical chink appearing in front of the vocal processes,
and a more or less triangular opening Iirhind them (Fig. IS^J).
IiiAGNORis. — The diagnosia is based upon the history, symptoms, and
laryngoscopic appearance.
Prognosis. — When associated with simple laryngitis, provided tlie
paralysis is not complete, recovery usually takes place williin a short
time, but some cases extend over several months, and occasionally the
puTuljsis is permanent.
Tkf.atmext.— In over-fatigue and in cmos resulting from acute in-
flammation, rest for the voice, with soothing inhalations or feeble ustrin-
■(^t sprays, are most benetieiul. In some instances, especially where
fatigue is the cause, prolonged rest for many months is necessjiry.
When the ulToction has already extended over sovend weeks, astringent
or stimulating sprays to the laryiu should be used; but if contraction of
I
£08
DISEASES OF THE LAHYNS.
the mnacles is iidI rcndily induced in this way, the galvanic or 6kredio
current should he tmiiloyod for u fow moments daily. Bitter and for*
ruginoiis tunics ni;iy i)e utfeful, but of idl remedies dtrychuiue in Inrge
doses is must beut;lluitil.
BILATERAL PARALVSIH OP THE I^TERAL CRIC'O-AKYTENOID
MUSCLES (ADUL'CTORS OF TUB VOCAL COnOS).
SynoH^ms.— FunctionnI aphonia, hysterical or nerrous nphonia.
lu biliiterftl pniiilysis of ilie lateral crico-itrj'tcnoid muscles, tlio vixail
cords act imperfectly iiud arc not approximated aeeurately during at-
tempted phunatiou. It eh chumcterizud by \os» of roice, uud is most
commonly observed iu yuuug women. It is oftt;n associated with paral-
VKiH of the arytenoid muscle, uud sometimes tho])08teriorcrico-arytenoid
rauBules of both sides.
ExiOLoaY.— Tho aflttotion is caused by hysteriH, anaemia, general do-
bitiiy, phthisis, und sometimes by simple catarrhal intlammntiuu in
^
Tta. iea.-riHALviti»i or inx Tbtho-
Attrraioia Jtvxrupt xna ['AimAt, Pamai^
TBt» or TBI AHmCKOID.
Fio. 194 — Faulvsu or TBI I^twjuj,
Cpioo-Arvtkhoid Hi,-»ixk>. AU«ai|ited
pbonattoD.
vhicl) the congestion disappears, hut the paralysis remains. It is prob-
ably due in some iriatancrs tu lead or un<eiiiral poisoning.
STMiTOiiATOi.O'iY. — Functional aphonia often comes on suddenly
without apparent cauw, hut sonietinuis ia excited by shock or friglit.
Occasionally a patient who lias retti'ed in perfect voice finds herself
nnable to speak in the morning. In other cases resulting from an
acute cold, hoarseness oomes on, gradually growing worse for twenty-
four or thirty-ail hours, until the voice is lost. Occasionally exposure
Lo a draught of air marks the beginning of the disease. Not very
nirely the affection is intermittent, the voice failing and returning
ever)' few days for a time. In itume of these instances it is possibly
of malarial origin. One peculiar feature of many cases is ibat while
voluntary movements of the cords may be lost, the reflex often remain,
HO thiit, although the patient cannot speak, she may cough, sneeze, or
laugh aloud. Sometlmos such patients talk aloud iu their sleep, bnt
arc nnable to do so when awake. When the paralysis is complete, no
sound is caused by biughing or coughing.
Tho larynx is often paler than natural, but iu catarrhal cases it U
MILATERAL P.LRALrSI&.
M»
coBgtsud. CpoB anaBptx ai pbonaoco. t^ Toeal eoi^ n-nuin in (b*
lespinioTT poation tFl^. 1541 cr more bai tmperf«c:lT tov^tnj ihe
medtu line: somedaies one is more complelelj pualTivd than the
other. UsiuUt od ananpted {^konaiion the cords are appn>xinMt«^ to
Tithin aboat oee^i^th of an inch of «aoh other, and in not a fev
cases the edges mar tooch for a moment, and a short sound of a may he
emitted at the time, thoogh the patient is otheraise aoable to talk. In
complete paralrsis, the glottis remains videlj open vithout moTcmeni
of the Tocal cords during attempted phonation.and vhere the abductors
are also involved the cords maintain the cadareric position midiraT be-
tveen phonation and inspiration. J. Solis Cohen remarks that some-
times this form of pai^vsis is associated vith 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, ^\\iud
edition).
Diagnosis. — The affection may be confounded vith cases in which
the loss of voice is due to feeble respiratory action, or those in which
Fia. ])%.— Xacketxik's I.artxokal ELEC-rmoDBS.
approximation of the cords is impeded by swelling of the inter-arytenoid
folds, or by morbid growths, cicjitricial tissue, or diseiise of the crico-
arytenoid articulation. The history and symptoms, together with t\n>
hiryngoscopic appe.irance just described, leave no room for doubt as to
the diagnosis.
Treatment. — In hysterical cases the voice may frequently bo re-
stored by very inJifferent measures, such, for example, as simply intro-
ducing a mirror, or throwing a mild astringent spniy into the larynx;
but in many ciises prolonged use of tho faraiUo current to the utTected
muscles, applying one electrode within the larynxand the other without,
will be necessary to effect a cure. In most instances I liave fountl
astringent or slightly stimulating applications to tlie larynx every
second day, conibined with the administration of tonics, most etTective;
and of all tonics for this purpose, nothing can compare with strychnine
in full doses. It is well to begin with about gr. -,',-, throe times daily,
steadily increasing the dose until constitutional effects are produ<ied,
which may not happen until the patient is taking as much as gr. ^^ or
mSKA.S£:ft OF THE LARYNX.
even gr. | at a dosp, When the phyBiological syniptomft occur, the dose
should be soroewlmt decruiified. and then contiiMicd in un uiuuant just
short of prodnring ttpni^modu^ rontniclioti of thu niuddus, until I'ui'uwrji
is L-oinpIoto; or the qauntity may uguin bo iuuj'CUiiud, In the inuum
before mentioned.
UXILATKKxVL I*AKALY8I» UP THE LATERAL CRICO-AHYTEXOLl
MLSCLK ILATKKAL AOUl'l-TOIl OK TIIK %"IK;AL CORD).
lu unilateral pandysis of the luteml cricuHirjtcnoid muscle one eoi
remains HlnJuctud during titteniptL'J phonutioii, thus rendering the voit
hoiirse or »hriU. There is no Jejijon of the larvnx itself, but the reeul
rent larvn^eul nerve is generully involved.
Etiology. — The ulleulioii is caused in most cases by pressure U[Hin
the recurrent Uiryngi>ul nerve, as by an aneurism of the aort-i, i*»ncer
the (esophagus, xnuligniint tumor of the neck, or enlargement of
'4
I
FlO. IW ~(.*KIU*TEttJkL PaKaL'
TMU am TUK l.cn Latxiul Outrv-
Aurrmaiti M^-w^ut. I)u« to Um
pTHKiirw of »a kocuriam oa Uw
leTt rvcorrmt iMTDgwJ norra.
Pia. |)<:. -Tmk umk u F»o.
IM, IK PauxAnoM.
FlO. I'M.— tSll^T1iaALP«RAl.V>
U> or niB RMIIT LiTKNAt. Cuoi^
AKvm'oui Mi-*<n.c. wmiKwnx-
iMa oir I.CFT Art Krtnu<iTRi
Fot.0, rhon«tl'>n— l^^rtoonl iMO»*
bag far beyao<l %Ua DkeObUi llBe.
deep cervical glands. It is wmelimes caused by chronic lead or arsen-
ical poisoning, by exposure to cold, or muscular straiu, and not infre-
quently by hyeteri:i.
Syjiptomatoloot.— There are nsnally no constitutional maniferta-
tiona but the symptoms and signs of a tumor pressing upon the n-cai^
rent nerve may frequently be detected. There is slight or considerable
impairment of the voice with lose of volume, and, when paralysis i«
comiilete, aphonia. The sounds pmduced by coughing, sneezing, or laugh-
ing lire nlwayA allured more or lesa, imd these acts are sumetimes unac-
com|mnied by sound. In phonation, the affected cord remains at the
6ide of the larynx (Fig. 187), and the supra-nrytenoid carlibiges croa
each other, ihe „ne from the sound side passing in front. The mucous
aicmhmne covering the rtfftuted cord is often found congested. When
caused by pressure of a tum)>r. dysphagin is frequently present.
'-^^Nosis,— The diagnosis is readily made by laryngoscopic exam-
■I
BILATERAL PAHALYSIS. SU
Tkkatmkst. — The cause of tlie tlil!iruUy must, if jiosnible. be fuimd
and removeii. LocuJ treatment h of little or uu viduL*. In ii few in-
stancee. ovitlcntly fmictioiuil, whieli had existed for a uumhpr of montlis,
I have brought nbontii oure br the afliuJnijttrHtitin of Urge duses of
strychuiue when many other remedial nieaBurea had failed.
PARALYSIS OP THE ARYTENOID ML'SOLK '(KNTKal abductor
OF TllK CORDS).
lu paralysia of tlio nrytenoid muscle, owing to the noD-upproxlma-
tion of tl>c inner surfuoes of the arytenoid curtilages in phoualion, there
is gaping of the poslenor or iuter-cartiliiginous portion of the riraa glot-
tidifi, with coiigeqiiuiit iinpuiruient of the voice. Conguatiou of Iho
larynx \s iisrtally present, for this furtn of paralyeia must frequently re-
aulu from acute lir subacute laryngitis.
rtO. MB.— ZlKllflM3l*S DOUILK ARD SlKOUl LiimORAL EuCTkODIS.
STMPTOMATOLOftY. — HoarBeness and fatigue in talking are prominent
■ymptoms. Inspection reveals a triangular opening at the posterior
[part of the plottis during phonation.
Diagnosis. — The diagnopts is rendiiy made by inspection.
Treatment. — fstimulunl inhalations and astringent upplications ap-
propriate for the laryngeiii infliimmation which coexists are indicated,
iln thia, as in othur forms uf paralysis uf the laryngeal niuacles, if of long
Standing, funidizatiun uf tlie aflected muscles and the administration of
strynlinine should be tried.
(ILATERAL PARALYSES OF THE POSTERIOR CRICOARYTEXOID
MUSCLES (ABDL'CTOK.S OF THK VOCAL LOKDH).
Bilateral paralysid of the posterior crico-arytenotd muBcles is a
dangerous afTection of the larynx in which the tocaI oords are not
drawn aside during inspiration, but renmin near the median line*
olosiug the glottis and caiisiug atriduloua respiration and greiit dyspnuca,
rithout alieration of the voice.
Anatomicai. anu Patuolooical Characteristics. — Tho affection
is gouorally duo to dUense of tho ceutrul ncrvuus system, but miij be
(iroduccd by morbid proceaacs which involve bolh puciiniogHntric or
both recurrcui lar^iigctU. ncn'ea. Tho rccun-L'iit nerves und their
briiucbcH, mid tho iiitiades tlieinselves, have been found atrophied. In li
few casen the iiiUHcles bave been Xoiiiid atrophied, though tho brain and
ueiTOs have appcan^l healthy.
Etiology.— The condition, as before stated, U nsuully caused by difr-
ease of tho central uervuus Hvsteni, and ia evidently sometimes caased
by syphilis, tho lesion of nhich may bo central or along the coarse of
tbe m-rve, or in tlio nuisolu itself. It is freqnontly duo to pressure npon
the pneumoga«tric or reonrreut nerves by goitre, enlarged bronchial
glauds, or aneurism. Canc«r of the tliyrold gland or of the cpsophogus
may hove a simihtr effect. Ocoaaioniilly the paralysis seemB to reealt
from simple catarrhal inflammatigiij or from hysteria.
Pia. ISO.— BtLiTXiui. PxiULVErs or thk Po«-
TUU<» CtlCO-ABTTCOID ML-aCLC»— tXBPIIU-
TltiN.
FlO.im -niLATUUL PAKiLnUK fir Ttnt Pv»
TtON
SyMPTOMATOLOOY. — ThesjTnptoms will depend upon tho nat-nreand
extent of the lesion. Since the HlamentK of the recurrent nerre supply
antagoutstio muscles, those diKtribnte^l to either tlie tiddaotors or tho
abductors may be most involved, but experience shows tluit the Utter
are usually implicated first. Whoro the function of the nerre is com-
pU-tely destroyed, the muscles of both sides are paralyzed and the cords
remain iu the cadaverio position, offering no intpodiment to resjtirH-
tion, though the roioo is lost When the abdnctur filaments alone are
flffcctcil, the voice roniitins, bnt inspiration is grontly obMructed. and
e.\treme dy^^pnwii supervenes upon tho slightoftt exertion. A fetding
of suffouatiuu may occur not only ou exertion, but occasionally from
spit^m of tho adductors, especially during aleep. Kxpiraiion is qui^t
and nnobKlnicted. When the abductor mnaidds alone are porulyzi^d
tho voice is not lost, but it is usually weak; if the adductors are alio'
implicated to a certain extent, there is punstjintlya waste of sir in phona-
liuu and tbe patient in tiilking become* qniu-kly exhnnsted on acooitnt
of l]ie great hibnr thrown on the expimtory nuisclcs: congh and e.\pocto-
nition are altto tlinb'ult. Loss of strength, emaciation and febrile excite-
mcnt, are frequently though not always present. On inspection of the
larynx, tbe vcfcal oorda are soeu very near tbe median line; during
BI1.ATEIUL PAHALYHIS.
613
liration tbo rima gloltidis will measure from oiio ta two lines in
width (Figs. 190, 191).
Ou inspiration, tlio lips of tlie f^lotlia ure Btiokcd dunnwurtl and in-
ward below their uorniul ]iluue, and wilh cx}iir,ilioij, ure furood njjward,
the glottis being 8oniewh:it diLUtd, so tbut ilic air csc;i]>l'8 freely. The
vocnl cords and mucons nRMubrimt' of tlie l.irvni ni:iy be of a normal
color or slightly congested.
BiAGKosis, — In iidults the true nature of the disenfto is at once sug-
gested by proniinenl inspiratory stridor: the chuniclenetic uppoamuco
of tlie glottis on inspinitiun leaves no doitbt as to the diagnosis, except
as between this condition and mihenion nf the rintrr sur/acra tif the aryt-
enoid cariilfige^, wliicli aoinetiriies so closely resembles It that in the
Absence of previons history a ditTerential diagnosis may be inqiossible.
This affection may be diBtingnlshed from sjfajfm of the adductors ii8
follows :
Bilateral paralysis or tqe
ABDUCTORS.
Inspimtory tlyspncra cuiutxiDl; Miny
be iiicixu^ed (luring sle<.'|i.
Vocal cords immovuble.
Spasm of the: AmnjcroKs.
InHpiralory (iysfinira temporary ; iJi-
iiiiiiislieil oi* abM-MiT iliirini; sle^p.
Vdi'ilI coi-Jh more or less constootty
vni-ymg in tensiun.
Proonosis. — The duration and final result necessarily depend u}M>n
the nature of the lesion; where the paralysis is decldeil, the prognosis
is always unfavorable, and iv fatal result may oecur at almost any time
unless tracheotomy or ijitubution lias been done. It is only in a few
«ases, of catarrhal, syphilitic, or hysterical origin, that good results can
Ik* expected from medicinal treatment.
TkivATMent. — The grwit d;iiiger from suffocation renders it neces-
sary to adopt some preventive measure. For this purpose, an O'PMjer
intubation tube may be introdnemi and worn while the influence of in>
lernal remedies is being tried : but if this does not succeed, tracheotomy
had best be performed. Except wlien these (Patients can be closely
■watched it is nut safe to let them go, even for a single day, without one
■or the other of these operations. Fanidization sliouhl he tried, and
Bucb remedies used as are most likely to remove the cause, such as us-
tringeut and stimulating sprays in the catarrhal conditions, strj'chnine
and other tonics in the hysterical form or where there appears to bo
functional interruption in ihe central nervous system, and the iodides
in the s^'philitic variety or whou the pressure results from enltirged
j;lands or goitre.
514
DlUJiASJSJS or THE LARYNX.
unilateual paralysis of the posterior CRICO-ARYTB-
NOXl* MUSt^LK (ABDLtTOU (II' THK VUL'AI. CORD).
In unilulemi {vrulysis of the posterior crico-arytcnoid DiiiMile^ one
vocal cord remains i:i the modiuu line during Lnspimtion, with conso'
qiu-iit dyt^inxiiit and st^iJnlous rDfipinitioii. It id due to lesions einiiliLr
to those which cause bil.it^rnl pjiralyais, but it most fn-qm-ntly rf>tinlt&
from periphonil cansee, us, /or instanco, catarrhal inflammation, or the
implication of one pneumog&stric or recurrent laryngeal nerve by muUg-
nant disen^o, aneurism, or other morbid growths.
Symitosiatology. — Tho symptoms arc ohstmcted inspiration, stridor
and dyspiiten, mid slight alteratioi' of the voice. There aro also
proseut more or less irritative fever ai;4 t*.*e symptoms of the primary
dideaso. On inspection the aflocted cord h seen to remain stationary at
.-3?.
^
Tut. IflS.— Umlitbiul Pakal-
TSIK W ■niK lj:rT IVuttkbihii
CUDO- AKVTKMOI O— IXM>IIUT10K.
lU'
fia. 1*3.— UNiumuuL Wait-
niK or rai Lirr pD«rauoR
Fill l'.H.— AKi'iitUjnib or
RlOnr VOTAL CliRD— .SrBCI-
na-PaoKATici)!
or noar the median line, while the movements of tlio other are normal
or slightly exaggerntcil
Diagnosis. — The symptoms and laryngoaeopic appearance leave no
qnestion as to the diagnosis.
pRoaxosis, — THo affection is much less dangerous than bilatcnil
paralysis, but it \& usually best to give a guarded prognosis, since it is
impossible to tell huw soon the disease which has implicated one nerve
may involve the other. When due to sini^tlo catarrhal inflammation*
hysteria, or syphilis, recovery is the rule.
TuEATMKNT. — If iM)ssiblL>, tlie cause should bo removed. Fnradtdni
or galvanism and constitutional treatment similar to that recommended
in paralysis of both muscles should be employed.
ANCHYLOSIS OP THE ARVTKXOID CARTILAGES.
Anchylosis of the arytenoid cartilages is a rare ailectiou, the diag-
nosis of which may be attemled with great difHculty, since it closely
simulates pandysis of the abductors or adductors of the vocul corda. It
should bo 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. SIS
a patient conTalescing from typhoid fever complains of the symptoms
of laryngeal disease.
Treaxmekt. — If the condition interferes with respiration, attempts
should be made at dilatation by Schrotter's sound or O'Dwyer's intaba-
tion tubes, and tracheotomy must be done if necessary.
ATROPHY OP THE VOCAL CORDS.
Atrophy of the vocal cords is extremely rare, and so &r hae 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.
foU
mUEASJiS OF TUB LARYNX.
UNILATKKAU f'AKALYSIS OP THE POSTERIOR
NOIi* VUSCI^E (ABnUCTOK ok THK TOCkb
In uiiiliitffml (wmU'tiis of the posterior rrif-'o-nn i
vociil ci*n\ ruitiuiiis i:i the meJiun line during iuaj
<)iu'iit ily^piiu>a mill 8t.'iJiilou» reHpinitioii. It is
to LluiKv wliicli uiiise hiIjiC<)ritl paral)'.sis, but it m>
froni pcripiicrnl cuiisos, as, for instance, witarrlu
implication of one pncumugii^ric or recurrent !••
naiit disease, aneurism, or other morbid groni'
Symitomatoloov.— ThoBVini'iouiBureolt
and dvBpiKBa, and slight alteratioL* of thi
pnwcnt more or less irritatirp fi'vor ar.^3 t?-
disease. On insjHKtion the niTected corrl '*•-
Tva. nt— UMtukTSUL Pakju.- no. tW-
ISM i» mm Lxrr t^Hcrnuoit t«« >•'
Catco-AHrmma-lHHrtkAmn. dui'ii i.
or Doar the median line, wbili<
or sliglitlv exaggitratcd.
Diagnosis. —The sympt»>
question as lo the diagniMT^
PROGXUSIS.— Thi
]HiralyfiLs, but it is >
iiupossible to tell h<
may involve tli-
hysteria, or syi'. .
Tkkatmknt. — if
or g»lvant«m nn'T *
in paralysis of ' ■
AKCKY
Anchylm-'-
Diseases of the Nose.
:apteh XXX.
DISEASES OF THE NASAL CAVITIES.
■
INFLUENZA.
Stf nonff ma.— Bpldcmic catarrh, epidemic c&t&rrhAl fever, grippe
Infliieiizti is a siwcifii: epidemic fever, ohivracterizcd by catarrbal in-
flamuiiitiou of the mucous mciubraue of the air passages ur digestive
tracts, and br marked aud sometinies profound disturbances of the
nervous system. It occurs in epidemics, whicTh spread raj>idly over an
entire mtntinent and attack th« greater portion of the po]iulation irre-
Bpoctiro of age, condition^ or sex, except that infants enjoy nearly com-
plelo immunity from the disease, although young children are fro-
(^ueutly iittucked.
AXATOMICAL AND PATHOLOGICAL CnARACTERISTICS.— No definite
leaionti cin be described as peculiar to this disease, for in most fatal
^-«naes death re-sulti^ from some couipUcattoii. There are usually signs of
inflammation in the mueom) membrane of the nir passages and digestive
trai't, and not infrequently in tlip serous membnines covering the bmin
or lining the thorncic or abdominiil cavities. Usually npon opening the
chest, the lungs are found (o conuiin hero and there depressed spots of
lobnUr con»)lidutiou. The mucous membrane of the larynx, trachea,
and hrotu'hiid tubes is congested, swollen, and more or less covered with
frothy or muro-pnrulent 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 gustro-intestinal mucous
membniiic is distinctly congested and swollen in patches.
KiioLUGY. — The disease is evidently caused by some powerful mor-
bific agent ill the atmosphere, but whether an irriUiting gus or a spe-
cific micro-oiganism has not been determined, fienerally speaking, the
disease cannot be communicated from onp to another, and, though i>onie
observations seem to iudtcato its contagious nature, this is still an open
question.
SvMFTOMATOLOGY. — Thc affcction is sometimes pi-ecoded for twonty-
fonr or forty-eight honrs 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 heudach^, jmin in the back and limbs,
constriction of the chest, and muscular weakness. Tbi)i is usmilly fol-
lowed by thc ordinary symptoms of acute coryza, with sore throat, fre-
S-iO
mSEASBH OF THE NASAL CA VITISS.
m
quc-ul liacking cotigh, inid in luuuy cuees dyBpiirani, even without any
affection of the lungs themselves. There iirc puroxyisma o( sneezing and
Beimations of stuffineHii iu the head, the eyea are Kuffused, and not infre>
qiiuiitly the inflammation extends to the £utttachiun tubeB and middio
ear.
Severe frontal headache is one of the most common symptoms,
and often there is great sorcuess of the mutjclea, attended in many cases
by shaqi neumlgic pains; extreme prostration and great despondency^
wholly disproportionate to the tjeveritv of the attack, arc often observed,
and actual delirium or mental vagaries are present iu many cases. Dis-
ziiiess is frcqviently experienced on rising suddenly. Most epidemics of
tlio grippe have been characterized by great rcstleesness and iuGomnin^
but in some the opposite condition has been quite prouounced. As
the disease becomes established, the face is often congested, and occa-
sionnlly jaundice, associated with hepatic tenderness, occurs.
The fever rises rapidly to 101 ' or 102° F., or sometimes even to 104" or
lO.'*" K; it is of a remittent cliaracter, usually attended by profuse sweat-
ing. Chtirles Warrington Earl« {Anldve/i of f*e(/ifitrirs, March, 1893)
states that in some children with inflnenza a high temperature persists
for a long time during convalescence. In others he lias observed a sub-
normal temperuturo, which in one instance, iu the axillu, i-nugcd from
J»3* to 98° F., for six days, ultliough eonvalcsceuce progressed favorably.
The pulso commonly ranges from 90 to 100, titough sometimes it runs
much higher. Iu the milder forms of the disease, the catarrhal innauima-
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
intlnmmation of the tniclica often occurs, and not infrequently the in-
flammation extends beyond, giving rise to bronchitis or catarrhal pneu-
monia. These changes arc attended by more or less dyspuiea and cough,
and are usually [ircoeded by hoarseness. The cough occurs in parox-
ysms, usually worse at night or in the cuirly morning, and is at first
attended by a frothy or clear ex]>ectoration, which later becomes muco-
pnrulent and often quite offensive. The diii^charge from the nares is at
first thin and watery as iu nn ordinary cold; later it becomes mnco-
purulcnt, and epistaxis is not uncommon. The tongue is usually coaled,
and the appetite lost; frequently there is tenderness, or colicky pains
occur which may be attended by nausea, vomiting and diarrha'a. In
m.'iny insUinces 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 hyperiemia and swelling of
the mucous membrane; and the mucous menibninc of the fauces is
lilarly affected. Upon examination of the chest, the signs of bron-
litis are genenilly present, even in companitively mild coses, and nil
Ln irequeutly the evidences of piieumouia or picuriiiy will be obtained.
UiAoxosib. — luHueuza is nut apt to be mistjiken for auy diseaae «Xt
lyrtrjcjiZA.
5'i\
•
cepL ucuto nou-speci^c rhinilU ur iutlumumtiou of the larjnXt tntcliea» or
bronchi from which it does uot matertiilly differ except in its epid^mio
nature uud tUo severity of the Bvinptuius. iHuUtod tsiscs of the Utter
frequently precede an epi<lemic of inriuenza fonr or fiv« works, prodcnt*
iiiil much the sume symptoms and possibly dno to the same cause;
but it mu«t not be forgotten that severe catarrhal inflamm»tiona of lh»»
upper air passages are common, indfpi'udtut of tho iHx'uliAr eoudilioiis
which cause intluen7Ji. Usually the history of an epidcmic> tho sovcro
hcfldnche, mental depression, muscular pnins. and sudden onset of tlio
attack render tlie dirtgnoais easy. Tho ^yniptoiii^ and signs of compU-
catiuE didordera will mH differ essent Lilly from the uKiiAlmnnifuslatious
of tliet^e affertiona, except bo far uji thi'V m:iy be nKHlified by the fever
aud nervous prostnition attending tho epidemic disoitso.
pHOtiXOSLS. — The cut-arrhul sympttnns usually begin to subside ill
three or four days, aud in mild aiscs tlie patient will not bo confined to
the house more ihau forty-eight to seventy-two houra; indeed, many
persons contiunc their atocations in gpito of the di^onec. When tho
diftoa^ ii more severe, convalescence mny not be eatablishud for a week
or ten days, and in some the affection may bo even more prolonged.
This is especially the case when the uilectiuii is complicjittwl by trachei-
tis bronrliitis, or iinuumonia, but in uiifuniplii'nted on&t-s convalescence
is usually fully cfit:ibli»he<l within ten or twelve diiys, even in the inoro
severe forms of the ulteciioti. ^\ hen occurring in iho very young or tho
aeed, or in persons grcutly debilitated from any cnusi>, or in persons
BQfferiug from chronic pulmonary, cjirdiac, or renal disease, inlluonui
must be re"iirded as a gnive affection; aud when its various rnniplicat-
iug disordt-rs are considered, it will be found that a conBi<lemblo num-
ber of cases, probably three or four per cent, provo fiitjil. When it at-
tacks pregnant women, abortion is liable to follow. Tlio iapi>rii>neo of
the epidemics through which we have passed during thu hiat two years
shows that functional disease of ihfi heart, prolructi-d fpvcrs of a typhnid
charncter, pleurisy, and pulniouury lubcrcuIuHia uro common sequels uf
uillucnzii. Rheumatoid or neuralgic pains not infrequently coiitiriua
many weeks after the subsidence of the acute symptoms.
Treatment.— No positive directions can be given for thu provontion
of tlie disease; but as it has been obaervedthat those who are exposed to
the outer air suffer most from the iiffeition, it is wise, during t-pi-
demica, for children and thoso cnfeebh-d by ngc or disease tu remain us
ranch us pob»fiblo indoors, hoping thereby to escape. As tho main
Bvmploms indicate great nervous dopre8.-iion, it is well during nn ejii-
d'emie to fortify tho system against an attack by tonin dowd of qulnino
and nux vomica, l^rge doses of quinine are said someHmua to abort
the attack, and the sume has been chiimoil fur opiates, oropintcs in com-
bination w-itb quinine, or ipecacuanbu. During the prngixim of the ilis-
euse, rest iu bed and gentle laxatives, refrigerant drinks, moderate doses of
o22
DISHASICS OF THE JfASAJ. CA VITIS8.
quinine, aud snuiU doses of opium or otbor anodynes to relieve tite cough
are rccammeudt»d. To relievo the pain iu the iDceptiou of the diseiuitt
no retnedv buK eeenied to nie iiiurv vulimble ihitii phenuee.iii ; Inter, lurg^e
do8e8 of potoesium bromide, whirh ia jHn-uliiirly ellicit'iit in alluyiiig irri-
tabilitj and quieting congh, together with extract of nnx Tomicu, ex-
Irart of hyoscyanuis, qniniue, and camphor, hiive proven most bene-
iiniiil. Tlio irritability inid inflammutiun of the mueuus nit.*nibrauu may
6ometimes be greatly relieved by tlio inlmlation of {tt<!um, or elenm im-
pi'egnnted with various soothing vaporR, fl8 nf ojiium, bdhidonna, or
hyoseyiimus. When rheumatic gymptoms are present, colt-hicum antl
the salicyhites, togetlier with alkalies, hnve been found most useful
Complicating diseases should be treated upon general prineiples, and
in jirotracted eases the nutrition should be carefully attended to. If
convalo8cence \i delayed, ii change of elimntc will frequently bo of greui
advantjige.
RHINITIS.
SIMPLE ACCTIf RHIKITIS.
Stf)ionj/mfi, — Aonte coryza, aeute nai>al catarrh, acute cold in the
bead, acute rhinorrhcea.
Simple acute rhinitis is an inflammation of the nasal mucous mem-
brane, gunietiines of one passage, but usually of both, often extending
into the maxillary or frontal t-inuses, the lachrymal ducts, and Kusta-
chian tubes. It is characterized by paroxysms of sneezing, hyper-
secretion, and more or less obstruction of the narcs. In infantii it ruusea
marked difficulty of breathing, particularly during sleep or nursing, and
is occasionally attended by attacks very closely resembling laryngifimus
stridnlutt. The discaso occurs iu all climates and seasona and among
patients of all agPR and alt cbiaaca of society, hut it is somewlmt more
frequent among children, some nf whom apparently have a congenihU
predisposition to it. ft is s:iid to be more frequent among ]:>erf>on8 of
nervous temperament and in those subjeec to rheumatism, yet it Is usu-
ally independent of diathesis.
ANATOMICAL ANT) Patmological CnARACTEnifiTics. — Thc mucoas
membrane becotncs swollen, red, and at first dry. but is soon butlied in
a profuse secretion of serum, which u little later becomes sero-purulent
and is loaded with an excess of salines, which arc very irritating to the
nostrils and npper lip. In exceptional caaea an excess of fibrin collects
in irregular masses, as a membranous layer, which is most often found
in the cor3'za of new-bom infants or in that accompanying the exanthe-
mata.
KTroLonv. — The most common cause is exposure to cold when the
body is overheated, biit uot infrequently it results from exposure to
undue beat, or the inhalation of dust or irritating fumes or vapora.
I
sofpLE AcvTB RHimrrs.
tn
Fraonkel bdievca that infantito coryza is generally due to diroct infec-
tion from tiic vaginal secretions at the time of birth. Among the occa-
sional t:au8ctt may be mentioned ox]io6iire to the niyfi of the sun, iui-
petigo or euzenia, measles, scarlet fever, typhoid fever, tertiary sypliiliB,
iodiam, facial erysipelaii, or extension of iufliimmation from the con-
junctiva;, pharynx, or larynx; and it is said to be cmused in sorae in-
stances by the cure of chronic dischargos, eiich iis those of otitis and
ophthalmia, or bleeding hemorrhoids.
SvwPTOMATOLOUY. — The alTeelion often comes on witli a feeling of
general malaise, winch may last fur two or three days, but more fre-
qnently 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 slopping up of tho nose and
hypersecretion of a thin, irritating sorura, which, after one or two days,
becomes thicker and bhuid. The nostrils and upper lip boL-ume red and
irritated from the secretion and freijueut use of the haiidkerchit-f. The
nasal passages are so stopped that the patient is obliged to breathe
through tho mouth, with great discomfort, particularly while ho is eating
and during sleep.
The general symptoms vary from slight disturbance to severe
pain and heiidache, with slceple&sness, mental and physical debility,
fever, and derangement of the digestive organs. There is sometimes
a slight chill at first, bnt the e:irlier symptoms usually consist of
sensitions of dryness or irritation in the nose and i\ disponitiun to sneeze.
Within a few hours there is slopjfing nj) of the nares, witli obtunding of
the senHt'5 of smell an<l taste, more or less pain, and frequently extension
of iiifiammation along the lachrynutl ductg, causing redness and sensi-
tiveness of the conjunetivfc. If tho intlummation extends along tlio
Eustachian tube^, there is a sense of fulness, possibly with pain in the
oar8, and often abnormal auditory sensations and i>artial deafness. The
inflammation may travel down the pharynx, cansing sore throat, or it
may involve the antrum, frontal sinus, or ethmoidal or sphenoidal rells,
causing correspondingly severe pain iu the cheek or forehead, or deeper
Boated.
Occasionally the disease is intermittent, lusting for two or three
days, and then subc^iding, to be renewed after an otpial length of
time. Any or all of the symptoms excepting the secretion may be
absent. The inflammation frei^uently attacks one side, not involving
the other for two or three days or until its course is conipleted in the
first. Exceptionally the cervical lymphatic glands become enlarged and
sore. The body temjjeraturo may rise two or three degrees and the
pulse be correspondingly accelerated. Obstruction of theanterior mires
gives the voice a nasal tone; but if the swelling is mainly in the posterior
part of the nares, the geuenil character of the voice is nornuLl, while the
articulation is defective, the letter m being sounded like I/, and ii like tl.
634
lil.'iKAlim OP THS NASAL CAVITIES.
The secretion, which at first woh Ihin^ Heruiia, ami irritating, nftor a
time t)econto8 thirker, whitish, yellowish, or greenish, uccorJing (o tho
intonsity of the iiillainnuit'iry process, ami tlio roltl is Huiil to huve broken.
The aocretioa may aniuinU to several ounces in tweiity-foiir Imuri*. Tho
frequent rise of a haiiilkurchief after a time hecoineti paiiiful, hut, m the
secretion hecoiiicj} thicker, irritHtlon grndiially auli^i<lej(. There is often
an iinpleasiuit c;itarrhal odor to llie hreuth; unil when tliL> nose ia com-
pletely obstrnuteil, the tougnti bt>come« ilry am] hrown from the contiuueii
mouth -breathing. The iip{>etitc ia not iufretjuently impaired.
Upon iii(>pection, the niiirou» inenibrane is found to bo swollen and
congcfitctl, and sunietimeg, though not commonly, here itml there are
flmall, dark-bi*on*n fitaius, indiciiting cxtniva«<Uiori of blood beneath lbs
mucous lucmbnine; or slight abnuions of the surface may be noticed.
Early in tho attack tho thin secretion may be seen moistening the en-
tire mucuuH inembruuc or flooding tho floor of the nasal cavily; later,
fine, cuhweb-likc ehreds of mucus are often seen stretching from sido to
side across the nuwtl chamber, and more or Icsa of the thicker secretion,
mucous or mnco-jjurulent in charat-ter, will bo found coHecled in the
nasal cavities, especially at the lower and hack parts.
Diagnosis. — Acute rhinitis is not likely to bo confounded with any
alleotiona excepting hay fever, inflanmiation of the antrum or frotitnl sin-
uses, or tho commencement of measles. In any cusc the history, tho
churucter uf the discharges, and tlie appearance of tho parU will soon
sottio the diagnosis.
pBOONUsiiS, — Attacks of acute rhiuilia sometimes last but a few honrs,
but usually they continue for from three daya to a week, and sometimes
two or three times as long. Tho stage of dryness gonenilly continues
two or three ho»i"s, that of free, thin secretion from twenty-fonr lo
forty hoors. The thick secretion ooinuionly continues two or three
days, when it gra<lnaUy grows thinner until the end of the attacJc.
The affection usually terminate-s by resolution; in children at the
breast, and in the very aged and inhmi, it has occAsionally proved fntsl.
Frequently repeatt-d attacks are liable to eventuate in a chronic ca-
tarrhal condition of the nasal mucous membrane. The inflammation
may leave obiit ruction of the luchryniiil ducts or the Eustachian tube^i, or
chronic inflammation of some of the adjacent sinuseji, and it sometimes
seema to he the starting point for muial polypi. Where these growth}
already exiRt, they are often found to cnUrge greeitly during acute at-
tacks of ooryza.
TitEATMENT.— Prophylactic treatment includc's daily sponging of the
chest with cold wiiter or salt and water, iMtthing the feet every morniogin
cold water, care reB|>ecting suflicieut warmth of tlic clothing ; and avoid-
ance of sudden exposure, dump clothing, wet feet, and in a word all
tbiugi which have been found to excite the inflanimation. In the be-
ginning a\\ attack may frequently bo aborted by moderately hirge
SIMPLE ACUTE RHINITIS. fiSS
doses of opium, quinine, alcoholic stimulants, or the ammonium suits.
Morphine gr. ^ to ^ or its equivalent, atropine gr. ^^^ with niuri>liiiio
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 cliucked
in a similar way by one or two doses of ammonium carbonate, gr. x. to
XX.; ammonium chloride, gr. xx. to xxx.; liquor ammonioj acetatis, z \.\
tincture of belladonna, TTlz. to xx. ; tincture of euphrasia officinalis, TILx,
to XX. ; ammoniated tincture of guaiacum, 3 i. ; or an emetic dose of un-
timoby. 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 consista
in the administration of a comparatively large dose of quinine, and tho
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 al>Hti-
nenee from liquids, as recommended by C. J. I). Williams, is said to
be efficient in curing attacks of acute rhinitis (Cyclofta-'J ia of Prac-t.
Med., London, 1833), the eoryza beginning to dry up in alxiut twolvo
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 \im\
time. If the disease was not aborte<], Morell Mackenzie recommendcl
five drops of the tincture of opium every six or eight hours. Tendropp of
the spirits of camphor on sugar may Ije effectively taken in thefiameway.
Five grain d<jse? of {lotassium nitrate, twenty minim (\fi*tT*. of the j-pirit
of nitrous ether, or two drachm df>ses of s/jlution of ammonium WMtnih
repeated from time to time are often useful in cutting^ short the diMane.
Turkish baths are sometimes very efficient, thoojrh extreme 'rare
18 necessary to avoid taking subsequent cold. JaU^randi and oih';r
diaphoretics have a similar effect, and diuretics and catharti'.i! m:iy
expedite the cure; however, these should only be given when the
patient can be kept indoors. Insfiiration through the nose of wirm
aqueous vapors or sprays of mild solutions, gr. ij, ad z '-' of amn-'^r.-'im
chloride or earbonnte. or sodium bi';art»ORate, or \■^JXi^k^\^^m 'rar^/'.nat*-, or
boric acid, gr, viij, ad 7 i., are s^jmetimes very grateful to the i»r*t>r.;,
and eeem to aid mo'-h in prompting resolution,
As a rule, the most satisfactory c/orse of treatmer.t will rje fo-jj-d ir»
the administntio:. at ^.TrX either of the morj»hine ar.d atropin*- '>r of a
cmnparativelv urre '\f^■•^t•i 'iuinir.e or of nnx vomicr* 'atA the appilrsiSion
totbe nare£ of a ir.e or two j.er cer.t w>Iation of cv-air.e in water, or 'r>ett«r
590
I>l:i£ASBS OF THE JfASAt CA VITISS.
still in oil, or the inButllatiou of h powder of four per ceut ot cocnine In
Bugar of iDtIk and sturch. In tho latter case it ia well to use also a
fipruy of liquid ulboloiic or bcuzoinol three or four times daily.
Oora.siouallj' pei-soiiH atv met io wlioin oily sjiniyii of any kind ng]p^vale the
disease. Id these the sohittun uf boric acid i» apt to be most soothing.
If the diseiiao ia not abortpil at onee, the copuine may bo continned in
£nmll qiiantitic>& tbri-e or four times u day. T}io spiny of liquid albolene
should be coutiutied during the atUtck^ and the patient may be given
with udvunlage, four or Gvr tinier (hnly, ^nmll dnses nf cannabis indica
ant] hyoscyaiaus, with niedinm doses of oamphoraiid ({uinine, or qninino
and phenacetin, or quinine and camphor mono-bromide. If opiates
are given, cjire should be taken to koep the bowels open; and in any
event it may sometimes be desirable to give gentle Inxativcs.
AoUTB MHi.viTis IN IXPAKTS requires especlul care to keep the nusnl
pasMgM open. This may be done best by the a])pliaLtiou of sprays of
liquid alboleue,or, in c:uiu8 wheru there ia 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 mires and givo t))e child
pain. Whenever it is deemed necessary to syringe the nares in a child,
it should bo placed upon the f:ii:e, and the warm solution introdu<^ed
slowly, so thai it may run out again from the op^tosite noslril.and not be
drawn into the larynx. Excepting (ipinm, most of the remedies rei>
ommended in the treatment of the diseiise in adults may be used in
smaller quantities for children, but usually it is l>cst to rely upon oily
sprays and suiall doaes of quinine, with medium doses of the solu-
tion of unimnniuui acetate. Tincture of euplinisiii utliciiialis given in
small and frequent doses is said to be peculiarly efTectivo in the onset.
TRAUMATIC OniyiTIS.
Inflammation of the mncous membrane is not infrequently ojtcited
by dust and vapors of chlorine, iodine, or other irritating subst-nnces
suspended in the atmosphere. It may also arise from the entrance of
larger foreign bodies, or may follow direct injuries to the nose. Tho in-
flammation is not peculiar, and the remedies indicated for acute simple
rhinitis are etpially applicable hvrv. except in case of fracture, when the
parts must bo replat'cd.and rettiinei] by nnsal plugs and cxterual (cpliulif.
Hemorrliage should he controlled by the measures suggested for epl-
etaxis, and if abscesses result the pns should be promptly evacuated.
Tho 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 {mtnssinni bichromate, arseni-
uus acid, and mercury which deserves special notice here. It ie charac-
terixed by ulceration lading to perforation of the cartilaginous septum.
CHRONIC liUmZTIB.
SST
The ulcer ia at first BinuII imd rouud, but aiibsequontly enlarges »nd
assumes an oval Bliape. Since it doea uot oxtenil to the lower and ante-
rior part of the eartUago, the bridge of the nuae never falls in. Ulttera
lire also occasionally fonnd on the turbinated bodies, but are less extL'ii*
t^ive than thu&e on the septum.
Symi'TOMatolocy. — The symptoms produced by the liichromato are
tickling and sneezing, accompanied by profuse secretion; tliis is at
first watery, but siibtjeqneritly it becomes thick and greenish, and later
contains erosta or particles of sloughing mucous mumbnmo, an<l Gnully
pieces of cartilage; but it is never offensive. Ileinorrliuge frefpiently
occurs iu the course of ulceration. The symptunis produced by the
other substances are 8:iid to bo similar; and whichever of those substances
ia the cause, the symptoms seem to result entirely from local irritation.
Tkkatmicnt.— Persons employed in trades where they arc likely to
suffer from this alTection should constantly wear plugs uf wool in the
nosirils. Where perforation baa once taken place, it is diflicull Lo pre-
vent the formation of a large openirg, but ordinary treatment will soon
check the surrounding inflammation. Thnae who have once siiiTered
from this variety of tmumatic rhinitis are said afterwanl to enjoy ira*
manity from commoti catarrh.
CHROSIC RHINITIS.
Synonyms. —Tlhinnis chronica, chronic catarrh, chronic eorysa.
Chronic rhinitis is a chronit; influnimiition of the nasal mucons mem-
brano characteriKed by dryness and the collection of crnsts, or excessive
secretion and discharge from the nostrils or naso-phnrynx^ with fre-
quent inclination to hawk and clear the throat. Hoih conditions may
be characterized by stoppage of the nares and interference with res-
piration. It is an affection found in nearly all climales and among
all classes of people, and is most pronounced in the fall, spring, or
winter months, when the temperatorc and moietorc of the air are most
changeable. It is most frequently met with near the northern seashore j
or on the borders of large lakes, yet it is prevalent even in some dry
climates, especially where the uir is filled with duKt, as, for example, in
Colorado and New 3Iexico. On the borders nf 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 fomier to sodden clianges,
and to fogR and the <lunip, chilly winds, especially in the spring, when
the southerly land winds have be<-ome warm and balmy, while the north-
erly winds sweep over water often still i*outainiiig ice, and colder than
the hind. The affection is most frequent in children and young adnltt
between the ages of ten and thirty-flvu years, but it often occurs in infants^'
and not infrequently in people past the prime of life. Persons follow-
528 DI8EA8ES OF THE NASAL CA VITIES.
ing outdoor vocations become less susceptible to the inflnenee of sud
den stmoepherir; changes, and are therefore less liable to this disease.
For conTcnience of description, chronic rhinitis may be divided into
four varieties : Jirui, simple chronic rhinitis, consisting of catiirrhul 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 chkonic rhinitis is a catarrhal inflammation of the mucous
membrane attended by little or no swelling and cliaracterized generally
by groat irritability and susceptibility to acute exacerbations. It is at-
tended by congestion and by excessive watery or muco-purulent secre-
tions.
KTioi.oftY. — The disease may be induced by the frequent repetition
of any of tliose contlitions 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 inhahition of damp, chilly
atmosphere. A predisposition to inflammation of tlie 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 tlio onset of the affection, and in many cases hypenes-
tlu'sia of the terminal nerve fibres in the Schneideriun membrane is
ni)jmrently the predisposing cause. In some cases it is favored by a
scrofulous or dartrous diathesis.
SvMrroMATOnnJY. — There is usually a history of frequently recur-
ring attacks of at'ute inflammation which have finally resulted incon-
stant irritation that is likely to have continued for months or years
before the patient has applied for relief. Itching, burning,and tickling
sensmtions in tlie nose are common, and sneezing usually occurs on the
CHRONIC RHINITIS.
62»
digbtest provocation. Keaduches and |min in the e;o8 aro fretjuent
sviniiUrms. Not iDfreqiieutly there is loss of tlic sense of fimell, uud
partial dcafucssj and occasionally the senee of taste is obtuuded. I'ro-
Iu8e liichrynrmtion is an ocrosinniil symptom, and in most cases thero is
a profuse watery discharge from the nose, re-cnrring npnn the slightest
irritation such us brentliing of cold air. In some persons, after a time,
the secretione become uiuco*purulDiit and of a more or Jess offensive odor.
Usually the gcnend heuUh is not perceptibly impaired, but somo-
times it is poor, with derangement of tlie digeativo organs mani-
fested by capricious appetite and a singgish condition of the bon-els.
When the secretion is thin and watery, the mucous membrane will gen-
erally be found congested, of a bright rod color, the surface moJBt, and a
•considerable amount of secretion collected in the lower ]uirt of the nasal
foasfl-'. Frequently cobweb-like threads of mncus will be seen stretch-
ing from side to side of the nasal cavity, and of^casionalty small, opales-
cent, trangparent, or yellowish granulations will be eccu studding tlio
anterior eiida of the inferior turbinated body. Tliese arc about a niilH-
metro' in dinmeter and appear like solid massi's. but when bru.shcd over
with the probe.they are found to bo small drops cif fluiil. Tho nasal cjivity
normally is from three to five millimetres in width but in more than
half of the cases extimined, deviation of the nasal septnm is i)rescnt. or
a CJirtilaginous or bony spur will be found projecting from one or both
aides. These, however, may Iiave no relation to the catarrhal condition,
and are of no consetiueiice as long as they do not obstruet nasal respi-
ration. In most instiinces thp rinrons niemhranc of the naso-pharynx
is congested, and here and there collections of tenacious Bccretions will
be found adhering to its surface; or tbeso may collect to be removed
from time to time by the act of hawking. In rare instances the nasiil
cavity remains of nnrmal size and free, excepting when olistnicted by
dry and decomposing secretion; if tbis be removed, the mucone mem-
brane is finind irregularly congested and of a bright red color in spots,
or pale and ana-mic. In most of those cases, the atrophic condition is
present, but in others there are evidences of hypertrophy.
I)iAaso.sl3. — The diagnosis nniy he easily made by inspection and
palpation of the part, wit h a eonsidenition 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 sermon after
reason: while the former comes on at any time. and is apt to be continn*
ous. with frequent exacerbations. Upon inspection of the part, the nasal
nnicous mcmbnine is found congested, and paljmtion with the prolw)
frequently rereads here ami there sensitive sjmts. similar to those which
are present in most cases of hay fever; hut the hypertrophic or atrophic
changes usually present in chronic rhinitis are not so common in hay
fever.
pRonKOSls. — The affection runs a tedious course, sometimes lasting
34
A30
DIS1SA8ES OF THE NASAL CAVITIES.
for many years. Some cases ereutuult; recover simiitjiueuufily, but
others go on from bud to worse, and tiDally termlaute in mine of the
other forma of chronic catarrh.
Tk(:atiip.nt. — The treatment of this vAriuty of rhinitis i« tedious
und often tuittHtigfuotury, but uouiilly consideruhle relief niuy be given
and in Bome caaes a cure tJlTteted by local ujip]ii;iiliun8. lu the treat-
ment, two objects are to be kept in riew^ viz., relief of irritability, and
the checking of excessive secretion. If the secretions arc jiroftitio and
watery, the nares will be kept clean, so that washes are iinueceseary. In
this clatis of cases, soothing powders or sprays arc most oflicacious, and
mild astringents will often be found useful to toughi-n tht< nicnibmne.
All applications should be so mild as nut to cause EmurLing for moro
than five minutes, and should, after brief discomfort, givo a feeling of
relief. The susceptibility of the miieoua membrane varies greatly ia.
different rases; therefore (ho mildest preparation should always be used
in the beginning. Oily sprays are of utility in most casee. Those
most commonly in tiso are fierivatives from coal oil, such as oleum
petroliim and liquid albolcnc; melted vnsclin is also used for the «amd
purpose. However, the effects of these are but tentative, and there-
fore they should only be pri-scribed for the imlienl to use at home two
or three limes daily. In some cjiseaof jirofuse secretion I liavuobuiined
most excellent results by having the patient apply twice daily a spniy
containing ^\ x. of terebene ad z i. of liquid alboleno. Indeed, this has
socme<i more efteclive than any other loctil application..
A sedative powder consisting of about five or ten per cent of boric
acid, twenty-five per cent of iodol, tive per cent of starch, and sugar of milk
to make one hundred grains, with occasionally one per cent of cocaine^
may in some i-asts be applied in addition to the spray once or twice
daily with much benelit. Cort;»in patients in whom there is marked
hypcrieetliesia of the nasal mncons membrane, npon going into th«
wind or dnst are subject to attacks of pneczing. accompanied by exces-
sive secretion, necessitating almost constant use of the handkerchief.
There is oonsconently soreness of the nose, which becomes the source of
mncli annoyance. This is the most obstinate variety of sim)de chn
rhinitis, Imt fortunately it ia nire. In searching for the sensitive spot
A probe shonld be parsed to the back part of the nasiil cavity and drawn
forwanl over the various parts of the mucous membrane; as a sensitive
spot is touched, the patient winces from the pain or inclination to
Giioeze or cough, and sometimes says that the probe pricks or burns.
The most effective treatment '\* superficial cauterization of the ticnsitivp
areas, as practised in the treatment of hay fever. SiNjntive powdors and
sprays should he used in the intervals W'tween the cjmterizations. which
•honid not be mmie oftener than once iu five to seven days. The can-
torluitions deMrny the terntinal fibres of the hypersensitive nerve, hut
are not deep enough to destroy the mucous membrane.
Cn^VPTER XXXI.
DISEASES OF THE NASAL CAVITIES.— CoH^umerf.
HHlii WIS.— Continued.
CHROXIC RaiNITlS. — Co?I^J»a«rf.
Intuukscrnt rhinitis, also known as clironic cAtarrh, And by iiame
considered as one of the forms of hypprtrophic rhinitis, is the moat
frefjuent of iiH vjirielies of CThroiiic rhinitis; it is ehariicterized b^ in-
termittent swelling of the Sclincidcriun mucous membrane, with more
or less ocflusiou of the nasal passugee. The ewcUiiig may involve botli
cavities at unce but usually ufTects one side ut a time and may chungo
in ;t few moments to tlie opposite nuris. This is must notic^eable when
the patient is lying upon the side, the nndermost imvity being occInded>
bnt the swelling generally ch^mges to the opposite nnria within a few
minutes ftfter the [vitient turns over.
AKATOMICAL and PaTHOLOOICAL CUARACTEItlSTICS. — Tho mUCOUft
membrane is usually congested, but is occjisiunully pale, and upon one
or both sides may be swollen. The tumcfaution is most frequently
found over the inferior turbinated bodies, but it sometimes involves
th« niidflle turblnals und ihut part of tlie septum directly opposite.
Frequently no swelling whatever is found ut tho time of cxAuiinatioTif
though the liistory clearly shows that it is present several times during
the day or night. Tho swelling interferes with nasul respiration and
favon* accumulation of secretion in tho nasal aud posl-nasul cavities,
consequent partly upon deficient evaporation, and partly upon in-
creased activity of (he secreting glands.
In niostf^asea the pharynx, and in many the larynx, finally becomes
the seat of chronic inflammation: and in many cases partiid dcjifncss
results from swelling of tfio mucous membnino in and at tho month of
the Eustachian tube. The pharyngitis and laryngitis, dependent in
part upon extension from the luircs. are chiefly tho results of mouth-
breathing, which becomes necessary wIk'Ii nasal respiration is ol>8tructed.
ExioLOflT. — The causes are those of simple chronic rhinitis.
SymptokaTOJvOOV. — In most cases tiiere is a history of unusual sus-
ceptibility to colds affecting the niwd cavities. These attacks are most
common in the spring and fall montha, though in some persons they
arc more frequent, in winter, or occasionally even in warm weather.
63'Z
DISEASES OF THE NASAL CAVITIES.
After a rariable time, daring which the attacks of cold in the hcnd have
groMm more and more frc<|uent and prolonged, the a^eetion finiiDy he-
coniea fixed luul ttie patient is annoyed much of Iho time, especially
at night, bv ubstruetion of nasjtl rutipirution nttendid bv hawking uid
«fforta to clear the throat, particularly in the morning ur after e:itiu^.
"When tc'imcioiifl muc-us adhert-s to the upper surf:ice of the palal«, the
Tioleul effort to dislodge it often Ciiuses vomiting. Often the putiunt*
are annoyed by eHght hacking congh, and by frequent hoarseness, espe-
cially on attempting toaing. By Raulin, of Marflc-lllt>8 (/Ifviifi (h tart/n-
ffoloffiff (VoioJogie rt (fe rhittoloi/ie. Annual of' fhfi Cuivrrmtl^ Afvttical
ScienceSt IB'J'i), this is attributed t»j muscular fittigiic c-iuimn] by excessive
Tibrations of the vocal bands iu an effort tu compcnaute for the In&s of
resonance caiiBt^d by the nasal obetructiou. Iu »uch cnam the vnice hi
often been ajM-edily restored by reducing the byiiortrophit's nf tlic M'ptiim
or turbinated bodifS. Nevertheless many pors«jns who suffer from all tbo
symptoms of nasal obetructiou become so accustomed to it m scarcely to
recognize the fact, and when questioned, affirm that they hure no diffi-
culty in breathing through the uo«e. They cliiim to sleep well, uud
assure the phyi!ici:iu that the throat is not dry in the morning, that they
always sleep with the month closed, notwithstanding the fact that
insiK'ciion shows the nares to he more than hulf closed by swelling.
Many compltun of lu-adnche especially in the morning, of pains in the
eyes, of frequent hawking to clear the throat, or a slight hacking cnngh,
of dropping of mucus into the throat from the naso-phftrynx. and of
obstruction in the nares, especially npon taking cold, which they con-
tract Tcry easily.
The symptoms in mild cases uswally disappear during the summer
months, or upon change of climiite, even thongh it he but n slight
change. This is peculiarly noticeable when patients leave the vicinity
of our northern lakes, e^jiecially in the spring an'l early aummer when
the waters are icy or cohl. In some there may he little difficulty in
tempcmtc weather; but in extremely cold or extremely warm weather,
or upon sliglit exposure to draughts, or change of teraperaturo as in
going from a warm to a cold room, or the reverse, or oven 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 *inctze upon going into
bright gaslight. Sometimes the Inbalulian of smoke or of odors from
certain plants, or drugs, will irritate the mncons membruno and excile
excessive seerotion. with swelling. Many patients cTperience sens-itiona
of itching or litrkling in the mouth, or a feeling of drj'ncss, fulness, pres-
sure, or sluffinesB in the nose, as the principal symptoms. Often tho
pharj'nx feel? drj* or uncimifortable. especially in the morning, and
sometimes obutinate pricking or neumlgic paina are experienced in Iho
fauces.
Occasionidty the patients are annoyed by repealed attacks of redneta
CUHOmc RinNiT18,
fi33
a.i](] iiin»mnmtiuu of tbo end uf llic nose. In many instances the voice
id thick ur iin&ul, and it ufteu becumes htHinie from tho uccompanying
lurvngitiii, «o thiit piitient^ iire usually iiuubk- to siug or shout, and oisily
bewime fntigiiod upon prolonged Lilkiiig. Such pui-Kuns uro gcuomlJy
obliged to keep tho mouth partially open niuuh of the timeipurticularly
when walking in the wind or during active exertion, and they are fre-
i|ucntly in tho habit of yawning or talking deep respirations to make up
Cor tho constantly doficiout supply of oxygen.
The secrttioua may or may not bo increased; they may be thin and
watery or thick and teuatious, or they may dry intu crusts whieb are re-
moved every two or three days from the nostrils or naeophiiryns. In
the nose these crusts are most likely to c<dlet!t upon the anterior part of
tho septum, or the anterior ends of the middle turbinated bodies. Fre-
(luently fine cobweb-like shreds of mucns will be seen stretching from
the turbinated bodies to tlieeeptum,n8 in simple chronic ca-tarrh. If the
secretions collect and remain for any length of time, they become par-
tially decomposed and offensive, giving the peculiar catarrlml odor,
familiar oren to the laity. The tongue ia commonly coated with a
vhito or yellowish fur, espeeially at its base, and the digestive system la
io frequently dit>turbed uh to lead to the belief that in some oaseu it \» the
direct cauHs of thiH disease. Gaseous eructationa from the stomach, and
constipation^ are frequent concomitants.
Upon inspection, the mucous membrane is nsnally found congested,
thougli occasionally it may be paler tlian normalj 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 ie ob-
served at the time of tho examination; but on the other hand tho
nares may bo completely obstructed. Swelling of the soft tissues over
the septum is not infrequently obser^-ed, especially running borizontally
Along its upper half, and it is not unusual to find similar swellings run-
ning vertically from half to two-thirds tho wholo height of tho vomer
near its posterior border. The swollen membrane at the upper part of
the septum is usually uf a slightly deeper hue than normal; that f-een
with the rhinoHcope at tho 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 tho probe, ex-
quisitely sensitive spots are frequently detected, as in simple chronic
rhinitis. Whenever swelling is present, the soft tissues may be easily
presKC-d down until tho bono is felt beneath, but the dent thus formed
quickly disappears as the probe is removed. Upon palpation, in this
way, the mucous membruno over tho septum will often be found swollen
two or three millimetres in thickne^fi, and that over the turbinated
bodies from two to five millimetres. In uncomplicated eases of this
affeetion, upon the insuffintion of one or two grains of a four per cent pow-
der of cocaine, or spraying the nares with a weak solution ot the same
534
DIHKASEa OF TlfS NASAL CAVITIES,
drug, tli« swelling will speedily subeide and tlic ciiTJties appear of
iiurmal size. Sometimes this occnra spontuDeously during the exnminn-
tlon. from llie fright caiisio^i by i«ii).';zestioiis iis to the proper trentniciit.
Sometimes ttie swclUt]^ will promptly diaappeur upon exercise, and it is
not unctjmnion for patients to And tliftt they can breiUhe much more
oiifiily ntter going^ upstuirs, or for tltem to say that they have to get up
and walk iibuiit in tliu night in order to brmitlic.
DiAONiisis. — The affection is to be distinguished from simple chronic
rhinitis, from hypertrophic rhinitis and from nasal miicons polypi.
Intnmeecent rhinitis is differentiate'! from ^^iwjtle rfuiiuic rhiuHig by
swelling of the mncona niembnme, and the occurrence of frequently re-
peated nasal obstruction.
It is distinguished from fii/pfrtrophir rhinitis by the intermittent
character of the swelling instead of permanent occlusion of the naree;
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, whi<di does not affect true hypertrophy.
We find that nattal mumus po!i/pi are of lighter color and mare
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 iutume«ecnt
rhinitis, and, although in tliu latter affection the swollen tissue may be
compressed, the enlarged body cannot be moved upon its base as can
ft polypus. Again, cocaine diminiHlics the swelling in intumescent rhini-
tis, whereas It rendcni the niueuui; polypus, in most instances, more
prominent by diminishing the swelling about it.
Pkoososis, — If left to itself, spontaneous recorery from the diseMe
occurs in a few cases, but usually it extends over months or years, and
eventually terminates in hypertropliic rhinitis, though orcaslonnl cases
appear to pass directly into the atrophic form. The frequent occlusion
of the nares leads either to jtharyngitis or laryngitis, or both; in many
cases, thruat-deafnces results from involvement of the Kustaehtan tube.
the inflammation extending not infrequently to the middle ear. The
general health suffers from inij>erfcct oxygenation of the blood: and
although to the casual ohaerver the patients may appear well, they
become easily fatigued, are nnablo to stand exerciite, 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 trenenil condi-
tion, under approjiriatc treatment of the nasal affection, liemnnstnite*
that they have been present.
TnEATMKST. — Prophylactic treatment is of the greatcsi importance
in all persons pre^lispo^etl ti> catarrhal affections. They should avoid
exposure to dranghta or cold or to undue heat, especially lu badly ven-
tilated room*, and so far as possible the inhalation of air containtDg
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 mom-
CBRomc R/IiyiTIS.
535
ingB in wtid witter, are often useful adjuvants in the prevention of colds.
Aruto rhinitis occnrring in individuals thus predisposed slioulrl be cured
as speedily na possible. In all cases the condition of tho digestive or-
gans should rocoive pureful itlteutiun. In ihe eiirly sUiRes tlie regular
use by tho piitjent of seiliitive remedies, imd tlio uituusioniil uppliciitinn
of mild astringents or stimulants to tho nures, constitute Lko best means
for thti cure ul the disease.
The milder stiniuliiiingiLppli(ui.tinns, which miiy be miidc two or three
times per week, consist of aqueous solutions of zinc aulphiite, cjirbolio"
acid, and zinc chloride (Form. 94), of sufficient strength t** cause smart-
ing or discomfort for not more than ten minutes. Aqueous solutions
may be employed for homo use two or three times daily, such as: boric
acid gr. x. nd z K "' Ireteriiio V[ x\, to Ix, ad 3 i., or sodium bicarbonuto
and biborate afi gr. iss. to ij. ad 3 i-> or distilled extract of lianuimeUs
or of pimis canadensis til xxx. to I. aJ 3 i. \ saturated solutiuu of boric
acid in camphor water is also a useful soothing application. Oily prep-
arations such as oloum petrolirm or liquid ulbolcne containing ciimphor
gr. i. to ij., menthol gr. as. to i... oil of rioves ttl lij. to v., or terehone
iH viij. to xij. ad J i. (Forms. lO.'i, IOC) are generally more beneficial than
the aqueous solutions. Tho oleaginous liquid alone may be used as a
fiogthiug application to prevent the cont-nct of irritating substances with
the mucous membrane. In addition to these, the sedative powders al-
ready mentioned in speaking of simple chronic rhinitia (Form. ICG)
may also be employed oul-o or twice datly with benefit in certain cjises.
Cocaine in any quantity should never be used continuously, not
only because of tho danger of forming the coaiine habit, but bocanse
when used for any length of time it seems partially to pantlyzo tho
vasomotor nerves, thereby causing turgescence of tho cavernoua tissue
and thus increasing the difficulty wc are trying to remove; but it will
be found most efficient in temporarily removing swelling and relieving
the acute exacerbations of this atTection. Cocaine is most conveniently
employed in powder (Form. IGG), which may be blown into the ob-
etruotcd nostril two or throe times in twenty-four hours, in quantities
not to exceed one-thirtieth of a grain of cocaine at a dose. Even iu
this quantity it should only be used for a few days, and it is seldom
necessary then excepting at nigLt or early in the morning.
For tho applicatiim of ponders to the nares, 1 gire patients u
short glass tube about four millimetres in its iuturnul diameter and four
inches in length, flattened and expanded at one end, but round at the
other (D B, Fig. 105). *
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 tho glass tube: its
Hattened end is placed in the nostril, the other end of the rubber tube
between the lips, and tho patient gives a short, quick puff, which blows
the powder into the naris. The rubber tube is made of the common
fi36
DISKAHES OF THE If ASA J. CAVITrm.
draiuuge or uursing-bDttlti tubing with a calibre of about three mUli-
metree. When thu phyflician makes thu api>licatiou biiiiHeU, it is tit-at
to use a hand-insufflutor (Fig. lOS). An; application which is mude as
often ]ifi two or three tinips a duy should not cuuso smarting or dis-
comfort for more ihun throo to five minutes, and should nmke tlio
patient suhfiiH)nontly feel better, instead of worse; but stronger upplitui-
tions, us already recommended, may bo niude every two to live duya.
The Bprays may be applied by means of any suiUible atomixer. Tho
atomizer which I have found most satisfactory is shown in Fig. 196.
Flo, KM,— Povpnt BLOirnL Thnw kUm tube* (% stw). Slnlsh* ("be for dm*), b«nt tubes I
tiruo-pbarraraa) or burnctMl «p|>t]catloiut.
When Becrotions collei't in hirge quantities, the patient should
the nose once or twice daily with an alkaline solution, or with a Raliry-
lato solution (Form. 187). An excellent alkaline solution may he made
by diBflclring an eren teaspoonful of sodium bicarbonate in a half-pint
of lukewarm water, or one-half of a teaspoonful each of sodium bicar-
bonato and sodium chloride in the same amount of water. lu some in-
stances sodium chloride alone, in the sjime proportion, seems to answer
a better purpose. This I recommend in cases where the eodiam bicaiv
Tto, ISC^DArtDsoV* Oib ATtwisn, No. 90 04 rfM).
bonate causes an uncomfortable sensation of dryness. After the at
has boon thoroughly cleansed, the upplications already recommendwl
should be made. In fully developed cases of intumescent rhinitis Ihrso
remedies will give tho patient temporary relief, but can seldom if ever
effect a cure, and they should therefore only be employed as an aid
more radical treatment, which consists of the canterization of the swollen'
CHRONIC HftmiTIS.
0a7
tissue either by chemicul ugeiUa or by the jjalvano-cautery; or in the re-
moval of pdrtioTiR of the tiissue with the i;teel-wire ennre. The latter is
belter snite<) to the cnse of hypertropljic: rhinitis. liofore cauterizutioii,
the |iurt should bo thoroughly ana>ethetiziHl by cocaine, as rtcominended
in speaking of bay fever.
Of the various chemical agents wliioh hate been recommended,
strong acetic or chromic a<:id is most itaefuU and of these two the
latter is more generally preferred liy hiryngologiata. It niuy be em-
ployed in eolutioTie 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 iilwaya apply it, if at all,
in the latter manner, since its ellects can bo better controlled, and in-
jury to other part* can be more easily avoided. A few of the crystals
af chromic acid being placied upon the end of the flat aluminium probe,
it ia held over the Hanie in such position that the acid sluvly fuses, and
fchen ao that it (k)oU upon the desired place. The futied acid is then
-nhbed over tliopart to be cauterized, which becomes of a brownish color,
md immediiitely afterward an alkalinespray is thrown into the nostril to
aeutralize any excess of add, and to prevent it from being diflnsed to
fn. im.—'Fu.T Najui, Pnou iM ilse}. Made of Aluniliilmn uid bent kc ui uigl* of SS*.
other parte. 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 uf 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 ono time or to cauterize too largo a
aurface. Uusworth prefers toucliiiig only at separate points with the
•icid, claiming that the small eschars, as he expresses it, pin down the
mucous meriibnine to the bone beneath; but in my hands this plan has
been letw galisfnctory than the ono already rct'onimcnded. I would
not advise a repetition of cauterization until complete healing has oc-
curred, whicrh will require from ten to twenty days. LI. Uolbruok Curtis,
of New York, who ha^ had excellent rpsults in the treatment of this form
of catarrh, informs inc that he touches the Iowlt half of the inferior
turbinated bwly 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-cantery, a
more irritating discharge, and a sore which heals more slowly than
that by tlie latter, while its effects cannot be so accurately controlled,
The treatment is therefore more tedious and gives the paticut much
J}38
DISKASKS OF THE NASA I CAVITIES.
more discomfort, iind the result is no bettor than that obbiineU by iha
hot electrode.
In Dsiug ilie gitlvano-cftutery I employ an electrode (}fo. 3> Fig. 91),
vith A blade u bout fifteen milUmctrea in length consisting of >ta ^1
|ili(tiuuni wire. One, two, or more narrow, linear incisious tbe whole
Jeuuth of llie ttirbiiiutcd boU^v, und deep enougli to jual giitze tbe bono
in two or three places, should beruude, one at u sitting, witb u suflicient
intorvnl for healing to occur before the rauterizatinn is repenl-cd. These
lineti are usually made at the junction of the middle with the inferior or
tniperior third of the lower turbinated body; and in from ten to fifteen
days afterward, a similar cauterizatiuu i^ uiude upon the other side. In
the same length of time subtieciucDlly the Grist cauterization will have
liealfld, and if necessary the treutmont may be repeated upon the aide
first treated.
Immediately preceding or following the cauterization I apply to
the nares a solution of ni v. ad ^ i. of oil of cloves in liquid all>olene,
and after the cauterization follow this by the insufflation of two or three
^niina 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, whunerer out of doors. Ho is also given
a four per cent powder of cocaine (Form. 168) which he ia directed to
use throe or four times daily, providing the tissues swell so :is to occlude
the nares. At the end of four or five days he retonis, and a probe is
passed between the septum and the turbinated body to prevent adbe-
«ion; or if tlie thick muss of exudate, resembling false menibraue,
which usutilly 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
solutinti of ziin; gtilphute and carbolic acid, aa gr. ij. ad 3 i. The imticnt
is then given, to use once or twice daily, instead of tlic powdor fint
employed, n similar powdi-r to which has been added twcuty-tivo per
cent of iodol.
In most cases two or three times esich day after the cauterization
the patient also uses at home a spray containing gr. \ of tliymol,
gr. ss. of carfMitic aeid, and nt iij. of oil of cloves ad f i. of liquid albo<
Icne, or, if thi^ cuu^^es any Irritation, a stilt milder application. Most
pAtientfi find this mnthing, and it prevents the formalion of dry si^aibs;
but for putionls to whom oleaginous sprays of any form are irritating^
a epniy of lioric acid. gr. viij. ad 3 i., will be found most bcneficia];
though any of the soothing sprays already recommended may be em-
ployed to suit the indications of the ca»c or the fancy of the patienL
If the soft tissues over the middle turbinated body or the septum swell,
they may be treated in the same manner.
In a few cuaos a single cauterization upon each aide will be sufficient
to effect a cure, and in the great majority of cases two cauterizations upon
CHRONIC RHINITJB.
539
«acb aide are Bufllcient; but occnsionally three, four, or eren more will be
necessai-y before the diseuee is clieoked. During die ireainienl, aud for
a few weeks afterward, it is usually best for tlie patient to use some
of the sodative or sliglitly stimuluiit S]n-ay3 re<.'(>miiiended fur the
treatment of mild cu^es of the disease. If the treutment is properly
carried out recovery may be confidently expected in at It-a^t nineteen
cases out of twenty. The troitment usually rcquirt-s from six to twelve
weeks M-ith iiii average attendance at the physiciuii's ufGee of about once
a week, though many cases are cured much more i»romj)tly, aud rure
cases demand more extended treatment.
In using the galvano-cautory, I emjiloy a current sufiicicntly strong
to heat the platinum wire to a white heut within two seconds after
contact is made. The electrode having been carried to the hack
part of the tissue to be cauterize^!, ami turned so that the platinum
'wire rests agiiinst the tissue, the circuit is closed, anii as soon as
the sound of burning is heard^ the electrode is dRinm slowly forward,
or, if tlio bone is not felt, moved slightly backward and forward until
it grazing 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 tu eool 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 mnch bleeding
may follow; if it is only of a cherry-red heat, or if it is too small, it
will cut through tlie mucous membrane too slowly, so that the time
necessary fur a sufficiently deep cauterization will allow ouough i"a*liutioii
ef heat to burn Kurruunding tissues.
Occasionally, in E<|dte of all precautiuri!^, 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-
groM'th or duflectiou of the septum. If adiiesions form, they mu^t
be cut or brokeu down, and the purts kejit apart by a jiledget of wool
er bit of rubber or gutta-percha until healing occurs. Sometimes an
application of nionochloi*acetic acid will ])rcvent siihiiequent adheitlons.
When patients find it hiconvenieiit to call within four or Uve 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-
aion, and occasionally the wound does not heal as it would if proper at-
tention could liave been given at an earlier date.
In a few cai>e»; too much reaction will follow a cauterization of the ex-
tent recommended; in these a lino only half way across the turbinated
body should bo mode at once. Usually the treatment causes little or
DO pain, and no subsequent inconvenience except such as would be ex-
perienced from au acute cold in the head. The discomfort following
DISBAaES OF THE JfASAL CAVITfKS.
the uiut«rization moet frequently results from the cocaine; itima(
often he relieved by u cuj) of strung coffee or ten to fifteen grains of
potussium bromide. Utiiilaelie ucuaBionally follows, whiuh is beit re-
lieved by five or ten gmin doees of phen»cctin, repeated in one, two,
or three hours aa needed. Coexisting pharyngeal or laryngeal in-
Hammution should receive appropriate trcatuienl at the lutnie time;
though the phyaician may with perfect candor assure his patient that,
as soon a* the niitiul obstruction Ia removed, at least four-fifths of the
difliculty arising from tlie nther affection will disappear, and that the
remaining trouble will probably disappear within a few months oven
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 u
soon as the patient returns to his former abode.
ITvi'KKTKOi'iiio RiiiKiTis IS a commou affection, next in frequency
to intnmeRcent 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
narcs. though it varies much from time to time in consequence of the
swelling.
Anatomical and pAxnoLootCAL Charactkristics. — The mucous
membnine is usually congested, hut may be paler than normal, and
hyperplasia of the mucous and Kubmiioous 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 c-iise the inferior turbinated body upon the concave side of the
septum is apt to be much more hypertrophied than iU fellow; indeed,
the bttcr will sometimes be found atrophied, so that patients can
breathe more easily through the side which appears most obstructed.
lu addition to hypertrophy, swelling of the soft parts is usually present,
so tluit the uasul cavity is from oue-half to two-thirds closed or entirely
obstructed.
Etiolooy. — Hypertrophic rhinitis is usually preceded by frequent
attacks of acute catarrhal inflammation, from wiiich intumescent rhini-
tis is at length developed, finally terminating in true hypertrophy. li
is produced by t|ie same couditions tliat oause the intumescent form of
the disease.
Syuptomatolooy. — 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 nu«e, csjK-eiulIy at night or in the early
morning, and by excessive discharge from the nostrils, or into the naso-
r
I
CHRONIC RHINITIS.
MI
pharynx, with hawking ami cleuring of the throiit, or hoarsotiess. More
recently one or other nHris liiis l>eea coiiatantly obstructed, &o that the
month mu^t bo kept open upon any exertion uiiil during slepp. Kre-
quonlly the eenso of hearing is obtunded; inijced, mout cages of deaf-
uess are the result of hypertrophic rhinitis. Frt^iiientlv the goneml
health tiuffera in eonsequcneo of imperfect oxypenatioii of blooj. Often
the piitient RofTers from frontal or occipiUl headnchu or a feeling
of preesure over the bridge of tho nose or forehead, and occaaionully
tho eyes are affected bo that reading is painful or impoaaiUe, except for
kf^
t— e
no. lA— KvpnnopKT op Invaioit TcuixAncD Botnr. CroMMctknn oT bMiI. rrum mwa
•BCUttd. a, XMiUb iiirtilnairO bodj-; b, loftiior Uirblaalnl XnAy tifpertrephl«d; c, mpertor tuiM>
iMtcd bodr ; li. siiIkchM oflto: «, orilke oC Buil«dri«ii tiib».
a few minutes at a time. There ia usually some dysphonia and dysp-
noea, the mucous membrane, especially over the inferior turbinated
body, is thickened, and its surface ia uaually more or less uneven in ap-
pearance, Eonictimce preaenting distinct nodnlee. The amouui of swell-
ing varies much from time to time, and it may be uniform over the whole
turbinated body or limited tu portions of it. Thus, it ie common to
find either the anterior, middle, or posterior portion of the cavity most
occluded : or along the upper portion of the tnrbinated bodies there
may he but little thickening while the lower portion touches the septum,
the inferior border resting upon the floor of the nares. Whonevor the
mucons mcmbrano of the two sides of the nasal caTUy is in con-
tttct, we ustially find rt consiflemUle collection of mncus or muco-pu^ u£
tlio lower punion of tlio fossa. In miiuy cuses eobvob-liko shruds of
mucus will bi' found extending from side to side its in oilier forms of
rhinitis lUroaidj discussed, or the dried secretions may have colloctei] in
crusts ujKin tho cartilaginous septum, or about Ibo middle turbiuat«d
body, rsiinlly the vault of the phtirynx is cungosted. iitid coniairift
tenacious mucus or dried masses, and tlio posterior ends of the inferior
or middle turhinntcU botlies are enlarged (Kig. 11*9). Thcs« commonly
appoar in the rhiuoscope of n gruy color, but occiisionnlly of darker hue^
even ])urple, itnd the surface has il noduliir or nisjiberrydike iiitpeiirance.
Tho posterior ends of the turbinated bodies of both sides may be so
enlarged aa to project into tho naso>pIiurynx, and may even come into
contiict )>ehiTid the septum, nearly or quite occluding- tho choane.
The middle turbinated bodies are much less frequeolly hyperLrt>phi«d
Tn. IOPl— BrftiiTHai>HT or l*o«TiiUOR Kkim or Ikvrkim TvMaitiATBD Bocm.
than tho inferior, but when enkrged they press against the septam,
frequently cuusing iieumlgic puius in the forehead and eyes, and seus:^*
tion» of presiiure on the bridgo of tho nose. Oocasionally the middle
turbinated bodies are found hypertrophied, while the inferior are normal
in size or perhaps atrophied.
ITypertropby of the soft tissues upon the septum in tho majority of
cases is found at its middle or upper third, running ncaily horizontally,
or extending voriieally near the posterior edge of the vomer.
Diagnosis.— Unless tho parts are carefully examine«l, the nllcctioB
is apt to be confounded with iiuy of the other causes of nasal obstmc-
tion; but by a considcrutiou of the history,und n careful inspection and
palpation of the parts, it may bo easily di^^tlngnished from ull diseaaea
except intumescent rhinitis ami syphilitic afTections of the nose.
The tissues are ciifilly impressed wiih the pr<ibc in intumnnrnl rfittti'-
tin, and swelling nijiidly and completely diMip}H.>ars on appHcatiou of
cocaine, signs not obtained in true hypertrophy.
It is impossible to disLinguish hyiHTtrophic rhinitis from Htfphililie
(iufa-nf tif the woAC, attended simply by persistent swelling without ulcer-
ation, except by careful considcmtiou of the history and watching ro>
A
CHRONIC HIUNITIH,
343
suits of specific treatment. It is often diSicult to got the sjHwiflo his-
tory ol Hvpliilitic [lutieutH, for reasons iilreaJy indicilud.
Exitessive hy|>ertrojk}i_v nf the ;uiterior or posterior cn*I of tho tur-
binated bodies is distinguished from juucomt jutlypt by inspection, iind
(lalpatiou wiii» tlie probe^ which can be passed between a polypus and
the cxteruiil wall, but Cttiniot be so mtiniimUted iu hypertrophy. Th&
posterior end nf the tiirbirmted body whiMi liypertrophied has inncli the-
color of u mticous polypns, but its surfi'iie^ \in1ike thnt of a polypus,
is uneven and slightly nodular, and it is usiiii^ly of a deeper hue and
has not the tmnsUioent appearance of tho polypus.
Prognosis. — Hypertrophic rhinitis left to itself may extend over a
period of Buvenil yeary- I have known of no Ciisc terminating iu less
than one year, but have seen one woU-inarked ease where the affec-
tion merged into atropine rhinitis within eighteen mouths. In many
instances the hypertrophy gradually increiwes or, after a certain point
has been reached, appeal's to remain witlioiit change; but in a considern-
ble number of cases, atrophy Unally 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 cau8»<
tho ofTcnsivc odor of ozaMuu In more fitvorablc cases, atrophy continues
for a time until the nasal uavities once more bL>come free, and then ceases,
whereby spontaneous recovery results. There is a connnon belief M-ith
the laity, and among physicians who have been in practice for moro
than ten or fifteen years, tiiat little or notlitng can be douo for chronic
catarrh by treatment; and this belief was well founded until the advent
of the improved methods of treatment iu vogue during the last decjidc.
Although the genpr.il hejdth is often aomtjwhat im|utired by this
affection^ there is little or no evidence that it ever terminates in tuber-
culosis. It is true that patients suHeriug from chronic catarrh fre-
([ueutly die of tuberculosis, but apparently no more fref|ucntly than
those froe from the nasal disease. On theoretical gronnds, it would ap-
pear that obstruction of the nares, by interfering witli free expansion
of the lungs, would sooner or later cause collapse of some of tho air
cells, with a consequent chronic inflammation and finally tnberculosia.
I have seen some coses whicli seem to substantiate this hypothesis.
Treatmknt. — Various medicinal substances have been recouiuieuded
internally and locally for tbo cure of hypertrophic rhinitis, but none of
them nrc of much value excepting when used in cunnecition with proper
surgical measures; and a eure cjin iwldom he effected oxcr-pt by the re-
moval of some portion of the redundant tissue. This may be accom-
plished by means of chemical ciuistics, the galvano-caut^ry. burrs, tre-
phines, scisBora, saws, or the snare. Among the chemical agents which
hove 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 XASAL CAVITIES.
acetic and chromic ncid. The former, especinlly, in tho form of mono-
olilorac«tic acid, ie useful p:irticubkrly in cases wbero tltore is liability to
aHliesion of tho opposing siirfaoes nfter camcrizalion, and either this
or tljc glacial acetic ncid may be nsed to rfduee hy|»enrophy of tho
soft tisAiice, bat they ure less etTioieiit thitn ebromic ucid. which, though
uu efTecttial remedy, ia opcu to the ohjectloiis mentioned nndor iiiiumos-
cont rhinitis.
Injections of carbolic acid, bcnctith the mncous momhranc, by means
of a hypodermic syringe, have been recommended, and the treatment
Hppoars lo have been successful in some instances.
Tlie mujurity of ejises may bt; cured by euuterization as itlrcady de-
scribed in tiiu treiitment of iutumeM-eul rhinitis. 1 prefer the galvano-
cautery for moHtrasoti,and make linc]triiiei;^ioiifl,aa already recommended^
two. thi-ee, or more of whicli may he necefwary upon the inferior and
|Hi8«ibly the middle turbinated bodies of eaeh side. Tn cauterisation
of the middle turbinated body^ 1 frequently nse a small loop-like or
pointed eleotrode (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 nsc the same lanoe-poinLed, ulender elec-
trmle, and carry it all the way fruin before backward beneath the mucous
membrane M'ithout burning througli to the Eurfuce except al the pointH
of cntranoo and exit. In sevenly-Gre per cent of cases, nut more than
two lines are necessary upon either Tnrbinated body, and in only five or
ten per cent will more than three be needed. When tho miihlle turbi-
nal is involved, generally one or two cauterizations arc all that will bo
useful, and if they do not succeed, some portion of the bone must be
removed.
In hy[»ertrop)iic rlilnlti.s, Harrison Allen hiu« recommended prt>£».
ing the incandescent loop of the galvano-eiLuter)' into tho tissue ntxl
drawing it forward until a small piece has been soooiwd out by
the burning wire. In some cases, especially in hypertrophy of the
mi<ldlo turbinated body, when the soft tissue stands out promiuentlv
it may be caught and removed by the galvano-cautery (craeeur,
particiihirly wliere there is objection to the bleeding which would
follow removal hy tho cold steel wire. When there is grcjtt hyper-
trophy of the soft tissues, it is far better to remove the redundancy by
the sciflsors or snare. Sometimes with the nasnl scissors (Fig, 200) I out
off ihe lower edge of the inferior tnrbinated body, but I prefer the
snare where the wire can lie made to bold. As a rule, in all these opom-
tinni! the parts should first be thoroughly atia'Sthetlzed by cocaine, but
flomeiimei? tho swelling is no roiluced hy this agent that the snare ciinnot
he made to hold, whereas the redandant tissue could be easily seenred
bpforo the cocaine had been applied. In such oi\gf*s it ia sometimes best to
introduce and tighten the snare finst and subppipipntly to apply cocaine.
In thoie patients who can easily endure pain the snare may be used with-
CJJROmC RHTNITIS,
.545
out cocaine, being; grndnaUy tijthtenwl until it canses the patient to
wince; then nftor resting two or three minutes it is tightened stllj more
until it agiiin causes pain, when another rest is t«ken; this process is
continued until the mnss is cut off. This slow process hus the ad^'an*
tagc of causing n minimum amount of blt-ctling. In hypertrophy of
the (interior end of the turhiniilcd body, if the snuro cuiinot \\v mailu Lt>
hold alone, the tissue may he transfixed witli a needle, ns recommended
by Jarris, of New York, ilio wire being slipped over tho end of the nee-
dle and tightened down behind it.
In posterior hypertrophy the enare should be armed with a No. 6
«toel piano-wire; the loop, of proper size, should he bent ahurply over
the end of the uaiiulu, iis recommended by Bosworth; and then drawn
slightly into the etinula to straighten it durtng introduction into the
naris. When it htw been p:i8ded to the b:iok pnrt, the wire Is again
crowded forward until the bend is brought to the end of the canulji^
when it springs outward, and may be made to engage the diseased muss.
The end of the snare should then bo pre&se<) firmly against the tnr-
biudted tissue, the wire dmwn taut, and 6ubw|Uontly gnuiually tight-
ened by the milled wheel. When this method is pructicahle, it is to
he preferred to the slower process of cauterisuition, for by It a large
amount of the redundant mass is at once removed, and the reatttion
which follows, as well as the conscfpient discomfort to the patient, is
much less than aftor cauterization.
When any operation liivble to be followed by much bleeding is
done, the nuris slioold be tamponed with lint or gauze, as recom-
mended in sjicaking of cpiytaxis and the operation for exostosis.
Even in cases where the snare or the scissors arc applicable, it is
usually also necessary to niutcrizc. It witi be seen that the treat-
ment of this affection is osHcntially thi? same aa that of the intumes-
cent variety of rhinitis, except that hero 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 tlie effort of the physician
to save a* much muc^u* membrane as ivmtld Hormally fover the jmrh, and
to form OS little cicatricial tissue as possible. In a considerable number
of eases of hypertrophic rhiuilis the bones are also enlarged so mnuh
35
54«
JilSBAfiR/i OF TIfE JVJSAX CAVITIES.
that no treatment of the soft tissue ran Bufilt^iently retnore the ohatrac-
tion. In those the bony tiBstio may be removed with ttaw am] wiaanrs,
or better with the rlomal burr (Fig. 201) or the nasal trephine (Fig. 202).
These instruments, ctttAched to the electric motor or dental engine, are
run bcMCiHh the macous membrane, enough of the bone being removed
to allow the si.tft tissno to coiitraet until sufficient 8]inoe is obtjiined.
Between the operations the same ecdatire or slightly stimulntjiig
powders and sprays should be employed that were recommended for
Flo. iUi.— NM.U. IftiiM (acuuU ftlx«'i>
treatment of intumesccnt rhinitis. If adhesions of the opposing anl
faces occur^ thoy must bo broken down or cut with scissorSf and tl
surfaces kept apart by gutla-ijercha, or a rubber plug, or by a pledget
of wool, until healing occurs. The wool is murh better llian colloii, as
it bet^onics larger when nmistenpd by the secretion, whercjaii the cotton
phtg becomes smaller. Sometimes by cauterizing the r»v surface with
monochloracctic acid, whioli has the property of forming on eschar thitt
usually remains until healing has taken pluco beneath, subscqnetit ad-
hesions of the part may be prevented. Whore aspnr of cartilaginous or
bony tissue projects from the septum, it is ustially necessary to remove
it before the Uypcrtrophied turbiuattid bodies can be sutistictorily treated;
otherwise adhesions are very H])t to take place.
Metallic, gutta-pHTclm, or soft-rubber tubes, sponge and lamtnaria
tents, have also )icen rewimmended for the cure of hyperlrophic rhinitis.
Via. Va.^'SiJut. TiWPaunw (avUml kLecJ. UixllAi-Atloii of Cunii.
When tents are used which swell by absorbing moisture, they should be
uDowed to remain for only a short lime, and should bo moved slightly
back and forth frequently as the swelling progresses, to prevent them
from beoominp Hxed toolirmlyin the caviiy. Tuben may be introduced
and worn ftir several hours at a time, providing thoy do not cause too
much pain: theoretically, this proce<hirc is excellent, but practically a
tube large enou|L,'h to affect all of the diseased lissne can seldom he in-
troduced into the nostril. Furthermore, in the majority of cases the
iiar«a are so sensitive that tabes cannot he tolerated; therefore, tbU
form of treutniont has becu abandoned except for some special oMeB,
I
CHROmC RHINITIS,
547
*^*jj
Wlialever treatment » adopted, tho cavity should not bo r.iudc brgor
tlian nartiml. Frequently patients vriU urge the physicion to nmke it
BO large that tlicy will never bo ti-oobled again, oven upon taking cold;
but ihig procedure is injudicjoiis, and would Bubse<|ut'ntly !»e regretted
by both patient and physician j far if the calibre is grt-iiter than normal,
Boeretions are liable to collect, deromposBj and give ottaujiive odors, aa in
utrophic rhinitis. It is better to do too little than too much; but tho
patient should not be kept under treatment while wo are accomplisbitig
notliiiig. Tho physiinan must not bo cotiteutel with making soothing
iipplications which ^ivf? but temporary relief. Theso can be made quite
rs well by the piilient, and if for any reagon the soothing form of Iroat-
nent seems best, we are to remi'mber that no good will result by seeing
the patient oftener than once or twice in a month.
Sl'bmuoous infiltration of tbb sides op the toueb is common
in chronic rhinitis, especially in the h}^)e^-
trophio vai-icty; it is characterized by more or
less difficulty in nasal respiration and inerenMl
cretion. It is often o^ocititcd with chronic in-
flammation of tlie pharyugt-al mucous membrane,
iU)d sometimes with adenoma of the vault of the
pharynx. The altered mucus collecta in the
posterior nares and dro{>a iuto the ttiroat or causes
frequent hawking. The svmptums are thot^e of
po6C-naBal catarrh. InHpectiun by the aid uf the
rhinoscope reveals a yellowiuh white or gray putfmess on one or both
sides of the vomer, near ita posterior margin (Fig. 'j(i:j).
l)l.\QXos]s. — There can be no diilicnity in the diaguoisie when pharyn-
geal affectione have been excluded and the characleri«tie ajiiieanmce*
just mentioned are discovered.
Treatment. — We should contract or destroy the oedematous tissue
by means of tho galvano-cautery, or we may tear it off with foroejw.
The former is most effective. Astringents have little efifeot.
ATitopiirc iiHisiTi8 is a chronic intlammntion of tho naso) mncons
membrane, characterize*! by abnormal enlargement of tho cavitie*,
and the (■ollection within them of dryiug secretions, giving rise some-
times to an extremely offenaive 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 (Uiseaaea of the Nose)
is most common in girls. I have never observed it in children under
eight years of age nor in adultK over forty; most cases occur before the
twenty-fifth year, very few being ol>serve<l in patients more than
thirty-Bve years of age-
AxATOMitAi, AS» Patuolooical CHARACTERISTICS.— The nasal
cavities are widened, even to two or three times their normiil size, the
turbinated bodies appear 6mallcr tiian normal, and in advanced casea
FlO. COO.— SlIHDOaLI IM-
FILTIUTlOil AT SlOEa Or
VuMKH iCVUKItf.
£48
DTSBAHES OF THE SASAL CAVITIES.
they may have entirely disappourud. It is not unusual to finti the in-
ferior lurbiuuted boilies much suiuller than, norma), while the middle
iurhinuU are still hypertrupbietl. As a result of chitngcs in the mucoua
mombrauL-, involving its blood vessels and glunds, the fiverctiou btj-
conioH louacious and of u niuco-purulent character; and in eouacqucnce
of tha large »ize of Ihu niuut cavltji's il U imjKtssible for the putiunt Lo
seouro a sufficient blast of air for its expulsion; therefore it dries npoti
the surface, partially decomposes, and thus forms crusts which may
coniplelt-dy block the earities. These crusts are finally separated by the
increased sccretiou beneath them and may then bo expelled, but only to
be soon rcjilacnd by otlicra of the same chanicler.
The pathology of the disease ia still a mootc>{] question, and it would
be profitlf^s for us to enter into the controversy. [ favor the theory
th:it in most cases the atrophy ia the result of previous hypertropliy.
The mncoutt niembraiie U usually ans^mic» 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 leas complete obetruc-
tion of the narcs for a considerable period, uometimea dating from an
exanthematous fever, and at others from an injury, leads to the belief
that the afFectioii is usually j)recoded by chronic catarrhal inflammation,
and favors the theory tliat atrophy results from an antecedent hyper-
trophy.
Symi»tojiatoi.ik»y. — 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 al» thick, the lips
thickened and prominent, and the whole physiognomy is lackiug in ex-
pression, as in often i^een in the strumous diathesis. The eyes are
often affected^ the sense of smell is usually lost, and parti^d deaf-
ness commonly exists. The secretion, wliich 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 crusta
formed by drying of tlie secretion are expelled. The breath has an
exceedingly offensive odor cau{:od by decomposition of the retained
secretion. So great indeed is thit> that it will often speedily pL-rrnoate
a whole room, though, perhaps fortunately for tin- patient the sense of
smell is usually lost, so Lliat hv is ."pared much personal discomfort, Tho
foulness of this in<leiiicribable wior is only second to that of sypliiliiic
necrosis of the nasa' bones, and is so peculiar that, when ouce detected,
it becomes a valuable diagnostic symptom.
Upon inspection of the narcs, we are at once impressed with the
abnormal size of the cavities, unless they be choked by dfied secre-
tions. When the crusts are removed, we observe the small siie, or
absence, of some or all of the turbinated Indies, with perhaps hyper-
trophy of others, and lind that usually ve may easily see the muo-
I
I
cimomc nrrryrrw.
549
'^I'harynx and often the orifice of the Enatarhian tnho through the
^nostril. The secretion whioh has remained longest in the nose is of
Wk brownish or bhiokish color; that less old, of a yellowish or greenish
Ime. In most oaaee where crusts are found upon the surface, atrophy
of the niitcous nierabrane is very apparent, and the odor is offensive.
In some ciiseH the secretion is thin, of u purulent character, and may
be easily wiished away, even tliough the patient cannot expel it by
"blowing the nose. Immeiliately after washing the nareg the mucous
ZQcmforane may appear redder than normal, as the result of the cleans-
ing process, though it is commonly anemic.
DiAOyosis. — The uffuction ia liable to be mistaken for lupus, syph-
ilitic disease of the nose, suppuration of the accessory cavities, aud rliiuo-
liths or foreign bodies in the nose. TJiei-e is iiHiiidly no (lilliculty in
distinguishing it from iupug, because of the extcrnul inunifestAtions
of the latter dtsense; but in /h/mis imlgariftt crusts and scabs similar to
tho.-^e found in atrophic rhinitis are formed; thege are usually closely
adherent to the septum inatciul of the tiirbinuls; and unlike the erusts
in atrophic rhinitis when removed, they leave an ulcerated surfsce which
usually bleeds and is marked in one or more places by the typical
lupita tUDLTcle.
On account of the offensive odor, syphilitic tiitettse of the nose is espe-
cially liitblu to be mistaken for atrophic rhinitis; but in syphilis, upon
exaniination with a probe, dead bone is often detected, and upon cleans-
ing the part, ulceruliuu or perforation of the septum or luird pahtto
18 apt to be found; at the satne time there may be falling iu of Iho
bridge of the nose, which does not occur in simple atrophy.
An offensive odor arises from suppurniion of the ac^fissory cnviiies, but
unlike atrophic rhinitis tbis is almost always unilateral; the correspond-
ing naris is not likely to be enlarged, and the sense of smell is aeldom
lost; therefore the putleut can generally appreciate the odor sooner ihaa
those about him.
An offensive odor, with profuse discharge from one side, arises
from rhimlithB or foreign bodies in the nose; but after the parts aro
cleansed, offending bodies may be readily detected by inspection or
palpation with the probe.
Prognosis.— If left to itself, uti-ophic rhinitis continues for many
years; but it is seldom observed after the thirty-fifth ytmr. As the history
shows that even witlt the most indifferent care most patients evenlually
get well, it is probable that there is a spontaneous tendency to recovery
ftbout 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, »nd it will not reappear if perfect cleanliness is observed. Wo
cannot hope, however, to euro the anosmia, and the deafness associated
with atrophic rhinitis is seldom remediable. Restoration of the atro-
DISEASES OF THE NASAL CAVITIES.
phietl strnctoree can eeldnm be expected, thongh I haro eeon a few
in which undoubted atrophr, with great enlargement of (he nasul cavi
ties, has bo far disappeared as a result of treatment, that the narea
came of normsil size, and in one case even smaller than desirable. There-
fore lagree 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 feitd air from the noee,
and probablr from |«irtiiii absorption of the secretion is speedily romcdiod
as the local tliecose is relieve<l,
Tbkatjiekt. — Judging from the great importance attached by Tsri
ODS authors to spoeiid forms of local treatment it is probably of little
ooDsei^ueucc what rfiiiedics we employ, bo that they be used in anch
manner as tu keep the uares cleansed and disinfected, and the mucons
membi-nno slightly stimulated. Cleanliness must be insiiiteil upon,
otherwise any form of treatment will be of little av.iil. It in maintained
by some that this cleansing mnst 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 unuec
I
Fw. Ifti-isoALB* Nahal tivttixcs i>j«iie).
for the physician to perform theso ablutions if he will insist that the
patient do it himself. The {Hitieut should he directed to wash the
nose thoroughly tno, three, or four times daily, using from huU to
one and n half pints of fluid each t'lmi?, as may be found necessary to
accomplish the object. In some cases it is sufHcient for the patient to
snufT Auid through the nose from the jxilm of the hand. In others it is
better to uso some form of nusiil syringe (Fig. JiO-l) or the nasjil dourho,
though the latter should bcftvoided if possible, on account of the danger
of causing duifness by forcing Huids through the Kustachian tubes to
the middle ear. In using any form of uiisal syringe or donche, but little
force should be employe<l, the month should be kept open, and the
patient must be careful not to swullow during (he washing process. A«
a rule, the solution should be warm, thongh with some patients the
stimulation of cold douches answers an excellent purpose. Pure water
is soniftimcs sufficient, though usually it is belter to use solutions of
Bome of the sodium salts, of which sodium chloride or bicarbonate, op
the Bidicylute mixture (Form. ItiT) may be employed in tho proportioa
cunoNic jwiyiTis.
551
of » heaping teaspo'onful to a pint of luku-warni water. Sea salt may
bo nsed in place of the common article, but in no better. Carbolic iicid,
listorino, or other ontisoptics in small quitntity muy be aildetl to ibis
solution if desired. After tlio part is thorougldy rlpiiiiscil, vjirious renio-
dinl iigeuts muy be employed, the object being to sJigbtly Btimulatc tlio
niucuiitj mumbruuti with the hope of iniproviu;^ its nuiritiou, iucreafiiug
tho gliuidiilar secretion, and preventing siippumtion and decomposition.
For the latter pui-pose iodoform is au excellent agent, thongh too offen-
aire for use in private practice.
In hospital and dispuueary work no remedy has given mo more satis-
faction in. atrophic rhinitis tliau a powder cunsistiug of cfpial purls of
iodoform aud boric acid, which is thrown freely Into the nusul cuvitiea
two or three times a week, after the parts hare been cleansed by tho
patient as diret^ti^d. In private practice, europben or iodol may take
SUr/A'Smtth.
''^ftTrSJrnS*^
Fia. Jon. — Nihil. ]>oicnE.
Flo. 900.— TuvBLKU' NUAL Doocm*.
the place of iodoform. I use the latter much alone, and also variously
combined with mercury bicliloride, myrrh, gum benzoin, Uerberine,
boric acid, aristol, and cocaine, with sngar of milk as a base (Form. 170
to 17:i and 181).
Powders are nsed when there is free secretion, and sometimes,
even though thoro is much dryness of the part, they have a most satis-
factory effect, especially if associated with tho uleuginous Dprays of car-
bolic acid, inenthul, oil of cloves, or other (•imilur substuucus in liquid
albideiio; the rule bi-ing that whatever application is made rihonid not
cause the patient discomfort for more than five or ten minutes. The
powders nnd sprays f generally give in t!ic fullowing sirength, to be
used by the patient two or three tini-is diiily: mercui-y bichloride,
from one-leulh to one-fifth of one per cent; iodol, twenty-five per cent;
boric acid, ton percent; aristol, five to eight per cent; gum benzoin or
myrrh, twenty per cent; berboriue muriate, ten per cent; cocaiue, two
Me
BOKABm OF THE SASAt CAVmES.
•r ihnt per cmL Th« <T**J* cantam of m— thol •oe-traUi to
flilfcaf •D»pcr«e«t,etfbalie«culoae'ftfUi«f oneperoeUyoU of dorai
«a»-ltalf to «ae per eent (Form. 10ft t* IM). lebdiToI «Md u • opcij a
flT« per eeat oilj «Hatio«i Li reported to Ittve gives good reaolts ia
thwe mifi Where Uw wcretiaa it profuse aad of • mM»>fwmlMit
davaeter, frooi ofia righf h to oite-faalf grain to tfae oonee of atcrrarr
WcUorido in an aqoDOcu «ololian is an exodleot reaicdT. Simikff
■pplkatioiu fhcmtd be made bj the phjacian ealBcaenU; stroa|; to
eaaaa dkeomfort for half an boar. It is best for the patient al first lo
Ti«it Ibc pbjnctan onoe or tvice a week, in order that be to%y be certain
that lb« clanaing prooMi ii properl; accomplished and that the ap-
plicaiiont are of proper itrenglh, bat after a short time tvice a month
it afoally nifitcient. In mild cases from one to two |ker cent of rocaine
■dded to the powder which the patient oms at home has appeared to
have a mostbeDeficial action in stimolating the flow of blood to the parts.
The HfActa of oocsiae ta caoiuig' contraction of the blood rewtli and
DOtts ttiaua i% w«ll knowa; it U alto true tttat If OMd coBtmaally for a coasklcra.
Ua laf^tb of Unit?, it frequeotly inrreaMa the coagartioa aad Krellinjt, which
probably acconnts for th« beaeflt sotnetimea derived from iii use ia these
McDonald {op, cit.) recommends tincture of saiiguiDaria, fire to
thirljr drups to a [ihit uf warm wuter; iilso tampons &aturjted with
glycerin or boro^lyceride, but especially Gottslein's wool Umpomi, or
whnl he terms the phyeical method of etimulating the circolation by
ptirtJHlly rlrHJiig the no^trilH with cotton wool and causing the pAtient
to inhale through this obstmctiag mass two or three hours daily, lie
\\iti recommends a simple nasiil rc-apirator for a simiUr pnrpose. D.
Hryson Dclavan {Srio Ynrk Mediinl Journal, 1897) and uther larjmgol-
ogiits report saluifactory resnils from stimoluting the mueuus mem*
bmno with the electric current, the positive pole applied to the nape of
the neck, the negatiro to the mucous mcmhmne bj moms of a piece
of nopper wire enr-loscd ill a pledget of moistened cotton, with a
current of fmrn four lo seven milliumperes. In addition to the local
rumcdicv, gratt beneHt is oftrn derived from constitutional tre:itment.
Quinine, iron, strychnine, arscniouH acid in some form, and iodine ar«
most beneficial. The latter, in moderate doses just sutticient to excite
nasal secretion, is frequently found most sdvantagcous. Good diet
und proper clothinK should ultriivs be supplied, and a change of climate
will sometimes be found bcncticitd.
I
rnAPTEH XXXIT.
DISEASES OF THE NASAL C AVmES.— CofUinuea.
HAV FEVER.
Synonyms. — Hny uethmn, rose cold, June cold, autumnnl catarrh,
rhinitis hyperfesthetica, caurrliiis aestivus.
Hay fever is one of tlie rciiroses occurring periodically aud churac-
tei'ized by irritalion auil intlammutiou of tho Timcous membmno of the
eyes, nosu nud air piissHgcs. uttcndcd by prufusc secretion and asthmucic
uttucka. Isuluted cusea may occur ut any time uf the year, but in this
country the afTcction usually prevails fn>m about the middle uf August
until the lattor pnrt of Septeniber, or until the parly f roe '.«; thougli a
considerable number of cases are observed in .M)»y, June, and July, and
occasional instances eveu in mid-winter. In England it is most preva-
lent in June and July. It is rather more common In men than in women.
Jt occurs at all ages, but is most frequent before the prime of life; 1
have seen it in childrtin five years of age, and have known it to afflict
those as oIJ as eighty or ninety. Seldom found among the working
classes, it attacks ]>referably tlioRe of education and cultivation, and reit-
idents of towns and cities rather than dwellers in the open country.
Anatomical anu Patiiouumcal Ciiaractebistics. — The inflam-
mation generally afTccts tho uusul mucous membrane and cunjiinctivie,
but often extends to the f rrjntal Rinuscs, and may bo severe in the fancca
or entire respiratory tract. The membrane is usually highly congested
and swollen, but in some casee, 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,
eonietimes being manifested by constitutional symptoms and again by
lociilized abnormal sensibility either iu the whole or a part of the respi-
ratory mucous membrane.
Etiology.— Heredity and nervous temperament prciUspoBe to this
affeetion, but a great variety of snbftances may crcito the attack where
the predisposition exists. William 11. Daly, first pointed oot the re-
lation between hay fever and certain morbid conditions in tho nasal
passages (Transactions of the American Laryngological Association,
1881). Subsequently his observations were repeated, and his ronclu-
siotis confirmed, by Roe, Hack, J. N. Mackenzie, Sajous, and others;
Mid although the disease is not so uniformly dependent upon the coudi-
JL
554 DIHEAHES OF THE NASAL CA YITLSS.
tion of the nawl mucona membrane as some of these authors sanrwm
yet in most cases such a relation is undoubted. Commonir the atta
appeara to be brought on by inhalation of the pollen of ambrosia
misiae folia, known also as Roman wormwood, rag-weed, or hoc-weorf
that of solidago odora, known commonly as golden-rod, but it ia f reou *i
excited by dust and smoke, especially in railway travel, and bv
emanations of rosea and other fragrant plants, or the pollen of c ' t
grasses, as wheat, barley, oats, rye, or even Indian corn. It mav I
be excited by the dust of ipecac, salicylic acid, benzoic acid, and' 1
podium, and sometimes it is brought on by exposure to heat or li* h
or by over-fatigue. So strong is the neurotic influence in this disMj
that imagined exposure to influences which had formerly excited
attack have been sufficient to induce the return of the paroxysm - f
example, an artiflciul flower or even the painting of a full-blown *
hus brought on an attack of the disease.
SvMPTOif ATOLOOT. — The attacks often come on the same date of s
cccding years, regardless of the temperature, the conditions, or surrounrl
ings; but in some is a variation of a few days, apparently depends
upon atmospheric conditions or environment. There are two well
marked types, the catarrhal and the aathmatic. In the former the diH.
ease usually comes on suddenly, with irritation of the mucous membmn
of the fauces, conjunctivie, and nares, attended by frequent sneezinp^
in tlio latter, asthmatic features are usually developed after the na^l
symptoms have existed two or three weeks, but they may come on ind
pendently. The asthma in this affection commonly differs from ordinar •
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 th*^
diHcaso by a tickling or stinging sensation in the Schneiderian mucous
membnine, accompanied by violent sneezing jnid itching of the con
juni.'tiva', 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 baek part of tlie head. Swelling of the conjunctiva*
eyolidfi, lijw. or tip of the nose is frequently present. Constitutional
symptoms are often marked by elevation of temperature, aching of tho
muBcIcK, generiil nmhiifle, and sometimes groat weakness. One of the
moHt uniform roiicomitants is swelling of the Schneiderian muroui
niemlminc, which causes obstruction of tho nnres. and thus interferes
with rcKpiration, in many rase'i leading to the asthmjitic attacks. Pro-
fuse watery discharge from the nose, sul>se(|iu'ntly becoming muco-
purulent, and which is often very irriUiting. is nearly always present
The nuurouH niertibranes affected are usually of a bright red color
thoiigli oceasionully aiiii'mie.
l>i nJSDSis.— Hay fever may be confounded with pimpU- jiente rhini-
tis or *'c asthma. Tho essential points of difference are the his-
UA Y PKVER,
559
tory, the abrupt, commencemenl, Ih© exceastvo irritation; and the oc-
currtMK-(: of asthmatic p.-irDxyDm3 flunng the day instead oi at night.
This liigtory, togpther with the detection of very sensitive areait of the
nasal mucous membrane by lightly touching it with the probe, are sufli-
ciout to establish the diagnosis, except during first altoeks or in young
children, where it is sometimes necessary to watch the jjatient lor 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 eiglit weeks, according to the patient's
surroundings und the atmospheric conditions, and not infrequently
the patient remains greatly debilitated for several months. The
H«thmHtic attsicks may continue several hours or two or three days, and
then disiippear as suddenly as they came. Some lose Bosoeptihility to
the disease with advancing years. The affection is not dangerous to life.
Treatment. — In most cases the attacks maybe prevented by clmuge
of cHmato— sometimes a chaago from city to country or vice verm is
Buflicietit — but most patients find the greatest relief in cool localities by
the northtfrn lakes, in places near the seashore, or at high aUiludfs;
or from a lake or ocean trip, which removL« them from the pnllcn-
latlen air. In ibis country, the most favored spots are in the Wliite
MiHintaina of Xow Hampshire, .ind in the region about Xfaekinae,
in the northern part of Miehigan. Jfany obtain complete immunity
from the disease in the high altitndos of our western states and terri-
tories. No locality will be found equally bencUcial for all individuals,
and some will suffer severely where others have complete relief.
As the diseaso commonly occurs in neurasthenic persona, nerve
tonics and s<*dnt.ives are especially indicated. It is well to begin the
admiiiistnitiou of lliese remedies a month before the attack usually
comes on, and to continue them until convalescence is established. To
this end the various preimrations of quinine, Btr}'chniue, or arsenious
acid, and asafcjetida or some of the prefKinitions of valerijin are most
serviceable. I have found peiruHarly henefLcial a pill containing medium
doses of brucia phosphate, alccjhnHc extract of hyoscyanius, quinine
valerianat'.', and camphor mnnobromate, with or without small doses of
sodium ci'.licylale, pheuHcetin, ai-etanilid, or asafa-tida. These may be
given before and during the attack, with the effect of greatly mitigating
the patient's sutTrrings. During the attn<:k, opiates and hclliidonna in
small doses ;tre 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 instend of the^e from a twelfth to an eighth of a
grain of morphine, or from one two-hundredth to one one-hundn-d-and-
twcntieth of » 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 le^s
likely to be uupleusant. Local stimulating inhalations, of ammonia.
55S
DtSKASES OF THB NASAL CAVITIBa,
iodine, or chloroform arc tfoinetimei usefn], though Ihejr must be em*
plnytnl gutirdetUy le^t ibcy iucreuse the irriUition.
For relief Xroiu the iu:btag of the conjunctivs, weiik BolntionB of toad
acet«t« are eepeciallr recommended by Mackenzie. I luive found mfMt
beneficial a solution of Botlinro biborata gr. r. to x. oJ 3 1. of cumphor
water. AS'ith this, the eyes may be bathed as frequently fts dosired.
Tlie lipa 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. *S), to each ounce of which bus been nddcd
ten or twenty grains of zinc oxide. The irritation of the nasal mticotu
membrane m:iy sometimes be largely prt^rented by wearing plu^ of
wool in the nostriU to exclude du8t and other irriuting eubsUiucett.
Bathing the eyes and no«e with either of the solutions recommended,
or with very hot or very cold woler, will sometimes pire great relief.
Aaa local application totheSchneidorian mucous mcmbr.inc, n spray
of a saturated solution of boric acid will sometimes be found very grute-
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 qu.inlitio8 of
atropine, morphine, or cocjine. The latter remedy girea more immediuto
relief than any other we possess; but nnfortunately its continued ow \%
frequently followed by most serious consequences. With some patienta,
oily sprays will Wt found mure Ixmeticial. For this purpose a raoet
excellent combination is tliat of thymol gr. i, oU of cJoves niiij., aud
liqnid albolcue 3 J., to which in some cases a small amount, not more
than one-half of one per cent, of tlie alkaloid cocaine mny be added.
The strength of this solution may tie slightly increased in some eases
with advantage, bnt core should be taken not to make it irritating.
A similar spray useil Hve or six times a day will sometimes prevent the
paroxysms of this disease. A powder containing three or four |ier
cent of cocaine hydrochlorato (Form. 1 >><>) 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, aud this
should not bo long continued. Uccause of the temporary relief af-
forded, patients are very apt to uao this remedy to excess, therefore
physicians should never give written prescriptions containing it, and
should insist upon kuowiug exactly how much the patient ii Dfing. I
have known several lives wrecked by neglect of tliis precautioi>. During
an acute attack of bay fever, nasal douches uf weak solutions of qniniue,
salicylic airid, sulphurous acid or other antiseptics have been recom-
uteudiHl ou the theory that the irritation is due to the local action of
microlx!8. These applications mxva to have been beneficial in the hands
of some physicians, but iu my experience tUey have been disappointing.
When the attacks are duo to sensitiveness of tlic nasid mucous
membrane, tbedieteaiH) may be cured by judicious operative measures.
Those consist in removing any spur from the septum that may be large
i
n.ir FEVHH.
ool
:
enongh to impinge npou the onter wall, the mnovnl nf polypi, linear
cauterization iilong tlio tiirbinatod body to prevent extreme swelliDg,
And, i)U'6t iinpnrtiuu, ftupcrHrial imittcriziitiou of all spotg fuuiid to be ex-
tremely sensitive. The superficirti aiuterizaiious should siniply sear the
mucous mcinbriiuej lejiving it iii much the same condition us the intcgu*
mcnt after a blister; it must not be burned so doeply as to ctiugc :iny
amount of cicatricial tissue. The linettr cuuterizuLions are the same iib
those recommende<i for hypertrophic rbiuitia. The operations on the
septum and for polypoid growths are described elsewhere.
The nasal cavity should tirst be thoroughly examined inrith a flat probe,
the various parts being gently touched and the sensitive spots marked
upon a diagram representing the two surfaces of the narcs. A solution
of cocaine (Form. 140) is then applied by means of a small pledget of
abeorbont cotton wound on the entl of a Hat nuaal applicator (Kig. 1^7).
The pledget saturat^-d with the solution is carried hack to the posterior
part of tbenaris and as it is brought forward is ruhl>ed gently over every
part of the mucous membrane to b>(> auiPsthetized. This occupies about
thirty seconds. A minute later -the application is repeated with a fresh
pledget. From two to four such applicati'ms are generally surtieient.
The cauterization may eominouly Iw done without pain as soon as the
patient ceases to feel the probe ruhljed lightly over the surface^ even
though pressure may still be felt.
The part, having been thoroughly ana-stlietiiscd, should be sprayed
■with liquid alholene, and then rubbed over quickly two or three times
with a fiat, guarded electrode (1» Fig. 91) nntil aspot altout acenlimetre
in tliameter has been seared and appears of a white color. It should not
bo biirne<i deeply enough to cause an appreciable scar after healing has
taken phico. The cauterized pare should l>e noted npnn the diagram,
and after four or five days a similar cauterization may he 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
anrfaee has been treated and no part remains peculiarly suusitivo to the
probe.
After the cauterization, the patient may be given a four per cent
powder of cocaine, which may bi; insufflated into thu uares once in three
to five hours for the following Ihrco or four days. Together with this
it is well to give an oily spray similar to that already recommended.
These ram terizat ions may sometimes bo repeated every two or three
^ays; 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
nsually l>o conducted without in any way interferiug with the patient's
Tocation, and without serious discomfort. From tifteen to thirty trcat-
jnents are generally necessary to cover all of the disoaaed surface. The
^following year a few spots may be found still seusitiva, which were
overlooked previously or not burned deeply onoagli: or possibly th(
ni:iy result from new dovclopniciit of the disoase.
The trejitnmnt im best cnrrird out during the warmer portiona ol
tlie year, eitlier be-fnro the iisiml time of tlio jittiit.'k or iifler it IiiiB
eitbsideil; for during the nttiiok it ib linblo greatly to increase the
pfttteiit's distress, l^y this method from forty to fifty per tent of the
cases uf hay fever may be iMiied, about twenty-fiiu per cent more may
be greatly benefited, and the remainder will uauitlly obtuin iiullicioitt
relief from the nasal ttyinptoms to conipensiite for the diseoraforl exji&>
rieneed during the treatment. The Iruiitment is most apt to be bene-
6cial H'bere itslhnni hits not yet developed, and where the genend nervous
symptoms are not pronounced. Cauterization of the enrfuces with
chromic or carbolic acid iuid other caustics haa also been rei^nmuiendcd.
Asthmatic atucks i>ociiriing in connection with bay fever call for Iho
same treatment as simple spasmodic asthma. It is always best for the
imtieut to seek a different climate during the season if possible; uud
this is especially important in those who sufTer from debility for several
weeks or months after the attack, iiiul 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 utherwlso might lust a life-
lime.
FURUNCCLOSIS OP THE N09B.
Furuncnlosis of the nose is a couiparalively frequent affection, char-
acterizci) 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 pomts are attended by redness and great soreness of
the end of the nose, and a larger furuncle by coustant pain. The
inflammHtion usually originates in the hair follicle. The affection lasts
from tiiree to seven days, and, ujMjn discharge of the pui<,heiding quickly
takes place. In many individuals tlie attack frequently recurs, and in
some, one or more of these small abscesses r.re nearly always present.
TuKATMKKT. — As in all other abscesses, the indications are to evao-
uate the pus; but it is most important to adopt some mensnre which will
prevent a recurrence of the attack. For this purpose* remedies calcu-
lated to prevent the occurrence i>f suppuration in any part of the b^dy
are indicated, such an calcium sulphide, potassium chlonite, saline diti-
rotics and laxatives; brewers' yeast has also been used for this purpose,
with apparent success. Of the abuve, potassium chlorate has seemed to
n»e most valuable. Local applications of tincture of itMlinw or solutions
o* Bluer nitrate and of various oils and ointments have been employed,
*"th almost uniformly unsatisfactory results; for although the remedies
^'Ppcar beneficial at the time, the affection persistently recurs. It is
erne that in many cises any of these remedies may be used with uppur-
SPtSTAXIS,
&a»
EPISTAXIS.
eiit beiiolit; but it ia doubtful in auch instances whether the patient
woiiltl not havo recovered :ilmost iis opoeilily without tliem. In obstinnte
cxnmples the fsiet renmius tli:it lowil uppHesitJons, aa ji rule, do but Httlo
good. In two or three raises, under a anggpation for whidi 1 am in-
(lebteil to J. E. Best, of Arlingtoti Heights, III, F have Been speedy im-
provement and permanent cure result from the use, four or five times
daily for two or three weeks, of n two per cent aqueous solution of «ir-
bolic acid, which should be thoroughly applied with a small 8wab of
absorbent cotton wound upon a toothpick or other applicator.
L
^^H iS^ynonym.*.— XosQ-blecdiug, heniorrhagia uarium.
^^ Kpistuxis con&ixta of heiuorrhuKCi from the nose, originating eitlier in
the naaut cavities or the ndjiuMMit sinnaes. It \i mo»t frequent about
the age of puberty, is more common in eiirly ohildliood and advauced
age than in the prime of life, and occurs more often in men than in
women.
Anatomical and Pattiulogical Charactekistics. — Tho mucous
niembniuc may bo congested and swollen, or may uppeur normal ; but ia
most o-usoe erosion, iictual ulceration, or a small bleeding 2>i^iut may be
found ujiiin the cartilaginous septum. Sumotimes the septum is jier-
fonited.and the bleeding comes from the edge of tiie opening. In oiher
cases the macous membrane is thin and the blood vessels are near the
surface, so as to easily rnpturo upon engorgoment from any cjiuse.
OccasiouuHy the bleeding comes from the mucous membmne over
the turbinated bodies, from the adjacent sinuses or posterior nares, or
from tho easily bleeding surface of a fibrous or malignant tumor.
Etiohiuy. — Among the local causes are irijurj' from picking the
nose, tho introduction of instruments, violent snoexing, coughing, strain-
ing, tho inhalation of irritants, or the presence of polypi or other foreign
bodies in Iho nasal passages. The eonstitntional causes are alterations
of the blooil, such as occur in nnteiijia, itletliora. eruptive and relapsing
fevers, diphtheria, scurvy, purpura, and lia-mophiha; or ulmnges in the
walls of tlio blood vessels uccompanyiiig ]ihospliorus puli^oning, acute
yellow atrophy of the liver, Bright's disease, gout, rheumatism, uud oc-
casionally syphilis or chronic alcoholism. The afTectiou is also due in
Bome 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 resntt from the effects of strong emotional excite-
ment upon the vasomotor nerves. It is sometimes TJcarious, taking the
place of menstruation or of the habitual bleeding from hemorrhoids.
SYMr-TOMATOLooY.— In the plethoric, and in patients suffering from
fever, the bleeding is often preceded by flushing of the face, a sense of
seo
niasASBs OF thk nasal cavitiks.
fnlnesB in the head, with buzzing ju the ears, &rn] giddiness, and some-
times itching in the nose. It ubiiqIIv begins witliout apparent eau&e
frequently even while the patient is asleep, and Hows from one sid
in drops, which follow each other in rapid Bncoesaion; in severe casea)
it niftv rnn in a small stream. Usnally not more than a drachm of blood
is lost at one time, although it may seem very much more, to the patitiut
and his friends; but in others!, bleeding is rapid and persiiitent, and
sometimes miftirirnt to provi' f;it:]l. A liirge amount of hlood nmy he
lost wiibiii a fe«- hours, and tlic hTeoding may rontiniip for several days.
Martineau mentions a case in which twelve pints of blood were lost in
«ixty hours (L" Union Medicale^ lSii8, troisit-me s6rie, Tome VI). When
the bleeding is exoejwive, syncope is liable to oocur, and may prove
fatal. Where epintaxis occurs frequently, or continues for several days,
eerious anemia nuiy result. Usually bright red blood flows from one
nostril only, but it may pass back to the posterior naroe and eacap«
around the septum from the other nostril, or run down the throat. ^|
DiAOXOsis. — tfiniple cpifituxis may be coufuundeJ with certain neo-^'
plasms, or with ulceration, and «in only be distinguished therefrom by
careful inspection of the parts. fl
Prognosis.- — Most cjtsos terminate spontaneously within ten or ^
fiftccu minutes; but In some the bleeding continues several hours or
even days. The cases occurring in children withont apparent cause,
and those resulting from various injuries to the nose, arc seldom, if ever.
dangerous. When occurring in old pt;ople without provocation, epi-
staxis indicates degenerative chaiigeit in the blood ve&JoU, wliicli are
ominous. In suhjecta of haemophilia, bleeding is liable to prove fatal.
Nasal heniorrhagLui frequently rei:nrriiig and lasting several days at a
time, iinlp.-* properly Ireatfd, catifti dangerous ana*mia, and many tliere-
fore terminate fatally. In low forms of fever, and in dipbtht'iia, it is a
grave ennptom. As has been shown by liugblings Jackson, tbifi symptom
occasionally prccc<k-0 a^ioplexy (Ixmdou Hospital Clinical Ix-cturett and
Reports. I8fi6, \'ol. HI); 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 soem to have been induced by checking the flow.
TnEATMES'T.— In the majority of case« the bleeding does no harm
and need receive no treatment. When of a vicarious nature, and where
there is evideneo of plethora or of obstructed venous circulation, it
should not beclieckod unless long contiuuud. 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 implicitlv
relied on by the laity. To aid in checking hemorrhage, the head should
be kept erect, applications of cold may be made to the nock or directly
to the nose, or the application of hot water at a temperature of 1:20'' to
125"* F. As in most instances the blood flows from a small point on the
I
SPISTAXJS.
5t!L
curtilnginous s«pttim, it is eisy to efieck it by contiiuiouB compression
of the ala* iin«i for ten or fifteen mmutes nr by illrpct proseuro of the
finger upon the septum. Compression of the fjidtil nrtcry is iiiso recom-
mended.
In continued bleeding vbich occurs from points far back in the
nurcs. other nietbods must be employed. The iiisiifflutlon of pow-
dered aluni, tunnin, or m:itico leiives wil] often lie found efficient. Tho
Altim is liiiblo to catiso excesRive pftin, »nd tnnnin niso is frequently pain*
ful; iHiwdeied matico, however, has been found much lees painful, and ap-
parently is quite HH effective. Tho application of nspniy of tinningr. j:,
ad 3 i. answora well in some caaeSfOr a eolation of iron percliloridc iH xx.
ad 3 i. may be used in the same way; of the two, the tannin is pryfera-
ble. Jujectioua of ice water, or better, small bits of ii-e frc^^iieully
introduced, are often satisfactory. Internal remedies may bo given at
tho same time with more or Jess bcnofic. For this purpose the fluid
extract of ergot in doses of half a drachm every une to two Jioura, or
ergotine in proportionate quantity, is recommended; also, tincture of
opium in doses of from five to eight minims or medinm doses of lead
acetate, aloiio or combinctl with opium.
In the episUxis of purpura, MiioNamara commends a wineglussful
of spirit* of turpentine in a tumbler of brandy or whiskey punch takon
MS rapidly as possible (Mackenzie: '' Disoa^ies of tho ^ose and Throat,"
1884). Ilurkin, of Belfast. Irekind, claims to have obtained excellent
results (Transactions of the Xiulli Internalional Medical Congress,
VoL IV), in preventing the recurrence of epistaxia by conn tor-irritation
over the livtr. In persistent bleeding, when simple remedies fail, jilug-
ging must be resorted to.
Simple plugging of the nostril with cotton or lint, and holding
the head forward until coagulation has tnken phice, will bo euflicicnt
in many cases. When it fails, plugging of the p*istcrior narcs must
bo the resort, or better still, filling the whole inisiil cavity with a
AtyptLc and antiseptic tampon of gauze or lint. Sometimes tho nurts
may be easily and effectually plugged by an air sack, opemted on the
plan of Barnes' uterine dilator, hut this method is not usually very
aucccssful. Oompnrssed sponge or simply strips of sponge may be
packed into tlm nares with tho forceps or applicator and M-ill usually
quickly chock hloeding, but these are ntmuved with dinimlty, and
occHi8ionally some piece is left behind, Ciinsing an infinite amount
of trouble, which might bo avoided by carefully tying each bit of
aponge with a strong tbreud, and numbering the threads by knots to
indicate which should bo removed first. One of tho most convenient
taiuiHxis for the nose is made by tying a strong tbrvad to tho middle
of a bundle uf fifteen or twenty ruvellinga from surgeon's lint, abrjut
four inches in length; one or more of these bundles being used. After
the naris is tilled, all of the threads may be wound about a bit of lint
3fi
set
Piasjasa of tbb saxjll cAVirrxs,
sad teefced into the noitriL This taapon ha» the merit of
little paiii and of being euilr extruMcd, proriding the Threads hmn
been avmbered a« sJrasdjr BicsiUoned. In nting »t of ibese, it is vrt
first to blov into the nsris foar or fire grviiu of io4ufonn or of m "»^
fare of eqasi ymru of kMlofom sod boric acid. ^
A BKWt rffifsrtoiu oMtbod of cfaeckio; execisiTB bleeding from UN
BOM, vUch I aiJoptrd some jean ago, and one easy of applujstkin,
ciit* of tataratiiiga strip of antiBeptic gaaze abont an radi
foorfeet m length with a thirk svnipT mixtarf of taofim
i4lcli has been add«d a little glrcerin and a few drops of carbolic me^
ThM it itnffcd Into the nose, fold after fold, nntil the naris is ftl^|
Sometimes to the end first inirodaced, 1 attach three or four str^Q
thmida aboat two inche* apart. Thu end u then psueeij through
naris iatu the oaaopharrDx, the free ends of the thread bec^g left
ing from the nostril. The etrip is then rapidly poshed io until
poiterior [tart of the dvitj u fall, after which the threads arc drmi
npon •(} aa to pack the gauze tirmlj into the posterior naris.
whole cnvitj is then filled with the strip of gauze, aur remaining
tion being cut off. Thia ia to me the most Batiefactorr means of pfag-
gfng the n.tris. and has prore^l efficient in the most severe cases where
posterior plugging would be indicate<l. The gauze may be rapidly
easily introduced, and rendily removed, and the method obviates
danger of preMiire upon the upt'iiiiigd of the Eiiiitucliinn tabe«
conseqaent induramatioQ of the middle ear. Tlie only di»M]Tunl
I have obaerred ure that its remoral is aumelimes painful, especii
flft^r ftperatire procetlures in the nose, and the tannin causes some
diviiluttlit con*ii4lenibIe amarting. Walton Browne, of Belfast, Irvlai
recommends a similar procedure, the gatue being impregnated
powdered alum instead of t.innin, and he says it ia not painfnl (TniDp
actions of the Ninth International Medical Congress, Vol. IV). thontfh
from my observation alum appears to cause much more smarting th
tannin.
I'lugging the posterior nares has long been practised for checkij
obstinate epjfttaiis. It is commonly jwrformod with the aid of Bellocq's
canuln, by drawing through the nose from the throat a strong string to
which is attached a plug of cotton or lint of a sulticient size to fill the
poHterior narie. By tnictiou on the string, tliis plug is tirmly pad
into the chotiitu. A plug is then introduced into the nostril, and
string tied about iL Lint ia much preferable to cotton for either
these plugs, iift the latter tends <>oiist:Lntly to i>ecomo smaller when it
comes sutunited with the secretions. A luop nt least two inches
length should be loft hanging from the plug that is dntwn into
posterior narin. or u string should bo nttnche*l iind li'ft protruding U
the mouth Ut aid in removing the tunipou. Both ^ides niny be treat
the same way, but the impaction of » large mass into the naso*
EPHtTAA'lS.
6G3
phiirvnx is to be deprecated. It is unsafe to leftve the post-nafuil plug
in jiotition fur more than twenty-four hours without renewal, as influrn-
matioii of the middle mr or snppiimtion of the maetoid cells is liable
to follow Biich practice, and occasionully death from gangrene, tetanus,
erysipelas, or gepMe^miu has rtsultcd. To remove the tam|>on, the
pledget should bo taken from the nostril, swid, when only one siile has
been stopped, warm water to which has been added a teaispoonfii] of
sodium bicarbonate to each jiint ?hould be gently injected throiiffh the
opposite side to loosen the tampon. The affected side may be earefnlly
washed in the same way, but force should not be used. The string
banging in the pharynx or jtrolniding from the month bIiouM then bo
pulled npon, and if noceasary, the tampon gently pressed buck 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 BelbiMfg canulu; it is passed through tlie uotitril into tho
thriiat and drawn f>ut at tho mouth by forceps; a suitable thread is then
ftttiiched und dniwn back through ihe naris. A well waxed thrend may
usually be easily passed through the nnria without the aid of catheter
or sound.
To prevent recurronco of tho attack, the cause must bo sought and
removed. In the majority of cases this will be found in a bleeding
point upon the cartilaginous septum, but occasionally njton other por-
tions of the mucous membrane. Sometimes ennterizBtion of this with
solid silver nitrate will be sufficient to cure; but usually it is best to
touch it with tlio galvantvcautery, the point of which shonid be heated
to a cherry-red and quickly touched to the spot several times, until tb&
surface is thoroughly scared. In most cases a single treatment of this
kind, provided Ihe exact ^pot has been found, is suHieient Lo eltect &
cure, but in others subsequent cauterization will be necessary.
CHAPTER XXXIII.
DISEASES OF THE NASAL CAVITIES.— Coniinued.
XASAL MUCOrS POLYPI.
Synonym. — Nasal myzomata.
Nasal mjxomats are tumors which grow from some part of the ma-
cons surface, producing obstruction of the passages and nsually execssiTe
mncous discharge. They are very common^ occurring more often in
men than in women, but are seldom seen in children under twelve years
of age.
AXATOMICAL A3fD PATHOLOGICAL CHARACTERISTICS. — MucOUS polypi
are grayish or pinkish in color and semi-tranRparent; they are round,
oral, or pyfiform, and vary in size from five to fifty millimetres in
diameter. They are somewhat yielding and elastic to the tonch, 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 peradventnre 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 mucons substance predominates. Sometimes their
structure is fibro-cellular.
EriOLOOY. — Though their ultimate cause is not known, polypi are
generally attributed to chronic congestion or to the irritation resulting
from flonuded hone. Woakes holds that mucous polypi are always as-
sociated with necrosis of the ethmoid bone (Nasal Polypi witli Neu-
ralgia, May Fever, etc., H. R. Lewis, London). While this may be an
antececjent in many cases of po]yj)i, either condition nut infrer[uently
occurs indt'iii'iuli'ut of tlie other.
Symitomatolugy. — At first the patient suffers from increased nasal
NASAL MUCOUS FOLYPI. 505
secretion and more or less occlusion of tbo nnsil pusaages, which is often
uggnivated by damp veftilier, and is increased by colds, to which he ii
very susceptible. The occlusion is usually more marked in one noris,
but tUc SL'Use vt obstrucliou fre<|uently chnngcs quickly from one aide
to the other, isigbtmare, heaJimbc, giddiness, epilepsy, rougestion of
the fauces, hay fever, usthraa^ and other reflex disturbances soniftimec
rwult from tlie presence of tliost; growths; but Mackenzie justly rt>-
mnrks (Diseaaes of the Throat and Nose):
WhiUt fully odmittiDg Ihat noany rcflox phenomeoa may arise from dta-
eases within the nose, I must (.•aiUioti thu yoiinper specialist that llie vurious
t-uiiipliiiiit« ryreiTctl Ut as resulting' from nusul disease ure niiu^li iiioie tii?qnentJy
iliin Lu olht^r coiitliliiins. and thai every otUei* po»&ible ttkUMi iiiUKt l>e climiQalcd
befor« the nonv in itici-tiuinated.
Bosworth dhows tliat mnrotis 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 tho nose; headiwhcs are comparatively comniou, and tbo senses of
smell and taste are often obtunded, although in many Ciises they mtty be
restored by the removal of the growth. The voice is modified in a
chameteristic: manner by the obstruction, and respiration is disturbed,
so that tho patient may be obliged to breathe entirely through the mouth.
A profuse watery and sometimes muco-puruleTit, though not offensive,
secretion from tho nose is common. Kpiataxis is not infrequent.
When the tumor protrudes from the nostril, it is usually munh con-
gested. By anterior or posterior rhinoscopy the smooth, glistening,
grayish or pinkish, growths may bo seen; frequently only one or two
large ones are visible, removal of which discloses many moro of smaller
size. A flat probe may be ej^istty passnl upon either side of the tumor,
and to tho tonoh it is found soft and elustic.
Diagnosis. — Those polypi ore to be distinguished from deviation
of the septum, thi<:kening of the turbinated bodies, chronic abscess of
the septum, foreign bodies lu the nose, and from fibrons> sarcomatous,
aud c:inueroag 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 tho soptum.
Tbey are distinguished from thickening of the turbinated bodies by
their color, which is UBUuliy much lighter; by their density, which is
much less; by passage of the probe between them and the oxtemal wall
of the naris, and by their movabtlity.
They are distinguished from cAr^HirnAn-Ms of the septum by their
color and density, by their pi-esence usually in both nares, aud by the
passage of a prube between them and tho septum.
Mucous polypi resemble /or^'^n bodies^ especially in causing obstmc-
JflBEAXEa OP TBB yASAL CATtTTES.
Hod uid * profiue diw hwiyi, bat tbr diidurgv in Uw ewe of foreij
bodia b Marif •]»>;> uffetuiTe — dm ao vitb ■hhitm pvljji. The
tocy of Um cue, togetfacr Ttib inpoetuB sad palprtioa of tlw
viU MteUish Uw iliapBonL
Fibnu*, mnammlmu, and MaevrMM ynmikt m tbe bmbI esi-ity ««
wnallT of dwyor eebr, and more resutaat so tte toocfa, tbcy bleed
tMilj, and, Xh*^ fibrooi grovtb* excepted, tare a more inregnWr mr-
/■«><! than poljpi. Tbe maligiiiiit (omon (unaUr grov moch more
npidlr, oftm caiujng cooaiderable pain, moeb dttfigttremeot, and
aooner or later grave eonrtitotional ffrmptosu. We would remdily de-
tect mrtilaijimBUM or maeomt immort br the aenae of touch.
We fre<in«itlr aee hjpertrDpbT of the mocou nembnne ManriattJ
with m/zonuta, bot, on tbe other hand, tbe maoous polypi mar caaae
•trophj of tbe voft tis«nes »nd #r«inetim^ eren of the iroay ftrnctnre*.
Pooovosis.— Tbe affectioo, if not relieTed br opcmlive procedorv,
Btoally continae* for a lifetime, canaiiig tbe potieal mncb dtscoufort
and anno\-anc«. Althoagh the obrtmctcd raapiratioQ mast eTeDtnalljH
cumproniiM? the general health, the affection does not i^pear to threaten!
life. Often tbe tamors remaiii ao small as not to attract the patient's
attention, bnt vhen they hare become large there is no reason to ex-
pert retft'gresrion. Spontaneons expulsion of one or more poh-pi aome-
timea oocnrs. They are very liab'e to recnr after removal, and are
aomctimei verr difficult to eradicate. Korelr mrxomata are trans'
formei] into mrainuitu, and according toSchifferv, of Li^ge, sooh obang«
orrnrs only in rahjet-ts past the fiftieth year (Tronaactioni Intema-j
tional Congreaa Ijiryngology and Otohig)", If.SUj.
Trkatmrst.— For dentmction of the growths tbe injection of irari-
OOi «i(li*trtncefl has been recommended, snrh b« zinc ohiorido, iodine^
sdoobi'l. (iirboUc acid, and solation of iron ptirchluride; also local appli-
cation* of itaturated wuter}' eolutiond of jKitoaeium bichromate. F. Don-,
Aldson, of BRitiniore, ha»!nI»«o remmnuindLHl introduction info the tumoi
of ohroDiic ncid on .1 shnrp pnjnted pro^jc, While the^ methods harej
aonuHimcii succeeded, they certainly generally fail. evet» in the hands of J
akilfnl openiturs.
EvnUion with the forceps, the oldest method, is still roont com-'
mnnly practised by general surgeons, though seldom employed by
laryngologists. Somptimcs, however, thp polypus forceps will he found
lucfnl. As coniinoniy pi»rfornied hy surgetma, this 0]>er:ition is lery
painful, there is mu(.-h h|i'0«ling, often some of the turbinated bones are
lorn away at the anmi' time, aitd rarely are the polypi coniplptely re-
moved. Some surgeouii sidvt^e that tbe nose be laid open and the parts
t)ion>ughly curetted. Thia would evidently be more efToctuiil than re-
miivul with fon'rps in the t>Id way, but it cannot he more thorough than
remoTul with the snare, f<il|r>wed by cauterization (or, if the operator
ivrofor, curetting), when Uuue under good rhinoscopic illnniination. by
UrASAL ^UCOVS POLYPI.
£67
■which every part can be seen ijuite im w»11 uh if the nose had b«en laid
open. .Sonielinifs pulyjii tuny bo out off with fi^-cepB or scisBors. The
gjIvauo-Kuitery t'crsisuur (Fig. aoT) affords tbo advantage of scaring the
h.i8o and tlnis destrojiTig it at the time when the tumor is cut off, but
it is 11 {•hiTiisy instrument comp;ireil wirh ilie ordinary steel-wire snare
which la the one now generally adopted by laryngologists. When polyjii
Fia tor.— UALtAtto-Cirruiv IlAXinx, wmt Ci-iascvb Arr,icfiMi»rr (>q stsu),
bod again after reniovjd, the best treatment is thorough searing with
the gidvuno-caiitery while they are still small. The oporution which
I have found most satisfactory for the nitijority of casea is done with
the steel-wire L-cmseur or snare (Kig. 208). This is a modificatiou of the
snare devised by Chirence Blake, of Boston. Good instruments fnr the
same purpose have Ikhmi devised by Jarvi;* and Sajous, and various modi-
fieations of these have been made by other iuryngologists.
The snare is armed with No. t> steel piano wire, which in practice
has been found to answer moeh hotter than otlier sizes. The loop is
passed in vertically, its under edge turned beneath tbe polypus, and
then with a backward and forward movement it is worked up as near
the pedicle as pciBKible. Tbe loop is now tighteneii, and, if lhoughtb(*6t,
the poI}*piiB cut off at onee, but usually iMitter results are obtained if it
u torn from its base by traction. There is little danger in tliis way of
C»e
Flo. AW.— iKOALa' Bkuuk, witb £zt)u Tl-brh (H i'w- UW^ <&*>•
removing any of the normal tissues, for it is almottt impossible to in-
clude witliin the snare anything but tbe polypus. Where [Kilypi grow
from broad bases, and are attached over the whole snrface of a tur-
binated body, the bone may he torn off witli the snjre if much tracti<tn
is made. Under such circa mstaucee 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 biise
as possible. Where polypi grow from a large surface of the turbinated
body, it is sometiniee better to remove the bone to prevent recurrence.
The operator should have at hand forty or fifty applicators (Pig.
DISEASES OF THE NASAL CAVITIES.
209), wonnd vith abAorbent cotton, for swabbing out tho blood while the
openilion prooecdd, as it is useless to try to Ciiioh tiiu luniors wliru
Iho nose is filled wilU blood. Whatever operation ia performed, the
parts should first bo thoroughly aaicsthetizod with a four to ten per
cent solution of cocaine, which is best applied by means of a hypoder-
mic syringe fitted witli a long, blunt silver nozzle (Fig. 210) bent at the
end so that the solution may bo thrown up about the b»ea oi the
h.
DKEE
Fls. SUt.—CoTTOB ArriMjATOK (if-A«ize.i. Mwle *if (-oplwr.
tumors. Sometimes both cavities may bo cle;ircd at once, bnt it is
usually preferable to remove what growths may be easily reauhod,
and to complete the operation at one or two subsequent sittings, as
this generally gives ihe pulieiit much less diKcumfort Ihuu one long
sitting. It will be remembered Lliat the effects of cocuiuo disiippear
in about ten minutes, and after blood has once begun to flow it !«
difficult to anaesthetize the parts again; furthermore, if too much
cocaine is used, its ooustilutional effects, even if not alarming, are ex-
tremely annoying. After the polypi have been removed, the patient
should cleanse tho nose once or twice daily with tho salicylate wash
(Form. 187), or with a wash of sodium bicarbonate, a teaspoonful to the
pint of lukpwarm water.
Antisepsis and healing will be promote*! by insaHlation two or three
times daily of a powder containing twenty j>er cent of boric acid, fifty
per cent of iodol, and sugar of milk sufficieut to complete the mixture;
together with tho use of a epruy containing about one minim of oil of
wintergreeu, two minima of carbolic acid, three minima of oil of cloves
Flo. 9ta— BTpocxnmQ Btewoi (K tite). Lone rilver (umle.
to an onnce of liquid albulcne. If secretion is profuse, ten minims of
terebene may be added udvantageotifely. Tho patient i^hnuld return in
about a week, u-hea it will often be found that sues which were invisible
at the time of operation have 611ed, and may be removed. l^Ie should
rettirn again in four or Rix weektt, aii that if the polypi are growing they
may be thoroughly cauterized with the gutvuno-ciiutcry. If (he sur-
geon ia not provided with this instrument, chromic acid may be u&ed
instead. In some ca^s mncnm^ polyjti do not return after thorough
removal, but usually recurrence takes pl:ice. and operative procednre^
must bo repeated from time to time until complete destruction of the
growths is effected.
XTAHAL PAPILLARY TUJfORS.
669
NASAL FIBROUS POLYPI.
SfpK>nt/7n. — Fibromata of the nares.
Fibrous polypi are extremely rare in the nare8> although not uncom<
mon in the nuso-pharynx. Generally, growths In the nasal cavity which
resc-mbUi tlbrous tumors in appeiinmce really occupy a histologiciil poai-
tiun midway between mucous aiul fibrciiis I'olyjii, termed tibro-mucoue.
These growths differ from mucous jwlypi in being harder and bleed-
ing more easily. They should ho removed, when possible, by the natu-
ral paiJg^igeR, with cutting forceps, snaro, or gnlTuiio-cautery ucnuseur.
The latter is best when it cau be accurately applied.
NASAL PAPILLARY TUMORS.
Synonym. — Papillomata of the nares.
Nasal papillary tumors^ though occurring more frequently than
fibrous polypi, arc still infrequent, though Hopmann states that small
warty growths aro more conitnuu than generally supposed, and he lias
met with numerous cases (Vircbow's Arik\i\ Band X CI 1 1, 1R8.3). He
[also states that Schaffer, of Bremen, \\m ob3erve4l them quite as fre-
quently. This \A different from the obtjerTations of Mackenzie, Zuc-
kerkandl, and various other laryngologists, and from my own expe-
Tienoe.
Anatomical and Pathological Chahactebistics.— The true pa-
pillary or warty growths ore stated by llopmanu to spring invariably from
the tower turbinated body, though I have seen one such tumor growing
from thu septum alone, and another instance in which several of theee
tnmors 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 Mackonxio, the luniors
were situati'd on che septum or on the inner plate of the alar cartilage.
Stmptdhatologt. — The symptoms which I have observed were those
referable to dry catarrh, with the utiUal signs of obstruction of the nasal
passage when the tumor was targe. Ho]>mann also observed frequent
cough and expcctonition, which he attributed to the papillary growths.
Diaonosls.— The diagnosis must be based upon the peculiar appear-
anco of tlio growtlis, which, unless they are moistened by secretion, is
similar to that of warts upon the integument, and upon microscopic
examiu.itiou, which will determine their papitbry character.
Prognosis. — The tnmors tend to increase in number, and are very
apt to recur when removed.
Theathent. — The growth may be destroyed with nitric, acetic, or
chromic acid, the cutting forceps or ourette, or the gaJvano-cantery.
In one obstinate case under my care, all of these methods were tried
«70
IfJitJiAUBS OF TI/K NASAL CA VlTlES.
Taneucctsafully; the warts repeatedly returued aguiu in four to aix weeki
alter eaeli removal. Finally the patient w»8 given a strong tincture uf
thuja occidentalia, which he applied to the part two or three tinieft dnilt.
This, with a few applications of chromic acid, finally erudicated the
disease.
^=^ ?»A8AL VASrrLAR TUMORS.
Synnnym. — Angiomata of the nose.
Vascular tumors in the nose are extremely rare. In their removal,
Jarris, who jud>fes from his own experience and a tubulated report
of 8i.xteen cases bv J. O. Roe, of Rochester {New York Medicai Journal
January, 188f>). cunsidtTS the cold-wire snare safer, simpler, and more
satisfactory than the galvani>-eautt.Ty or other agents (Intfrtiu/toual Jour'
nal of Surgery and Anii^fptics, 18S9). In one snccessful case reported
by him, the gradual removal ocrnpied three hours and there was no
hemorrhage. Reasoning fnim analogy only, the galrano-cauterr wotUd
Appear to be the best instrument in such cases.
NASAL 08SE0UR CYSTS.
Osseous cysts of the middle tnrbinate>(l l)ody hare roccutly lieen i'
subject of articles by 11. Zwiliiiiger, uf Hudupest, Charloe U. knight, uf
Kew York, and Ureville Macdonald, of London.
This variety of tumor is rare, and its etiology, pathology, and
symptomatology are not yet fully understoo<l. Charles K. 8ajous
{Annual of the Vniverml ilmlical ."^ciencfs^ ISlttJ) quotes Macdoiuild as
follows: " Whenever an ossvuus tumor prei^ents itself in the niidille
meatus of snch a size that it is obviously something further than a nujpl«
osteophytic periostitis, whether i>re«entiug an osseous surface covered
only by mucous nienibraue or whether it is concealed partially or entirely
by polypoid growths, the proljobility is strongly in favor of cyst. When,
moreovor, these app^^arances are accompanied by a pnrulent and fetid
discbargB, one may safely surmise that he is defiling with a suppiinitiug
c)'8t or aljscess of the middle turbinate. The fliagnosie is finally snlistan-
tiatod by Uie removal of n portion of the walls of the tumor by snare or
forcejis.
"The treatment is simple enough in case^ when the tumor has not
Attained ennrmons dimensions. The simplest way of effeeting removal
is to throw a strong snare around the mass and remove aa large a portion
OS po.-aible. The remaining portion of the walls may afterward be broken
Away with foroeps."
I have seen hut a single case of the kind, which was easily removed
with BQure and forceps. The cyst was flUed with a soft, yellowish cbMiy
:fASAi BONY TViions.
fin
NASAL CARTILAGINOCS TUMORS.
Synonym. — Eccliondrotnatti of the nose.
True rurtilagiiiouft tumors in the nasnl ciivitiea are extremely rare,
though a few ruees have beeu reported. Eechondnwes or carlihij^inous
outgrowths, however, are rery common, and will be considered elsfr
where.
Anatomical and Patholooical Characteristics.— Cartilaginous
tnmors flostly rpgemhie fibrous polypi; they are, howorer, sessile, gcn-
eraUy grow from the cartilsiginouB gepturn, and if not interfered with
TTiay attain an enormous size, causing great deformity of the face.
Symitomatoloov.— The symptoms are those of nasal ohstmction.
DiAOKosis.— The cartilaginous growths, when large, are liable to be
mistaken for Itbrous polypi, malignant growths, exostoses, or osteomata.
Practioally wc may exclude Ji(*rutiwla, because of their rarity. AVhen
preseut, they bleed more easily and are less dense than cartilaginous
growths. It is to he observed that »irf/tf/;m»/ /urnurx are softer, bleed
eiiRily, and grow rapidly. We readily distinguish cxrw/o/i"^ and frrfmn-
drosex by inspection as beiug simple outgrowths. It is distinctive that
Itony tumorH are harder and cannot be penetrated by the needle like car-
tilaoinous growths.
PitooNoRis.— The prognosis is favorable if the disease is detected
early, before great deformity has occurred. There Is no tendency to
recurrenee when the tumor has been removed.
TptEATMKsr. — fiemoval by galvano-cautery ecraseur is ths most sat*
isfactory surgical operation.
»
NASAL BONY TUMORS.
Synvnym. — Osteomata of the nose.
^asal bony tumors are uitually characterized by ubstractiou of the
nasid passage and severe neuralgic pains. Whmi occurring, they Ubuully
develop about the age of puberty, hut they are rare.
Anatomical and Pathoujiucal Chakactkristics. — Osteonuita
are usually ovoid in form, and they vary iu diameter from five millime-
tres to five centimetres. TJiey arc distinctly bony formations, some-.
times exceedingly dense, yet at others cancellous; but they have liltlo
or no connection with the osseous structure of the nose, and are gener-
ally atfciclied to the soft tissties by a c<iniparatively snmll pedicle. They
are covered by pcriosteura and mucous raentbrane, whioh Is fiTely sup-
plied with blood Teasels and of a pink or red color, and is ocuiisiunally
alcerated from pressure.
i^Tioi.oGY. — The etiology is unknown.
SviiPTOKATOLonv. — Early, the bony growth commonly causes intol-
fatccw-
Ottmlte
Hw ocean. Ther sn rety IikbV to ivev
rcrj diAcnU to mdicatc. fcwlj
tof rf i»tOMf«o»BU»ui'] aooordio* toSAMwi, rf Lttga,
o«v!t)r« r>rtl]r in sabject* pMt the ftftietfa i
UtfiuJ Omiprmm I.«r}ru(olo£y sod Otologj', 1689).
TKKiTMKiiT.— For dcftmetka of the gmwAs the iajwtiaQ ol Tvi-
mil r hu» been recomniaided, toc^ m ase chlMiHi, Jodiaa;
alcbli'... .-■ :i'. w-i'l. and Mlation of inm pCRUoride; aliB local apfili-
'miiifHt tii mianttm] wnivry nolDtions of poiaanai bii huaarte. F. Don-
tH^tttf- ' (M'Tf, liMftlw rtH.v)niinrDd«d intivdBcoaa iatoth* tsmor
«fMit I '"t 't ■li'irj> |M;int««) probe. Tkile tlnw wethodi hare
MW^IMH •r|m>iMH)«l, tlM7 tM.TliiinlT gcneraDT CatL ervzi is the huxb «f
(fl '■' ' . ■ mlof*.
11 with Iho forcajM, tbe oMCift mrtbod. is still nest mm-
fHf'«»)r frrw'ljiitrd by ((onurul lurgeoDSt tbou^ icUaiB emplored bjr
frt^r'(tf"l"fc(«t>* f^>nif>thiu<«. Iiowcver, tb^ poljpoB farecfis wiU be fonnd
(tcMftit An comniunly jinr/rrrnx*'! by BurgvoBs, Om aperstioa h r«nr
fmlitriit, lliero U much hlpmlinj;, often Mtrae of t}ie tmMasted bones sre
ttiru ttwuy Bt the mmi* tlrnr. ami rarely are tbe polrpi eonplptehr rv-
fii4fvect. .Some anTgt^u* nijri«e that the nose be Uid ofeik md tbe ports
tli-iioii^'lil}- t-urrttiil. I'his wmuI'I tridcntly be mors affrrtoal tban re-
iiK.val tt iOi fonTj>5 iu ilii- <»M iray, but it cannot be taon tboroneh tbah
removal with tbe irinre. followcl by cauterization (or, if tbe operator
er, curetting), wbfn duue under good rlunoaoopic iUnminstioa, bj
IfASAL Jfircoirs POLTPI.
5«r
which every part can be seen quite as v\\ aa if tlio tiose had bten laid
open. SoiiK;limc's pulypi tiiiiy be cut off with forceps or scissors. The
gulvano-euutory I'LTuseur (Fig. *.20T) affortli) the iidratitnge of searing the
base and thus deBtroying it at the time when the tumor is cut off^ but
it it* H Hiiinsy inatmment ronip:tred with tlie ortlinary steel-wire snare
which is the one now generally adupted by luryngitlogists. When pulypi
Via. JHC— <;AL%A5»CArTntY HaMULS. with CcBAUCCX ATTACimUrT (<<| llMl,
bud again after removsil, the best treatment is thorough searing with
ihe galvano-cuntery while they are still sniall. The opomtion which
I have found most satisfactory for the majority of cases is done with
the steel-wire i-cnisour or snare (Kig. 208). This is a niodilicatiou of the
snare devised by Clarence Blukt?. of liutiton. Good insLrunienttt for the
same pnriiose have been devised by JarviH atid Sajous, and various modi-
fications of thcBc have been mad? by other laryngologists.
The snare is armed with No. 5 steel piano wire, which in practice
has been found to answer much belter 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 a^ near
the pedicle as poiwible. The loi>p is nt»w tightened, :uid, if thtuight best,
the polypus cut off at once, but usually l>etter results are obtained if it
is torn from its liose by traotion. There is little danger in this way of
Cfts«
-*
Fh>. we.— Ikh«ui' Skibk, wtm Extha Tent* (U atte, iui|rl« S8*>.
removing any of the normal tissues, for it is almost impossible to in*
elude within the snare anything but the polypus. Where polypi grow
frnin Itroad baBea, and are attached over the wliole surface of a tur-
binated body, the bone may be torn oft witli tlie snare if much traetion
is made. Under snch cireumstances the experienced operator, noticing
the increased resistiuicc of the normal tissue, instefid of continuing
the traction, will tighten the screw aud cut the growth as near its base
as pusi)ihle. 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 ap[>lieators (Fig*
568
DISEASES OF THIS NASAL CAVITIES.
309), wound with absorbent cotton, for swabbing out the blood while tho
opcmtiou proceeded as it is nsoless to try to cateh the tuiiiura wJieii
the tiosc is filled with blood. Whatever operatiou is purforiuetl, the
parts should first bo thoroughly uuo^sthotizcd with a -four to ten per
cent Bolution of cocaine, which is beat applied by means of a hypodor-
mic syringe fitted with a long, blunt silver nozzle (Fig. SJIO) bent nt tho
end so that the solution may be thrown up about tho base ol the
Fia, am,— torroM ApPLicArom !jt-tt*x^). Matte of coniCT.
JEmiiors. Sometimes both cavities may be chaired at once, hut 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 give8 the ]Hitient much less discomfort than one long
sitting. It will be remembered that the etfects of cocaine disappear
in about ten minutes, and after blood has once begun to flow it ib
difficult to amesthetize the purts again; furthermore, if too much
cocaine is used, its constitutional effects, even if not alurnniig, are ex-
tremely annoying. After the polypi have been removed, the putiont
should cleanse the nose once or twiue duily with Llie Kilicylato wash
(Form. 18T), or with a wash of Rodiuni bicarbonate, a teaspoonful to the
pint of lukewarm water.
Antisepsis and healing will be promoted by insaffiation two or three
times daily of a powder containing twenty per cent of boric acid, fifty
per cent of iodol, and sugar of milk Buftinient to complete the mixture;
together with the use uf a spniy containing about one minim of oil of
wintergreen, two minims of carbolic acid, three minims of oil of cloves
c:3s^3l^mii^Kp^
m. SIO-nvpoOBiuno Stbwor Of bIw). Long BllTer nonle.
tftjWJJIiijftii" 0^ liquid albolene. If secretion is profuse, ton minims of
tfliibenemny be added advantageously. The patient shonid return in
about a week, when it will often be found that sacs which were invisible
at tho time of operatiou have filled, and may bo removed. Jle should
return again in four or six weeks, so tliat if the polypi are growing they
may bo thoroughly cauterized with the gulvano-cuulery. Jf ihe sur-
geon 18 not provided with tliis instrnmeut, chromic acid may l>e used
instead. In some cases mucous polj'pi do not return after thorough
removal, but usually recurrence takes jdace. and oi)erative prncedurea
must be repeated from time to time uutU complete destruction of the
rowths is effected.
NASAL PAPILLARY TUMORS.
£69
2<ASAL FIBROUS POLYPI.
Fiynonyvi. — Fibromata of the unres.
Fibroud polypi are extremely rare la the narcfi, although not uncom-
mon in the uuso-phuryux. Geuertilly, growths iu the nasal cavity which
reauuible libruus tumors in uppcaniiice really occupy a lii^lologicul poal-
tion nii(lw:iy between niucuuj and tlbruus polypi^ termeil tibro-mucous.
Th&se growths differ from mucous polypi in being harder and bleed-
ing more ejwily. They should be removed, when possible, by the natu-
ral passages, with cutting forceps, snare, or galvauo-cautery ccrueur.
The latter is best when it can be accurately applied.
NASAL PAPILLARY TUMORS.
Synonifm. — Papillomata of the nares.
Nasjil piipillary tumors, though occurring more frequently than
fibrous polypi, are still infrequent, though Hopmann states that small
warty growths arc more commou than genemlly supposed, and he has
met with numerons cases (Virchow'ft Arrhit\ Band XCIII, 1f>fi3). He
also states that SchafTer, of Bremen, liaH observed them quite as fre-
quently. This is different from the observations of Mackenzie, Zuc-
Iterkandl, and various other laryngdlogists, and from my own expe-
rience.
ANATOMICAL AND P.^TUOLooicAL Charactekistics.— The t me pa-
pillary or warty growths arc stated by Uopmauu to spring invariably from
tlie lower turbinated body, though 1 have seen one such tumor growing
from tliu septum alone, and another instance in which acvcnil of these
tumors grow from the septum while others came from the turbinated
body directly opposite. They vary in size from two to fifteen tnilli-
metres in diameter. In five cases observed by Mackenzie, the tumors
were situated on the septum or on the inner plate of the alar cartilage.
Stmitomatology.— 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.
PiA0NQ»i8. — The diagnosis must he based upon the peculiar appear-
ance of the growths, which, unless they are moistened by secretion, ia
Bimilar to that of warts upon the integument, and npon microscopio
examination, which will determine their papillary character.
PROdN'osis. — The tumors tend to incronso in number, and are very
apt to recur when removed.
TiiEATMENT. — The gTowth maybe destroyed with nitric, ac«tic, or
chromic acid, the cutting forceps or curette, or the gal va no- cautery.
In one obstinate case under my eare, all of these methods were tried
. ii^^mUt n?turneJ again in four to six weeks
nM)Kth»p*ti*'Qi wa6 given n strong tincture uf
1^ ^*P|Jwirf [(> the piirt two or three times duily.
of chromic acid, tiuully erudicated tUo
SCASAL VASCLLAB TUMORS.
of the nose,
ia Ihe nose are extremely rare. In their remoTol*
^-t^ xWff ft""* '"* ***" exi>erience and a tabulated report
^^^«bT J. 0. Roe. <►' Uochester (.VeK* J yri- Medical Journal^
tg>^L.vowdtrs the eold-nire sunre safer, simpler, and more
tlM ih«nilvano-cauturT or other iigenta {ItilfrfUttionaUour-
vw>4vrf ■"'' .'"''•^''/''"^^i 18*^9). In one gnccosaful case reported
k^^^» CtaiiniU removal occupied tliree hours and there was no
i ■■mZ^^H lto*wning from nmilog)- only, the galvano-caatery would
""z^Ti^* tbo best instrument in aiich caBee.
NASAL OSSEOUS CV8T8.
OMeouB cvHts of the middle turbinated body have recently been
kMct of articles by II. Zwillinger, of BuUiipest, Charles H. Knight, of
\V« York, and Grt-ville Macdonuld, of London.
This varit'ty of tumor is rare, and its etiology, pathology, and
fTinptoniHtology aru not yet fully understooil. Charles E. Sajous
I'jHHual of the Cuifersaf Atfdical &t>HCM, 1802) quotes Maedonald as
fellows: " Whenever an ussLout! tumur preaeuU iuelf iu the middle
pieatus of xiich a sizu tliut it is ubviously something furthur than a simple
tfteophytic periostitis^ whether presenting an nssL-uus surface covered
aoly by mucous membrane or whether it is eoneeabtd partially or entirely
by polypoid growths, tlie probability is strongly in favor of c)*8t. When,
moruuvor, these apfH-arances are acoom^ianied by a jmrulent and fetid
diaeharga, one may safely surmise that he is doling with a suppurating
cyst or alwt-esa of the middle turbinate. The diiigntwis is fin.illy substan-
tiated by the removal of a portion of the walls of the tnmor l)y snare or
forceps.
"Tlie trRstment in simple enough in cases when the tumor baa nol
attained enormous dimensions. The simplest way of effecting removal
is to throw a strong snare around the miuss and remove as large a portion
OS possible. The remaining portion of the walls may afterward be broken
Away with foroops."
I have soen but a single ease of the kind, which was easily removed
with snare ai)d forceps. The cyst was filled with a soft, yellowish cheeqr
itm.
ITASAL BONY TVHuRJS.
A?l
NASAL CARTILAGINOUS TUMOns,
Synonpm, — EcchQUiIn»rniita of the nos«.
True c-artilaginnii8 tiiiiion< in tlie tianil ciivities are extromoly ram,
fcliDUgli a few cHses have been reported. Eciihoudrosea or cartiUgiuoiis
outgrowths, however, are very common, and will be conBidered else-
where.
.Anatomical asij Pathoixjoical CHAKACTERisrica. — Curtilag^iTioug
tumors closely reseinhle fibrous polypi; they are, IiDwever, sessile, gen-
erally grow from the rartitaginous septum, and if not int-erfered with
may attain an enormous size, causing great deformity of the face.
Symptomatolooy. — The symptomB urc those of nnsal obstmction.
Diagnosis.— The cartilaginous growths, when large, are liable to bo
mistaken for fibrous polypi, nialignunt gi-owths, exostoses, or osleomata,
Pnictically wo may exclude jihronmtn, because of their rarity. When
present, they bleed more eattily :ind arc less dense than cartilaginous
growths. It is to be obsen'ed that malignant tiimora are softer, bleed
easily, and grow rapidly. We resuJily distinguish exostose$ and firhan-
4rinti!ii by inspection as being simple outgrowths. It is distinctive that
hfintf fitmor/r are harder and cannot be penetrated by the needle like CJir-
tilaginous growths.
Ff(ognosi8. — The prognosis is favorable if the disease is detected
early, before great deformity has occurreil. There is no tendency to
recurrence when the tumor 1ms been removed.
Tkkvtwext. — Uomovat by galvano-cautery ecrasour is the most sat-
isfactory surgical operation.
NASAL BOXY TUMORS.
SgnuHt/m. — Osteomata nf the nose.
Nasal bony tumors arc ui^ually characteriKcd by ubalructton of the
nasal passage and severe neuritgic pains, Wlien occurring, they usually
devtdop about the age of pubt-rty, but they are rare.
Anatomical and I^athohmjical Charactkristkx — Osteomata
are usually ovoid in form, and they vary in diameter from five millime-
tres to five ceutinietrcs. They arc distinctly bony formations, some-.
limes exceedingly dense, yet at others cancellous; but they have little
or no coiineclinu with the osseous structure of the nose, and are gener-
ally attuchc<l to tho 84)ft tissnea 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 rod color, and is occasionally
ulcerated from pressure.
ETI01.0QV. — Tho etiology is unknown,
Symitomatology. — Early, tho bony growth commonly cunses intoU
572
DmEAHES OF THE NASAL CAVITIES.
enblo itching of the nose, which is soon fnllowLHl by syniptoins of ob-
itruction, with impnlrmcnt of the sense of smell, urn) frequent epielasiE,
Ka it bc^ns to pii^s npon the surrounding pitrts, neuralgic puina Bome-
lioics bet'omt.' extremely eerere. Ineome instances, bowovor. llje nenta
of tieiidaLion urc ()un)lyzod, and no Bufrcnii<: is experienced. As tho
growth eiihirges, the nose muy be distorted, the check may become
prominent, and the uyeball crowded outward. In some caeea con-
tinuyrl pressure museg ulcenition and tinnlly perfomtion of the oxler-
nal parts. Such tumors are usually attended by an offonsivo diiicbHrgc
By inspection the tumor may be scon. Its density or iumovuhility can
bo aaeorhuiicd with the needle or pmbe.
Di.MiXosis. — Tho bony growths may be confunndod with exostote^
rhinnliths, or cancer. They may bo distinguished from Kxwtoses at Ch«
outset by their maT:ihiIity, and later by thfir different form, larger siu,
and darker color. We can distinguish rhiuoUlhs by an absonco o_
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 ■
eanceroua tumors grow much more ntpidly and are usually very soft, I
In all cases they may be easily puiu'tured by the needle. They, like
osttfomuta, cause extreme piiin and an offensive discharge.
T'ltoiisosis. — If the tumor ia seen early enough, it may be readilv re-
moved through tho natunil passages, but, when large, oxtemnl incJeions
are nceessary and scars remain, unless it can be destroyed by a dental
burr. There is no tendency to recurrence.
Thkatmest. — The Bofter forms may be crushed with strong forceps
and the fragments easily removed, but in the hjird variety, which is
most frequent, this la difficult, if not impossible. If not too large, they
nitty be ground down or drilled through with dental burrs or trephines,
and subsequently broken, but, if very large, on external inciaion iv
ns'jally necessary for their removal.
NASAL MALIGNANT TUMORft
Cancerous growths of tho nose are characterised by rapid groi
obstruction of the nasal cavities, an offensive discharge, frequent epi-
ataxis, and usually by severe paiu.
AsAToHH^AL AND PATHOLOGICAL CiiARAC'TEBiSTics. — They Com-
monly grow from the septum, but somelimos from the outer wall or
floor of tho nueal cavity. They are usually sarcomatous, but somctimea
carcinomatous. They tend to increase rapidly in size, and soon -en-
crou--h upon surrounding structures. They have a pale, slightly
Qodnlar or raspl jerry-like surface, are of soft consistence as a role, and
bleed freely when toucheil with the probe; their microscopic character-
islica are the same as those of similar growths in other parts of the
bodv.
NASAL MALIGNANT TUMORS.
673
Etioi.oqy. — The etiology is unknown.
Symithmatouioy.— At first there arc alteration of the Toice, impair-
ment of the sense of smoU, and sensations of stufHuess iu the nose com-
mon to all tumors in this locality. Other symptoms, however, rapidly
develop. A greenish, offensive discharge is apt to soon occur, frecjueiit
epistaxis tiikcs ptiiee, and great pain is often felt in the infnt-orliital
region. As the disease progresses, the hony slrucinres are pushed in
front of it or sepftrated from each other^ the eyeball protrudes, and
the mass, perfoniting the base of the skull, may extend to the brain.
l>cafTies8, liysphagio, and dyspnoja are all symptoms which may occur in
the progress of the case, and ere long conslitutiouul symptoms appear
indicftted by lo»s of appetite, the doTclopment of fever, and a marked
cachexia. Upon inspection, a tumor may be detected, usually of a liglit
pink hue, but sometimes darker, even brown nr black; highly vascular,
bleeding ensily when touched, and commonly soft and friable. Malig-
nant growths ulcerate early; the nicer presenting raised, ragged edges,
und a simions base.
Ur.\«sosiR.— Malignant tumors of the nose are to be distinguished
from rliinoliths, impacted foreign bodies, abscess, and benign growths,
M'lien the natial cavity lias been cleansed and well illimiinaled. we find
the appearance of a rhinulilh or impurfivl forntjn Ittydtf, and tliH eensa-
tiou it CDmmuni4:ates through the prolw entirely different from that of
a malignant tumor. An ftlt^t:em 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,
docs not bleed, is elastic to the touch, and is not attended by the symp-
toms so commonly found in nialLgnant growths. We may distinguish
heuujn tumors by their color, density, slow growth, and other symptoms
already described. In malignant growths, after a short time there is an
enbirgcment of tlie lymphatics, espocially those below the angle of the
}ftw. This doc« not occur with benign tumors.
Pi{OG\osi*i. — The disease nsnally nins a rapid course, terminating
within six or eight months in death. Sarcomata appe^ir to have been
eradicated iu some cases where taken, early, but carcinomata are always
fatal.
Trpatmbnt. — Astringents and sedatives may be apjilled as palliative
measures, but thorough eradication, when pnicticable, is the only ireat-
ment that afTorda any chance of success. Partial removal only aggra-
vates the disease and canses its more rapid growth.
li. I*. Mncoln reports a ease of molano-.iiircnma of the lower and
middle turbinated bones and floor of the nostril which, returning after
eeveml operative procedures, woe tlually completely cured by the nso of
the gnlvaiio-cautery ecraseur with cautcriiiution at the site of removal
(Transiictious of the American Luryngologicul Association, 1883).
CHAPTER XSXIY.
DISEASEiiOF TUE NASAL CAVITIES— G)B^i»«»(t
SYPHILIS OF THE NOSE.
A LOCAL mtt&ifeet&tioQ of coiistitutlomil syphilis in the uose may he
primary, eucoudarjr, or tertiury, ivnd may be cougeuiUil oracqtiired. It it
chtiructerizt'd in mild cuutiB by simple ubstriictiuii of tliu imrcs, and in
the more severe by extpnsivo ulccratiou iinij necrosis of the bunea a^^^
Anatomical and Pathological CHARArrERisTirs. — Tlie mnoons
mcMiibrane may be thickened iu piitelies or may be ulcerated. Condylo-
mata are soinetimca observed, and if the perichondrium or periosteum
benmih Ibe thickened patches becomes the seal of suppuration, death of
the cartihi{;e or bune \» the natural result. This Jiecrotfis may also fnU
low extension of the ulceration from the Kurface. Sometimes the pro-
CCAS is one of gradual molecular destruction or slow caries, entirely es-
caping observation during life. In such cases the bone, gradually
devitalized and ab^-orbed, is replaced bv exuberant granulations. fl
Etiology.— The sole cause is the syphilitic virus, but the severity ™
of the disease often appears to depend upon individual constitMtional
peculiarities other than syphilitic. According to Mackenzie, the stru-
mous diathesis seems to render the subject particularly liable to severe
forms of nasal syphilid; and tn countries where the disease is imper-
fectly treated, as, for example, in Epi'pt and Mexico, it becomes virnleut
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 passea for what the
narve terms suuQIes. Tertiary manifestations are seldom noticed i
until several years after the initial lesion; hut 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 obterTed
at the angle of the nostrils or npon the anterior portion of the mucous
membrane. Rvidenees of the disease in the mouth and throat and upon
the skin are usually present at the same time. In the tertiary stage,
i
SYPHIim OF THE JfOSS.
575
there occurs necrosis of the cartibgiiious or bony septam or of the tur-
biiiiiLed budiott, iieconipanied by ii tnost offensive odor of decaying tissue.
Extensive deetriictiuti vl the luiiuil bones ciiuiies fiillin;^ in of the
bridge of the nose, aud the onil cavity iniiy be entered by jmrforalioii of
the piibite. Deep, foul ulcers, with nigged edges and a dirty, gray biiBe»
are iisnally present. Before extensiro destruction has taken pbicc, the
turbinated bodies are often no uwullen as uearly or quite to occlude the
nares. The dead bone usually presents n blackish, uneven Rnrface,
though in eonie infiUincee notliing ci\n be seen except an offensive crust
of dried antl deceiving secretion, which must be thoroughly washed awny
before satisfactory examination can be tHRde; it can sometimes bo de-
tected with iL prohp, Uy the roughs grating sensation wliieli it coiii-
niunicatcs; occasionally the lesions are so siUiated that they cauuot be
discovered. Jn rare instuuces an offensire odor is constantly exhaled,
even though Ibo part« are apparently kept perfectly cleansed by Jre-
C£uent ablutions.
Diagnosis. — The secondary stage of the disease is not common,
and, when it docs occur, U very apt to escape (dMwrvatiou. It can
be distinguished from chronic rhinilU by the bistory of ila sudden
onset with very pronounced symptunis; by its wary obstinate course;
by the discovery of mucous patches or condylonmta when these exist;
and by the acknowletlgmcnt of infection when this Ciin be obtained
from the patient. The tertiary affection may be confounded with lupus
or simple atrophic rhiuitis. We can distinguish iHfntg from syphilis by
its occurring at an earlier age tlian any form of syphilis except the
hereditary. Again, in the begltinirig. the j>eculiar reddish papules or
tubercles of lupus are quite distinct from any syphilitic numifestiitions;
and,later^ the niutkcd preference which lupus showtt for the cartihige ie
characteristic.
The offensive odor caused by atrophic rhinitis is quite different from
the stench of tertiary syphilis. I^'pon cleansing the parts carefully, na
necrosed tissue will be found in oza>na, whereas it is ver}* apt to be
present in syphilis. In all doubtful cases, the history, the presence of
old cicatrices, or indnration of the tongue, pharynx, or larynx, or brown-
ish scars npon the skin or periosteal nodcs^ and finally the beneficial
action of potassium iodide usnally enable us to make a diagnosis of
syphilis.
Pkocnosis. — Syphilitic coryza in the adult usually terminates within
two or three weeks. Secondary symptoms and those of the tertiary
stage in mild cases, us a rule, speedily disappear nnder proper anti-
gyphilitic 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 bo endangered.
Treatment. —Syphilitic coryza requires no other treatment than
the internal administration of tonics, aud the local use of mild alkaline
576
DIBBA8ES OF TH£ NA8AL CA VITIES.
sprays or washes. Jndocd»auy secondary symptoma asu&IIy roqiiire qvAj\
luild coustiliitioual treatment, uud tuuchiiig of the coudylomutou^
growths or mucous patL-lies with tiiicture of iodine or eilvor iiiirale.
Tertiary syphilis, however, demiinda active coiiStitationul and local
treatment It is well to bc>gin with potassium iodide in uiodL'rate
(|uaiitiiy, and steadily increase the doses until the repumtivo procestj
is weU establishrd. To this end, not infrcijui'iitly t)ie drug mostl
be pushed to its physiolngiud limit. In all aises it or oilier'
gpeciJic medication should bt? continued in larger or smaller do«e*j
nntil a complete rure is effected. Small doses of mercury, or off
gold and sodium chlcridc, will sometimes bo found cspeciully bcU4^
fieial. At the same time, bitter or ferrupinons tonics are often de-
manded, and L'od-livLT oil wlien well iMiriie is useful. Good nutri-
tious diet should be provided. Local trejitment is extremely impor-
tant. The nose should be thorunghly chiunsed two or three timos daJW
vith the sodium salicylate wash (Form. 187) or a similar alliaiuie
^^ tWHWi-ttm
Vto. 411.— Insau' VimAX. OiKanito-FoBCKpa (S-5 dsp).
solution. Under this treatment supertieial nluers nsuiilly speedily heal;
but where deep ulceration exists, iu addition to cleansiug. the som
must be touched with Home stimulant or caustic. Kor this purpose the
most commonly employed caustic is silver nitrate fused upon the end of
an aluminium or silver applicator, hut in the majority of cases ' prefer
strong tincture of iodine to any other local remedy. The ajipllcntiuus
shonld be made daily for ten or fourteen days, until evidence of cica-
trization appears, and then even.- other day for a weolc or niore. uud
subsequently lei^s often. Kvcn largo ulcers under this treatment usually
heal within three or four weeks. If dead bone is present, it must be
carefully rumored with forcfps (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 u powder consisting of one part
boric acid and two ptirts iodol or iodoform; or with this, in case tbero is
much swelling, may be combined tno or three per cent of cocaine, and
five per cent of aristul to correct the ofTeiisive o<lor. Schuster si>«cially
recommends si'nipinjr the ulcer!- with a t»h;irp spoon, and nfterwnnl de-
stroying liny indunited tissue that nuiy remain with the g.dvano-rantory
or silver nitrate ( Vierteljaltreif»ckrift far Itennatohfjie v. Sjtphilia^ 1637),
t
CONGENITAL SYPHILIS OF TlfK N<)SK. ^t7
WI16Q the (lifieiue hns been chucked, if wrioua Uvforuiity pxiils, it mny
sometimes bo remedied bj an nrtitti'ial nofto, or in mmc vtac* by rhino*
phtstic openilions, wbicii arc describetl in the toxtboolta of surj^ry.
COS'OKKITAL 6YMULIS OK TDK NOHI.
Htirediturv syphiliB usuuUy mukes its niipmntiicu in oliildri'ii within
the first two or three veeks iiftcr birtli, uiul nelitom hiler thitn the
second month; but occnsioniilly not until the L'hild is eight or ten jean
of age, or at a later period, about pnborty.
Etiology.— The disease appears to be contruetod, in miiny instiineoi,
at the time uf birth, thoujih commonly during intnv-ntorine life.
SvMPToMATOLOOY.— Usimlly within a wct-k or two after birth iho
child appears to bare a bad cold in the lipud, (he naref are iitopped,
and thert> iipprarB a thin, irritiitin^ diat-hurgr, which notm hccunioN
mnco-pnrulent, rjuisirig rednefta, saroncuw, and eroHion of tlin noHtriU and
upper lip. The child is said to have the snufflfw. As the leeroLioiis
become thicker, the nH^uiI cavity is blocked with scabs, which eihale an
offensive odor. In some instances carles of Llio curtilageN and bones
ensues, not iofrequently causing di^lignrement for life. 8ucli children
are usually small and feeble, Hutlcr from truintsmus, and froqutnily have
a copper-colorud, i>apulur eruption upon the skin. Mucous patchDH are
probably present in the nose in most cases, but it is bard to got a view
of them; similar patches may often be found at the anus or at llio
angles of the month or eyelids.
DiAoxof^ii). — The dia^osis must depend upon the historjr, ih«
symptoms, the obstinacy of the disease, and ifao cITects of treatmtrnt.
PKOO506U.— The afTection runs u chronic course, with little or no
tendency to spontaneous recovery. Such children oft4>n die young; but
onder judicious treatment some may be ap|Kirently cured. In a con*
aiderable nnmber the disnnler may be checked, but it eontioaei to ro*
ftppevflt interyali for many years.
Tbeathext. — Mercurials and potasaiam iodide arc indicatod inter-
nally, and local treatment is generally deairable, though in younjt cbil-
drrn it is very difficult to csrry oaL Hackonzie praCen mvrcary
with chalk, which be administers in doaea uf from one to two gnina
twice daily, to which be adds, it this causes diorrfaffiA, one grain of
Dom'a powd«r or au additianal grun of chalk (I>is»««e« of tb«
Throat aod Noae, V^ol. II). Kri^'baen rtooniaieods thf i-utzttmi sillies'
UoB of mmnmtj in the foilowing nuumer propoiad by Brwlie (.Hcimoa
asd Alt «C Swigary, LoDdon, \i<1i): a diachm of awrcarial oiutmrat is
ipNttd wpoD ■ flsfind roIWr which is itntdMd annnid ttw child's thi;^
joM aboT* tba ksar, tb« ointment next to tiw akin. This is ren«w«d
daflj far tv« or tkxm weaks. afur which pot— inm iodida is admiai^
l«nla»3k,eod-ltnroQ,ormalt. Milk and wstor arc th« bealrtliielM
lor tks adaunirtniian id the drag to either childrm or adolta.
i7
TUBERCULOSIS OF THE NARE&
Tuberculosia of the iiiires la a rare affection cbaracUrixed by the far
matiou of tubi^rclMi of Tiirying sixe, with ulrerntirm and a fetid d
Jt is usually secontlarT, though Tornwoldt hoA reported a case in
the nasal symptoma preceded any other; and I have seen one case in wbicH
no evidence uf puhnonary lesion eould b« discoverod for feevoml mouth*
after thu appcarancu of the tuburculur ulcer in the nostril. Of thirty*
eight caeeft of nasal lubun^uluais collected by Michelson, uf KOniiniberg.
nineteen showed no tuberculosis of any other organ (Jrt/erHaJiottmk
klinUfhe lintidarhau^ Vii-umi, IHK'J), and 1*\ Ilulin reports fire prinkary
caaa^ {DeuttL-he tnetUcinirtbc Wuchi'iiKchriff, Lci{tsic, 1869).
Akatomk'ai, and l*ATnnr,nnic\i. Chakactkkistics. — The tuber*
cu]ar deposit may he obnerve<I either as thickening, with or witboat
ulceration of the nnicouB membrane, or In the form of tnniors Tarring
from two to thirty millimctreH in diameter. The disease in:ij attack
any part, but most frequently the soptnm is the seat of the tronble.
The nodules are generally sniull and of a grayish white color; the ulcers,
which may bo single or multiple, have a grayish base and fivqucnlly
raiaod odgoa.
Etiolooy. — The bacillus tuberculosis is uow gonemlly accepted as
the ultiuuitc cause of the diaeiue.
STMPTOMATOtooY.— The affection comes on insidionsly, and gonor-
ally progreAses slowly^ causing all the symptoms of offenfiire catarrh.
Tubercles or ulcers, as already described, may bo dctectt-d by careful
inspection. The ulcers are not generally painful and at first are not
accompanied by constitutional symptoms; tiut sooner or lator tubercu-
losis of the hings or larynx is developed, an<l runs its ordinary course,
DiAQXOsia. — Tuberculosis muy always be susjiected when obstinate
nlccrs or tubercles are detected in the nose, especially in EcrofulotiB pa-
tients, or those with recognized ttiberculosis of other orgnnp providing
syphilis has been carefully excliide<l. \\\ nccnratc dingnosis 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.
pRonNOB!8, — The progress of the disease is genendly slow, and may
extend over many years: but it osually continues until other or^iru
finally become involved, and then runs a more rapid course to a fatal
terminution.
Tkk,\tmf.nt. — The nares should bo kept clean. Tumors which by
their size interfere with respintion shonld be removed, and ulcers ahonld
be thoroughly trcjited with luetic acid, in strength varying from thirty
to one hundred per cent, with or without previous Bcrai)ing;, nccordinjf
to the indications. Treatment of the ulcerated surface by ourofully
touching it from time to time with the golvauo-cauter)* has been recom»>
EMPYEMA OF THB AlfTRlTM.
f>7&
mended, aud is adrantagcous in some cases. InauSlations of iodol or
indofnrm are al^o indicated; but whatever method is udopted, tho
tilcera urc verjr diflicull tu hciI, iind in many ca»cs tho troutment does
no appreciable good. When p:uii is j-reaent, Huofbing romedica are
required. Of prime imjHirtance ani all Ihoao mean;s by which tho
system may be fortified against tho spread of tho disease. It would
appear that tliese cassa, if any, might bo cured by the use of Xoch'a
tuberculin; hut in a single case uf the kltii.' iu which I udminiRtered it,
the results were most disastrous, and the progress of tho disease was
very much aooelerated by the presumed remedy.
RMPTGMA OP THE ASTRPM.
Empyema of the antrum, which waa accumtflly described by Johu
Hunter, connists of a eoUection of pus in the aiitnim of llighmore,
characterized by a purulent discharge having an ofTeustve odor, usually
^
''ScJJJUB
F)0. tic— Cxou^L' : ^ ]'■ s ' '."TiKCormoiiBcaixoroKWASDAaoirTnALrjJiIxciintFKoxT
<tr TUB Opkmxo or thi Narcx iirra tnk Nami PttARritx, Protn n phnu>Rni|>h nt n fnuern iwxTtion
prtiparvd by C. H. fitowtll, of Wuhlngton (4-6 nAUirttl aixel. a,a, Uiddle lurbla«c«d bodlui: b.b, bf
lerior turbbutted bodies; c,c,c,c, et&mold oelk; d.d, antra of Hlfcfanwre.
from one nostril. It is more commonly found upon the left Bide, but
.'recjuently upon the right, and occasionally on Uotli sides. The antrum,
as shown by Giraldes, is sometimea divided by 8«pta of bone, bo that in
this disease two or more pockota of pus may exist (Des Malwlies du Sinui
IklaxiUaire, Paris, IH.*}?). Dehivan, iu a paper read before the Amt^rican
Medical Association, iSection of Laryugology^ in 1889, showed that the
antra are liable to various irregularities in furroatiou, whirl) accounts
for some nf the peculiarities presented in tho symptoms ami Blgus of the
di»^aae. Tlie rnlations of these cavities to the nates and surrounding
parU are accurately shown in Fig. 79, and Fig. 212.
Etioloot. — Diseaae of the teeth Is the principal cause of the affec-
tion; but in many instAUcea it originates in morbid changes iu the nasal
DrSEASlSS OF THE NASAL VAYiTIES.
cavity or adjoining minuses, snch iw caries, polypi or graQoUtion tiseoe
in the middle moatns, or snppnnitiTo inflammation of the etUinoid odU
or middle nietilus, tlie \n\A fioni which enters the antrum.
Symitomatology.— The affeclion usually comos on inaidiouely wl
lustB for several months, or possibly years, before it is delected. Vthea
it has existed for sonie time, there miiv Ikj fouud considerable disturb*
anco of the general health. In most cases, pain in the cheek isoom-
pluinod of, sometimes radiating toward the car nnd frequently attcndri
by supni-orbital neuntlgia. But comparatively few of the pntienlsso/'
fer from toothache ur swelling of tlie face, the most common eubjec-
tive Kyniptoras being more or lesa ohatriiction of the nose, a foul
iiraell or taste seemingly from the throat, and discharge from one mw-
tril. The fetor is often appreciated only by the patient himself. «nd
is present in many instances only at certain honrs of the day. The di»-
churgo also is usmiliy periodical, occnrring in considerable qaantiiiM
two or three times a dny, though in many iuatanccs there is a continiwl
but slight flux. Sometimes this ia only experienced npon assuming cer-
tain positions, as when lying npon the affected side, or even upon the
sound side, or, again, npon bending forward with the head low down.
Sometimes the princii>nl flow is into the naeo-pharynx, where It mij
excite reflex cough, or even nunaea and vomiting. Upon inspecting the
nares, a pumlent discharge is generally observed in the middle meatus,
trickling down over the inferior turbinated btnly. Oftonlime* this, on
being wiped away, speedily reappears. Po]y]ii or granulation tissue may
be seen in a largo percentngo 6i cases, and with the probe caries may
not infrequently bo di'torteil. Ity tjipping over the miliar prominen
with the lip of the finger, pain or tendpmoss is usunlly caused, which
is not oxpericnood on the sound side. MoBride, of Edinburgh, not
that generally there is marked reilnesa of the gum corresponding tu th
diseased antrnm {Edinburgh Mfdical Jonrnnl, April, ISSii).
Diagnosis.— The essential }>oints in the diagnosis are the pain, fetor,
and disohfirge from one naris. The aflleotion is liuble to be mistaken f
disease of the fronUd sinus or of the anierior ethmoid cells, or f
polypus, ozsenn, foreign bodies, syphilis, cariea, or disease of w
sphenoidal sinus. A useful method of detecting pns in this locali*'
coDsiiils of iujeclinc, tlirough the normal opening in the middio nicat
a solutiuu of hydrogen peroxide, which, in case pus is present, will im-
meduitely cause a discharge of froth through the opening. '^'•""J**—
illumination, as suggested bv Voltolini, is often, though not universallr^
of great value in •iccidiiig obscure nwe^. It is practise*! by means of »
small electric lamp placed in the nmuth while the i>atic"t ia in a dark
room. The effect of this is to cause a rosy-rwl «uffu-*io» of the fa w.
cheeks, lips, and inferior eyelid in health, but the check and infi^^
eyelid will remain dirk in co*- the untruui i^ filled v\Vn p««- ■* J*>
cimdio power lauip, five to eight volu according to the strength of
EMPYEMA OP THE ANTSUiT.
581
battery iisetl, is best for tliia purpose. U may beiittached to some form
of tuuj:ue depressor. That abowii in Fig. 21^, wliiob is iosertcd into
the ordinary galvano-cautery handk*, I have fouDcl most convenient.
The patient may be examined in u dark room, or more easily niih the
aid of an ordinary photographer's focusiug-cloth thruwn over the heads
of both patioiit an<l physician. This method is of peculiar value in
det^ctiug cysts of the antrum, which are mid to render the ilhimiua-
tiou even more brilliant than in health, while solid tumors or pus prevent
the trangmission of light.
£mpf/emn of ihe fnmtal sintiSf nnnitended by closure of the dact, is
60 extremely rare that it m:iy be cscluded; when the duct is occluded
the external signs are so marked that the ftffcction cannot be mistaken
for disease of the antrum.
We frequently find futppurathn of the anterior ethmoid cells associated
with empyema of the antrum; bnt when occurring by itself it is distin-
guished from tbe 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 uf diagnusis the introduc-
tion into the antrum, immediately above the inferior turbinated bone.
Fid. 3ia.— iNOAU' Ki.Knnic Lamp (i^ulo'). Kor truii-llluiaiiiBCloc.
of a strong, carvod, hollow needle, to which is attached a small exhaust
syringe (Diseases of the Nose, l^dO).
Empyema is distinguished from pnh/pus by iriJ?pection of the nares,
bnt it must be roniembered that before any upcruliou has been done,
whenever polypi are attended with purulent secretion, pus Mill usually
be found in the antrum at the samn time.
An extremely fetid breath, which is appreciated by everj' one except
the patient, is continuously caused by ozarria. 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
Imlivs in tfte migc, but they may be easily distinguished from disease of
the antrum by inspection, and palpatio?! with the prube.
An offonsive odor and excessive discharge from the nares may be
caused by nf/philist, bnt it nearly always affects both sides, and inspec-
tion reveals ulceration, deotl bone, or other evidence of disease of tho
cavity itself, instead of tho comp:ir!itivcly healthy appearance found in
empyonm of tho antrum. Caries is also usually detected in syphilis by
inspeotion, and palpation with the i>robe.
Disease of the gjihcnoidul sinus Is very rare, and when it does occur
DIHEASKH OF THE NASAL VA VJTIES.
tho dlRchurgo fluwR into the throat, but not from the nostrils. It
wuiiM notc-jitiM) piiin iit the t-hcek or interference with tho transmtEsiou
of light; thcRtforo, it may rojidily he excluded.
pHuoN()Hir>.^-Aeuto CAAC8 Homotimcfi recover Bpontaneoufily within a
•hort time, but tho Affection may extend over mitny yeiire unless appro-
priiite tri'fttnictit is miojiled. Even under tlie most approved methods,
vilh froL* druinitgp, It in sonietimea impossible \q i-heck the forma-
tion nf j>llH.
Thkatmknt.— .Some cfiBoa have been cure<l by wnsliing out the an-
trum throiigli the nuturiil opening with detergent solutions or with
hydrogen ])oroxidc, but usnally free drainage must be established. Fc»
thiM piirposf, Hunter's method of opening theiintriun thruugh thesorkot
of kWw uf thi' mohirs is still considered, beil, the only ubjection urged
liguinil it being tho annoyance caused tho piitiont by tho offensive dis-
rhurge into tho mouth, und tlie possibility that particles of food may
otK^apv into the antrum, (.'liristopher Heath recommends puncture of
tho nnlrnm iihovu the iilrcolus (Transactions Udontologicot Socioty, ■
JCovenibcr. ISSII). 'J'he nmiu objection to this is the difficulty of keep-
Uig i\\v ujK-ning juitL-nt. The antrum may be opened through tho
a
I
1^ tl4.-UlLil>iAU>HB0M« Umili.
Inferior meatus hy means of trephine, drill, knife, or a long, carwi
•tn^ng tniear, us rocommendw! by Kmusc {firrliner kiittische Wack^n*
m^tri/l, ISj<11). The latter {KKaitiou obviates the objeetion to Hanter's
tnothiHl, but the opening is loss rasy of acce«s, and is more difficult to
mitihlHin until hualing has ocenrrvd.
My own prefim'Ui'o is for Hunter's method, a looih or a root being
r\trtii'ted whrn nevHw<«ry, or an opening being made through the space
left by n tooth whioh bus bwn already lo*L Various forms of trephine^
IJHUs und denlrti Uwr* have l>««n usoil for making the oitouing. but in
M* il\!bHu'»*)> li*»> •«mU «M instrument is vmj'Kmtl. I use Brunard's
\M U\W^\\\{\\ {T\]t^ KUi, which makes an opening ucorly a quarter
Nol withstanding statements to the contraix,
> > tx iminful nnless an anascthetic has been used.
iiit>vl^l AHii'kthi^u umy \ve tmlHoed by chloroform, ether, or nitnMs
1 '■ lbi> ulToei* ttt (luOader are uitually too evanescent— bat in
thi-tNi tbft \MK\ia limy Ik* fufliriently benumbeJ by injeetln^
y. I.. I . L i:,i. in tw„ ,if ihn?c places on uach side of tho aIveolBa,m
•..lull. .11 ..f au^int', almwly rt*commended (Form. 143). The opeaiap
Iwving Iwn made. llt^. tuurum shonld bo wflsbed out and a ^>U ar
rubber tulH> iniiv,iui.,'d to nuiintain its patency. If this pnoaatMBB
tteglecttd. the opmlng is almost sure to rhtno before ihe disease
red. ^Viiy good dentist can make a suitable gold lube whidi caa to
EMPYEMA. OF THE SPJ/EyolDAL SINf/SES.
583
fastened with clamps to the adjoining teeth. I have recently nsed with
gi-eat satisfaction rubber tubes (Fig. 215) of six millimetres diameter,
ninetftn ti> thirty-five milUiuetrea leugtb, and four niilliniotreji cjilibre,
willi Uaniies ai t'ltch end. With u wire, the end ot which has bycn bent
to a right angle, the diatauce through tlie alveohiM niiiy l>e measured
and a tnbe of proper length selected. The flange at the upper end uf
thi? tube is thinneJ, by cutting nway \U upper surface, wnlil it uiay
be squeezed into a gelatin eupsiile of propter size. This is then oiled and
readily puisiied through the opening into the antrum. A probe is then
Vw, flS.— lltQAU'' Dkaikaok Trim niR A.iTiidM. Full 'llAnirte'r; tbriw lUfTnrmK Ipofctlis.
passed through tlie tube, t}ie gelatin eajvsule forced off, llie flange opens
out, and the tube is thoroughly secure. Tlie^e tubes are inexpeusive
and very much more comfortable to the patient than gold. The sub-
sequent treatment cunsists of keeping the ciivity clean, and stimulating
the healing process by injections of iodine, zinc, copper, or hydrogen
peroxide in wsilcry HoUiliou; or by insufltiitions of boric acid, iodol,
iodoform, or aristol; or by Rdlntions, in liquid albolene, of carbolic uoid,
oil of cloves, oil of cinnamon, or torobono. If Ropta prevent thorough
cleiUising of the eavity, it may be necessary to enlarge the opening and
break ihem down. The patient should always stop the oponiug with a
pledget of cotton while eating.
BMPYBMA UF THE SPHENOIDAL SINUSES.
Empyema of the Rphenoidal sinuses is so extremely rare that no defi-
nite rules for diagiiosisi or treatment can be fominlated. These sinuses,
which occupy a poBiticui at the npjtcr bjick part of the nasal cavity,
just at its opening into the naso-pharyux, vary in number, size, and
form in different individuals (I''ig. 216),
Symptomatolooy. — Purulent inflammation of tliese cavities gives
rise to a persistent discharge of pus into tlie nares and nasu-pliaryiix. 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, aa shown in Fig. 210, is
thin, and in cases of long- continued empyema u gjwutaneouB opening
throngli it might be efleoted. The finding of pus uniformly in this
position, or trickling from it down the Hides into the posterior nares,
may suggest the true nature of the diaease.
Treatment. — Other affections l>eing excloded, and the dingnogis
established, the anterior wall of the sinus should be carefully perforated,
and the oavity drained and treated on the same princijdes aa empyema
5Si
DISEASES OF THE NASAL CAVITIES.
of the AntrDtn. Opening bis also been successfull}' effected through the
inner wall of the orhit in extreme cases.
INFLAMMATION OP THE FRONTAL SINCS.
luflummittion of the frontal eiuus is a coropnratively frequent afff
tioD, but owing to the dependent position of the duct in most cases tho
products of inflummatiou re:idily escjipe and tipontitneouj recovery speed-
ily follows. Humetimeg, however, swelling obstructs tho duct, and the
secretions may bo pent tip. Such oases I have seen readily relieved by
«•'
:(:
e
-rA:
^rh
L*- "<^
h^..
'^
■\^
\.
no. IIS.— Cbom SicnoH ur Hkad. From pliobiKraph of (rtvvn wctton prep*ml bj^ C. U.
6to«rell (15 nntursl Ktzei. a. HUldle Curbtnated body: Muferior turtinaUU Ujdy; c, Mi|wriar
turbluntcd b'xly; ri. splicaoitt CfiUs; e, fronuU ■inuft; /, Eiutoclilan oriOoe; p. naM>-pharyaz ■•
cloaed lu dioglutitlon.
the local nse of cocaine, which reduced the swelling euffioiently to allow
free discharge, and, this condition being maintainod for two or three
weeks, recovery ensued. In some instances, pornianoiit obBtruction
of the duct occurs, and then empyema of the fronUd sinus fullowa.
When this results, the pent-up secretions cveiitnully cauRe a tumor
at the upper inner angle of the orbit, disfiguring tho patient, and
displacing the globe of tho eye.
The occurrence of suppuration will be indicated by rigiirs, exces-
sive headaches, swelling, redness, aud some local a^dema and throb-
ling pain. Violeui paiu in the course of tho supra-orhitid and nasal
CHROSSC SUPPURAriVB BTH2I0!DITIS.
585
nerves is a common symptom. In suppumtion caused by simple catar-
rhal iuH&mmHtion, a emiiU opening made with u drill from tho nasal
cavity, is usually sufficient to alluw the coofiuud secretions to escape;
hiu when it results from syphilis, energetic measures are domaudod,
otherwise fatal involremeiit of the brain is likely to ensue. Then
the frontal hone should be laid bare, and the cavity opened with u tre-
phine in its most dependent part. Afterward prorision shonld be made
for free dniirmge into the nasal cavity, :t 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 chnracterixed by a persistent, somewhat offen-
sive discharge, and obstinate neuralgic pains in the temples and furehend.
KxiOLOOT. — The causes are unknown. In two cases wliicli have
couic under my observation, 1 am sutisfied ttiat the diseaKe was the direct
result of innammation of the nntruni, and not the cause of the latter, us
it is believed often to ho by McDonald (Diseases of the Nose, ISKO).
The suppuration results from abscess of the antrum in eonsequen'ce of
the occlusion of the opening from the latter into the nasal airity, so
th:it it booonios tilled with pus which crowds upwar<l and finally flows
from the openings which are frequently present betwecTi the antrum and
the ethmoid cells; by pressure tliis pua causes necrosis and perforation*
of the thin bones which separate the two cavities. The relation of parts
will be readily unOerstood by reference to Fig. 213.
Stmptom.\tology.— Patients frequently suffer from neuralgic pains
in the tcmplo or over the orbit, which are more or less intermittent,
and sometimes [Kiroxysmul. 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 affliction were it not for coexisting diseast* of the ethmoid cells.
There is usually purulent or mnco-purnlent discharge from the nctse,
which is often fetid, but not so offensive ns in oztena. This flux may
be scanty or very profuse, is generally continuous, and nsnnlly conios
from one side only. Upon inspection it may be seen filling the middle
meitns and rnnning over the middle turbinated body. Often inflam-
matory thickening of the external wall of llie middle meatus is sceUr
whitrh sometimes communicates through the jirobe li sensation of bony
hardness, but usually it appears and feels more like a polypoid for-
mation or fungous grannlation.
Oi.iososis.— The affection is to be distinguiahed from mucous polyju,
atrophic rhinitis with oziena, from suppuration of the autruui, and from
k
empyema of the sphenoidal nnd frontal sinuses. It may ordinarily be
distinguished from wvcotis polypi hy the presence of pus; thU roort
be wiped ftway, anii cnrioiia Imhio wliich oftim exists, or fungous ^muu*
lations are to be rarofully sought with the probo. Not iiifrtsjUi'Dly
small polypi arc HKSOciated with tliia atTectioii.
Siippnrativo ethmniililia rmiift b« ilislinguialied from suppuration of
the rttitmm by careful infinity into the history and symptorna anil by
persiptenoo of the discharge after the hitter cavity is known i« 1h» liraled.
We readily distingnish nirophir rhinitii by the abnormal size of the uwnd
OftTitioe, the peculiar stench, and ooHections of decaying cmst* of tnuco-
pns. From empyemn of the sphenoidnl and frontjil sinuses this itfTcctinn
is distinguished acconling t-o Max Schacffer {fieutsche Medinixcht> Ho-
chrni»fJtrift^ Tveipzig, No. U, 1890), largely by the position of the pas*
whicli in diseasi! of the frontal tiiniis coveTs the more or loss swollun
mucous membrane of the sepLnni in the superior meatus, nnd in diH-Ase
of the sphenoid cells passes down the pharynx, while in ethmoiditU it'
spreads out iu the middle meatus.
PuoGKosis AND TuEATMEST. — It Is probablo that some of the
recover spontaneously, hut 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 Jkcen the
parts cleansed, and as nearly aseptic as possible; and by jndicious stimn-
Flv, 21?/— Kouaooi Cvnts' Wami Boitli iH f*^)- tlied tor thv ethmoid cctla.
lation to encourage healing, Tf disease of the antrum exists, it most
he remedied iHii'nrd we can hope to cure tbo disease of the ethmoid celU.
Polypoid growths or fungous granulations may be best removed by Btur«
or sharp spoon, or small masses may bo touched with thegalvajiOK»ut«rv
or with moDochlorocetic acid. Dead bono must be carefully scruped
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 pnu; but car*
niui«t be taken not to exrite timlue inllamnrntion, which might extend to
the bniin. 1 have found the most satisfniTtory results from injectinc
into the ethmoid cells, with a long, slender silver luinula attached to a
hypodermic syringe, about lifty per cent solutions of the hvdroiran
peroxide, and subsequently oily solntions containing oil of giiuliUpri*
LUPUS OF THE NAUES.
.18T
v\ !., oil of cjiryophyllum rn. v., terebene lU x„ ad ? i. of li<jiiid alboleno,
the strength being slightly iiicreiisfid or diminisbed according to its
effect. It sboriM not ciuise pain for more tlian lialf an hour afler-
wiird. At the same time the nasjil cavity fiboiild be washed two or three
times daily, by mejir.s of the nasal syringe or Curtis' wiwh-bottle (Fig.
217), with Ji detergent solnriun, smd a similar oily propamtion, or one
somewlmt weaker may be used as a spray by the patient moruing and
evening. A powder containing five per cent of aristoU two per cent of
cocaine, twenty per cent of boric acid, furly per cent of iodol, with sugar
of milk for an excipient, may be itdvaiitageouely used by the patient
once or twice daily as an insufflation.
LUPUS OP THE XARES.
Lupns of the nares is a chronic affection of the mncons membrane
usually secondary to lupus of the external surface of the iioao, and
cliaracterizcd by the formation of sninll, irritable nodules which sub-
sequently arc the seat of indolent ulceration, followed frequently by
a process of slow repair luid cicatrization. It genemlly occurs in young
persons of strumous habit, and is mf>fit liable to affect girls.
AxAToMuiAi. AX[> Patuolouk A I. Cii A HAtTHKi-sTiCi*. — Two Varie-
ties of the affei-tion are recognized; one known as hipuA nou-fiMttens, in
whi(?h atrophy of the affected tissurs, including bone and cartilage,
occurs without ulccmtion; the other as lupus exerfeiifi, yvhich usually
begins on tho cartilaginous septum in the form of small, red, irritable
nodules; these gradually coalesce, forming raised, uneven patches, which
err long becomH the seat of deep ulreratiiin. This procoss extends
slowly, destroying the soft tissues, cartilages, and m'en tbo bones, tbongh
repair is often iimugur.tted before the latter perish. The ulcers are
covered with crusts under which the destructive jtrocess is going on iu
some places, while healing may be taking place in others.
Etioloot.— Pathologists now genemlly recognize lupus as a tuber-
cular disease, but the clinical history of the aHucliun 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.
Symi'Tomatolohy. — The diseaseoccure in young subjects, progresses
slowly, causing the physic:il appearance idready desoriliefl, and it is at-
tended by a disclmrge more or less profuse and offensive. The ulcers
are not ii(<tuilly ]Kiinful. As a rule, the disease Hrst attacks the skin
upon ilie cbeuk or noso, but it occitsionally commeuccs iu Ibo mucous
membrunu.
DiA(}N~osT8. — Lnpns is liable to be mistaken for syphilitic affections
of tho ncRC, epithelif)ma, and true tubercular disease. The e^seutiiil
points in the diagnosis are the history, the development of red, irritable
nodules, the progressive nlccration, and the slow process of repair.
J)ISEASES OF THE NASAL CAVITIES.
There is nsuallyu giwoific history in nffphilis^ whi'ih may be obtained
by the udroit physiciftii ; thickening' of the inncotie mcmbmne in putchc«
or extensive swelling of the lurhiruLted bodies comes on rapidly «nJ is.
quite unlike the slowly developing, smtilU red lubercU'8 xenn in lupus.
Syphilitic ulecraiioji, though rapid, may usually be soon checked by ap-
propriate iucul uuU iuternul remedies, which make iiu impre^iou upon.
luputi.
Wc cftTinot alwaya iliatiiiguiBh fpiififltmna from lupua in the be-
giuinng, hut litler a short time the characteristic foutuiija of the two
dise&ees rcudcr tlic diagnosis t*asy.
The small red Tiodules found in Inpns do uot precede true tuber-
cular tilrcrittiu/t, in which the ulcers are o{ a lighter color and present
few if any of the bright red granulations usually seen in lupus, and
show no tendency to re|wiir. The presence of pulmonary tuberculoaia
would be a valuable point in the dtugnosis.
Pboososis. — The diseaso continues for several years, bnt can sonie-
timea be checked by appropriate trraitnient, though even when the
nlcoratiou has hwiled tlicro is great tendency to recurrence, especiullr
if the cicatrices remain red and indurated. With advancing age there
ia sometimes spontaneous recovery. In some instances it extends to
the pharynx and larynx; in these, recovery is not likely to take place.
Treatmk.vt. — Arsenious acid and other tonics, with cod-liver oil
sometimes prove beneficial. The local treiitment consists in removing
or destroying the diseased tissnes by the kuife, curette, c^uistic, or the
galvano-cautery. The treatment generally recommended oonsiatA of
scntping the ulcera thoroughly with the curette, and then applying
lactic acid, which should bo repeatedly used until the process of repair
is thoroughly establiiihwl; other powerful cauati<'8 sneh as nitric ncid
caustic potash, and zinc chloride hare been recommended, but tbev
are more severe and seem no more effective than lactic acid. 'J'be
galvano-cautery has also been efliciently used for the same purpose.
Koch's tuberculin has n wonderful effect on the disease, and bus proven
curative in some oases. Complete removal by the knife is Bometimca
practised.
RHTNOSCLKROMA.
Rhinoscleroma is a rare affection, most cases of which bove been ob-
served in Austria, Hungary, and Italy, but a few have been seen la
Germany. As described it is characterized by the formation about the
nostrils or upper lip of smooth, Hat, sliglitly raised, and extremely hard
patches. The integument over these is either natural or of a reddish hue,
and thu.spots are tender on pressure, bnt not otherwise i>ainful. No con-
stitutional symptoms are developcil. The disease may appear in two or
more jjlnces sunultanoously: it prugrcssi'S tdowly, and may involve ibo
ala; of the no«e and septum, and may pus backward io the throat,
GLANDER&.
589
Urrnx. ani! even the trnclieii, causing extensive swelling of the mncoiis
niembraiie nnd syinptonia due to mechaniual interference with the fuuc-
tiuriH of the piirts.
Etiolo((V. — Ithinoscleroma U probably due to local infection, but
the specific cnuao haa not yet been id^iitifie*), though niitTo-organisnis
»re always to he fnund in the f^ells jind lymphiitii- epace* of the alTected
rpart, and some of these hiivo been specially BtiidieU.
Diagnosis. — Rhinoscleroma is to bo distinguished from syphilis,
opithelioma.nnd keloid. It is differentiated from syphHis by its chronic
course, the ubsctiL-L' of snftuuiiig uud ulct-nition, und the fruitlessuess of
ipecidc niedicatiou. Epitheiimmi is softer, it soon ulcerates and bleeds,
which does not occur in the affection under <»>nBidemLion and it is
much shorter in duration. Rhinoscleroma must be distinguished from
I'tfloiii by the location and progress of the case. Keloid U8u»}ly occurs
on the front of the chest as an irregular, cormgatod. cieatrix-iike cx-
cresuuuce, of slow growth.
Proonosis. — There is no tendency to spontaneous recovery, and if
extirpated or destroyed it is sure to recur, bnt it does not shorten life.
Trbatmext. — Treatment is of no avail except as a palliatire meas-
ure; obstructing masses should be removed from the air passages, and
in case the larynx becomes involved, tracheotomy should be performed
to prevent sufiocation. Injection of Koch's tuberculin produces no re-
sotion in these cases.
GLANDERS.
Glanders is a contagious disease derived directly by inoculation
nsually from a horse suffering from the affection. It is characterixed by
the formation of nodules, which soon become pustular and ulcerated, with
^symptoms of scpticH'tina and thick, muco-purutent, or sanious, offensive
'discharge. The affection is mro and is hardly observed except among
veterinary surgeons, groomet^ conchmen, and others whose occupation
brings them in contact with horse-s. The disease may extend to the
skin and various parts of the body, c;iusing intlauunation of the lym-
phatics, and it is then termed farcy. It may be either ucuto or chronic;
the chronic form frequently precedes the acute.
Anatomical and Patuoloqical CiiARACXEnisTics.— There is usu-
ally but little swelling and redness of the mucous nienibnme, which is
covered by scabs, beneath which ulcers will be found lu several places;
it extends in less degree to the mouth, throat, and larynx.
Etiology. — Glanders in the human subject is always caused bydircct
inoculation from a hoi-su suffering from the disease, and is due to the
bacillus malei.
fivMiTOMATOLOfiv. — The acute form is marked at its outset by chills,
high fever, and erysipelatong rush on the nose and face, soon followed by
Tesieles which burst and discharge a thin, serona flnid. These jiusLules
590
2>T8EASBS OF TBS NASAL CAVITIBS.
appear on the face »sgoniAte<l with bleK<i. The secretion noan clrJM
nnd forms n cnigt, under which » deep and raptdiv sproiiding ulcer t*
found. Obatrnriion in the nose nnd thro:»t is wnised by the pnstnle*.
The chronic nffeoiion is ehiiraoterized by similar symptoms, coming on
more slowly, but it is likely to be merged suddenly into the acute form.
When the disense bccomea fjiirly developed, tho uniRoleR »nd tfudons
are uften tmider uud the aeat of rheumatic ])ain. The voice be-
comes husky or even lost, and sonic dyspfUTa may develop; fret|uei]tly
there is slight cotigb. The diachargn from the nose and throat is always
extremely ofTeiisivH, and usually priifuse and thin at tirst, but Uiter
thick and glutinous, and sonietiniet; Htra-iked with blood. Nau^eOt
diarrhtipa, and abdominal pains arc sometimes experienced. As the dift-
eatfc 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 fur suroral years, and he seldom fully
regains his health.
DiA(iS(wiM. — Glanders is liable tn be mistaken for rheumatism, py*
emia, typhoid fever, syphilis, and Ecrofnloiis eruptions. The essential
points in the diagnosis are: the history of infection, the marked consti-
tutional tfvmptointi, nasal obstruction and olToTisive disc)uirge,p9iins in the
limbs, and abi4<resses in various parts of the body. It will be disiingtiiehed
from rIteunuitUm by the histor}', the presence of pustules and nlccrv
tion, and the occurrence of pain in the muaolos and tendons, instead of
in the articulations. It will be distingni^hed from py<smia by le0
pronounced rigors, and by the pustules, ulceration, and offensive naaal
disciiarge. It will be dif crentiated from Ifiphmd fever by the history,
the pustules, ulceration, and discharge. There i^hould be no difficulty
in distinguishing glanders from jftjphUis, if the history, marked consti-
tutional symptoms, and failure of specific mudicines to give relief are
considered. It is readily distinguished from scrofuhuit eruptiotm by
the marked constitutional symptoms.
Pbookosis.— The chronic disease usually runs from four to eight
mouths or even longer. Bollinger (Ziemssen's Oyclopadia of Medicine)
mentions a case in which the symptoms lasted for eleven years.
The acute affection usually lasts fur about three weeks when coming
ou iudcpendeully; but when followiug the clirouic disease, it generally
terminates fatally within a week. The acute disease is almost always
fatal, prolwbly always if the nose is attacked. The symptoms preceding
a fatal termination are protracted fever, night sweats, diarrhcpa, delirium,
and great exhaustion.
Tre.\tmrn'T.— No form of treatment seems to be of any avail, bot
the case should be managed ou general principles, and an attempt mad*
to relieve suffering and sustain the vital powers.
PERVEHTKD SENSE OF SMELL.
591
NASAL AFFECTIONS IN ACUTE DISEASES.
Aoute coryza is one of the enrliest symptoms of tneaftlex and it is oc-
cTisioniiHy followed by sovero iiiflunimulion, witii cpistaxis iiiul tniico-
piirtjlent secretions. Atrophic rliinitiii and ulceration of tlx- prjilnm
sometimes result.
Slight or severe acute rhinitis, with profnse serous or muco-pumlent
discharge and 80iuetimei} epjetaxis, may attend scarlet fever^
Au eruption in the Tiares, with ohstrnrtion of the p:L8sage8, and enb-
Bequeiitly epistaxis, is Bonietinics canned by i*mnU-pnx, and cases are not
very uncommon where the nostrils have become occluded by healing of
the ulcerated surfaces.
Very distressing catarrhal symptoms, due to coUectioa of secretions
and formation of large crnsta, sometimes attend typhoid fever. Under
the cruiit!^, ulcLTatlon may possibly lake place, aud BOiuetinies the sep-
tum is partially destroytnl.
Severe rhinitis sometimes attends rheumaiism, bnt more frequently
will be observed rheumatic or neuralgic pains, associated with but little
if any evidence of intlummation. In nil of these coses the diagnosis is
comparatively easy, and the local treatment is that suitable for acute
catarrhal rhinitis.
PERVERTED SENSE OF SMELL.
PAftOSMIA.
r Parosmia indicates a perversion of the sense of smell by which the
> patient experiences sensations of odors, usuully disagreeable, which are
not really present, it is said to be conipamtively common in epileptics
and among the insane, but ie also observed in those who are otherwise
perfectly healthy. The condition is aimlogous to neuralgia of a nerve
of common sensation. In souio it is constantly present, iu others in-
termittent. In some jKitieitts the sensiitiou occurs without an exciting
cause, whereas in others agreeable odors smell olTcneive.
DiAOXosia. — The diagnosis is made from the subjective featnree of
the disease.
TuBATUENT. — No mies for treatment can be formulated.
k
Anosmia.
Anosmia or loss of the sense of smell is dependent upon obstnictions
in the nares or disease of the olfactory nerves or lobes, or of their cere-
bral centres.
Etiouxjy. — Anosmia is caused by oltstrnction of the narea from nn
acute cold, polypi, hypertrophy of the mucous membrane, or presence
k
S9a
msEASiSS OF TUB NASAL CAVITISS.
of foreign bodies; ulso by disoaec of the olfuctory ncrvee, citlicr distal^]
or along the trunk, or at the centres. The most frcqncnt cauee ia
obstruction from mucous polypi, or swolling of the niiddlu liirbitiatetl
body, or of the luueous membrane covering the st-ptum directly oppoKile.
Ill thew cnBt'» it is nsuitlly intermittent. It not infrequently rcealtaj
from injury to the head, 08 from blows or falla, iind ciises are on recordf
in which it hua been eiiust'd by prolonged exposure of tlie olfactory nerre
to some pungpnt or extrcnu-ly disjigrfcjible odor. It hiia been cuuscd by
inhalation of irrituting vapors, snuff-tjiking uud luuul uae of solutions
of alum, or other noaal washes. It sometimes follows prolonged rhinitis
esppciiilly of tht; dry variety, frontal ueuralgia, or long-continued paral-
ysis of the fifth or seventh nervo, and it is oci-asionally congeniUU.
Symi^omatolooy. — In addition to the Iors of smell, the patient ift
usually depnved of the sense of taste for all substances with a dis-
tinct flavor, but bitter, sweet, sour, salt, and acids are usually rMoguised.
The loss of the eensc of smell may bo uuiluteral or bilateral, and is
often intermittent, returning for a few minutes or oven days, after ex-
ertion or without evident cause; but disappearing again without the
slightest known provocation.
Diagnosis. — The diagnosis is made from the subjective symptomaj
and the exclusion by inspection of conditions causing obstruction of tfaej
nares.
PitOGXOSii^— When due to mechanical obstruction, most cases are'
relieved when the obstruction has been removed, ('lises dependent
npon oatarrhal inflammation of the Schneiderian membrane nsnuUy 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
diseaae, the sense of iimell is i<cldom restored.
Treatmkst. — The condition causing the affection should be sought j
and, if possible, removed When this cannot be found, Mackenzie rec-1
oQimcnds the iuenfllation of a powder containing one twenty-fourth of
a grain of strychnine with two grains of starch tM'ice a day, and if it
does not succeed be Increases the strychuiue to one-sixteenth or eren
«ne'twelfth of a grain (Diseases of the Throat and Noeo).
CHAPTER XXXY.
DISEASES OF THE NASAL CAVITIES.-Co«^»tttt«f.
COJ«(JEKITAL DEFORMITY OF THE NOSE.
The principal nasal deforniitiea which have been observeil are: ab-
sence of the septum, duublu i3e[ituiii, narrowimsg of one uaris h8 compared
■with the other, and occlusion of the poaterior nitres by mombranous or
bony tissues. Ciises have also been recorded of complete absence of the
nose, and of double nose. Cloaure of the posterior nare« seriously inter-
fere* with respiration, especially in infants, and in them may be a seri-
ous menace to life.
TnuATMBNT. — Various phistic 0[>erations have been performed to
correct these deformities. Congenital closure of the posterior narcs,
which principiiUy concerns us, demands prompt attention, for infant-3
will not thrive unless they can breathe through the nose. A passage
must be forced througli the obstruction by u strong probe, blunt for-
ceps, or other instrument, and the opening thus made must be diluted
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 t^ble, blows from the fist, a baseball
bat, or flying missile, or the kick of a horse.
Syuitomatolooy. — The injuries vary from a slight fracture to com-
plete crushing of the noee 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 lime of the uccideut, and to recur from time to
time on sneezing or blowing of the nose. The sense of smell is often
lost at first, and sometinies it ia permanently destroyed.
Diagnosis. — In order to make an accurate examination, it is some-
times only necessary to inspect tlie part with the aid of the speculum
and rhinoscopc; but if much contnsion has occurred, complete anies-
thesia should be induced, to allow of careful munipulatioUj but even then
crepitus is not ufteu detected.
Pkoonosis. — 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
38
591
DlaiSAiiEa OF THE IfASAL CAVITIES.
inny have also caused fracture of the base of the skull and acrJonti injiirr
to tlie brain.
Theatmkn't, — With the patient under an ona-sthetic, the tTaffjUQnXA
phoiild be reptacc(]> ns nearly m possible in their uoruiul pusition. by tbe
finger and forceps; und if there tins been much diHiduruiiipnt, tlie part
ahuuIU be ix-iaiiied by plugging tiic uurcs lightly with iiulii!optie wool or
by the introduction of phiga or tubes of gntLa-])erc)m or other «ub-
stimces, or by a Kpriujj, as pnit-tised by Hoe (.Vcfc Vatk Mcilirnl Ti/vxrr'K
July^ 1891). At the snmc time a piaster of Piiris dre^iiing may be ap-
plied with benefit externally. Suiiietimes it vill bo iiec^uBMtr^' first to
reduce the swelling by cold uppliuatious, and wait from twentv-four to
forty-eight hours before un attempt is made to rej)lace the fragment*;
but it must be remembered that healing in this location takes place
very rapidly, and it itt desirabk'j therefore, to correct the defunuity be-
fore union has occurred.
DISLOCATION OF THK ^A8AL BONES.
Jislocatiou of the nasal hunfa is a rare accident, which in the fei
reported C4ises hue rettulted from a blow on the side of the nose by which
the bones at tho upper third of the organ have been laterally displaced.
Reduction is acoomplislipd by meiviis of combined internal and external
mnuipuUuon while the patient ia fully uutesthctized.
DKFKKCTION OF THK NASAL SEPTUM.
TTneompIicated deflection of the septum does not often exutt, bni,
associatoil with thickening of the eartihige and bone or enchondroma
and fX4>sitj^iti, it is one of the most common deformities of the nose. In-
deed, Mackenzie fuuud a deflcctiou of from half a millimetre to nine
millimetres iu over seventy-six per cent of 2,152 crauia examined iu
the museum of tho Royal College of Surgeons (Diseases of the 'I'bruat
and Nose). Delaran bus found among Kuropeuo races well marked
deflection in tifty per cent of several thousand cniniji examined (Trans-
actions of the Aoiericau Laryngological Assueiuliuu, 1^7).
Ax.^TOMicAi. ANO P vTHoi.tKiu AL CiiAKACTEHit'Tics.— The earliUgi-
nons or the bony septum, or Iwth portions, are simply bent to one «de.
the cartilaginous portion Tieunlly being most involved. The deformity
cause enlargement of one nasid chiimbcr, at the expense of its fellow.
Simple bending of the septum is uncximmon, for in most instances of
deflection there is also thickening, oapecmlly at the lower i>art of the
conrpx surface.
ETroLO((Y.— The causes of the nffcoHon are obscure. It wae at one
time thought to he often rongeuitd, bat Zuckorkundl, as reported by
Mackenzie and Delavan, states that it is never found before the tfeventh
DEFLECTION OF THE IfASAL SEPTUM.
505
year; this, hownvcr, is a mistiikc, for 1 huTc opemted upon seveml cases
in eliildron under four years of age, and I observed it in a child li'ss
than eighluen nioiiLbs old. Deluvaii believes thut it ia genorully duu to
injury, especially when situated anteriorly, and that otliurwistJ it U due
to liyjwrniitrition, particnlarly ivh(*n located posteriorly {op. cU.). Chas-
Baijrnac attributes it to hj-pernntrition {TSvlhtin <h ia SoriHe de chi-
rttrgie, Ifctol to l:^'i2. Tome II). My own observation is in accord with
that of Delavan, excepting that I have found comparatively few cases
that could bu i:Ieurly tnieed to iiu injury; and the evidence in support
of some of the oldur viows, as suggested by Mackenzie, is, to say tbo
least, insuflluieut. It u probable that not iiifruquL-ntly trauma is the
etiirtiog-point, but undoubtedly ebronic c:»tarriml congestion, by deter-
mining an increased flow of blood to the part, gives rise to hyperplasia,
SvMHT()MAToi.(mT.— When the deflection is great, thy most pronii-
uont diymptom is ttvie;ting 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 csartilage. even
thougit there is but Ittlle deflection farther back. More or less dltliculty
in nasal respiration is experienced according to the amount ef obstruc-
tion. Interference with the free passage of air through the obstructed
side causes the seoretion to noUect beliind the convex portion and in
the nasn-pharynx, giving rise to post-nasal catarrh. Pressuru upon the
external witll, espeoiully when this is tissociated with exostosis, often in-
duces atrophy of tlic uirhlnuteil body of that side, Mhcreas the inferior
turbinated body of the utlier side is usually hypcrtronhied : and thus il
fn'(]u<;ntly happens that itutietits find respiration easier tlirougli tlio
cavity which upon JiispectioTi seems most obstructed. As further eonse-
qnences of tho obstruction, tlie voice iwiquires a ii,a.s:il twang,and mouth-
breathing becomes necessary, with alt its attendant evils.
Diagnosis. — There is no disease witli which deflection of the septum
is liable to be confounded if a careful rhiiioscopic examination is nuide.
PuOGSosrs. — Most of tlie evil results of the obstruction can be reme-
died by a suitablo openttlon, and the external deformity may be largely
removed if (lie luutal iHines have not been crushed so as to cause dej>res-
sion of the bridge of the nose.
Trkatment. — The simplest trwtment that has been recommended
is for the patient to push the nose or tlie se]itnni Urmly over to the op-
posite side sovend times daily; but nnfortuntitcly tins is seldom capable
of uccomplishing any good.
In 3851 ChaJisaignac re<Tommended a form of treatment especially
applicable lo deviations with thickening of the rairtilaginoas septum.
This consisted in dissecting up the mucous mombrane and paring off
the superfluous tissnc. It is not always easy of accomplishment, but in
certain enses no better operation could be devised. Blanden first ad-
vocated punching out a portion of the septum and establishing free eon-
696
DISEASES OF THE NASAL CATITTSa.
nection between the two n&res (Compendinm de Chirurgie PniUqiM,
Tome III), but this does not afford the deiaired relief and cannot ba
xeoonimended. Walaham propoeea forcible replacement of the bent
septum (XCdaton : Patliologio Cliirurgicale, seconde Edition, Tome
III), its reailiency having first been overcome by stellate inciaiaDK.
This practice has bcon elTcctuuI in. moderate deviations of the septum
without thickening. Where the deviation is marked, the redundant
tiasue must be removed in order to obtain perfect results. In slight
F». S18.— IWMUI* SSKTW FOKOKN G« '^'•'.-
deviittions most excellent results may be. attained by making a cruotal
ijicieion through the curtilage, the cut being made oblitjuely so that the
bevelled edges will easily iilide paAt eucK other. The septum is then
forced into its normal position by forceps (Fig. 218), the vomer being
fractured if necessary, and a guttfl-perc'h;i phig of sufficient size is kti-pi
iti the obstructed nostril until union hn6 taken place. Where the stellau
incisionft are mado cither by kuUu or punch, the plt)g> or Adam's clamp,
must be worn in u similar manner; the plug is siiiiplcr and qaite as
etlectivo. In mast instances it will be found necessjiry to remove the re-
dundant tissue before a good result can be obtained. In cases where the
cartilage is bent, almost at right angles, jirross the nostrils, I bavo foand
it most satisfactory (us t stated in Transactions American Litryngological
Association, 1880) to dissect up the mucous membrane, remove a triangn-
lar piece from the cartilage of suflicient size, incise the cartilage farther
Pm. ns.— IROALH* BRrtvH KKirc (M rite).
back to destroy its resiliency, and then placea plug in the obstructed no*"
tril to maintiiin the septum in position nntil nnion has tiikon place. When
the obstruction is less complete, and there is simply devjiition of the sep-
tan, 1 hare frequently operated by making three or four horixonlal inci-
Bions through the cartilage from the front biickward, the cut being made-j
oblifjuely from above downward and outward; sometimes across thesej
near the middle is made un oblique vertical incision; the whole is then
pushc^l over and retained by a plug or tube of gutta-percha until nnion
has occurred. The main objection to this, and to other npcrulions in
which uo (issue is remove'^ - >hat certain parts remain thickened and.
SCCHONDROMA AND EXOSTOSIS.
597
the resilieucy of tho CHrtiUge is seldom perfectly destroyed; the pliig
then has to bo worn for several weeks, and when removed, in many iii-
stniices, the cai-tiluge witi iiguin return so far toward its old position iis
to [ireveut II silt is file tory result. During the past two years I Imvo fre-
quontly operntcd on these wises by euttiug through fruni the front
backu'iird, in three or four plru-es, and as tnunh as possible beneath the
mucous nienihmiie, with u c^nntU trephine about tvo and oue-hulf
niillimetres in diiiraetcr (Fig. 2l>2). The removal of these cores de-
stroys the resiliency of the curtilage so th:it it may bo reiidily carried
buck and retained in its proper position. Whatever operation is adopted
it is undesirable to perforate the e^rtilaginous septum because of th©
subsequent tendency of the secretions to dry alwnt the edges of the
opening and form obstructive crusts vhich are a constant annoyance to
tho patient. Perforations of tho bony septum give rise to little or no
inconvenience, pruvided they iirc as fur as on inch back of the nostril^
in which pusition the edges arc kept ujoisteued by the secretions, aiid
scabs do nut cullcct.
When deformity of th© nose and obatrnction to respiration result
from protrusion to one side of the anterior edg© of the triangular carti-
Flti. iiJU.— Imulm' KiuBT-ANaL.B CtnTiNO-FuHCRPit Oialar).
lage, tho most satisfactory operation consists of incising the mncons
membrane, over the edge of the cartilage, dissecting it back upon both
surfaces, and then cutting off with a right-angle cutting-forceps (Fig.
320) all of the cartilage that projects beyond the normal plane of th©
septum into the obstructed nostril. Tiiis operation not only relieves
obstructed respiration, but largely remedies the external deformity or
twisting of the nose.
In order to secure sutlieient anteBthosia 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 tlio outer surface of tho cartil:ii»i'; tho
mucous membrane on its posterior surface being anseslhetized in th©
usual manner.
BOCHONDROMA AND EXOSTOSIS OF THE NASAL SEPTUM.
Eochondroma and exostosis of the nasal septum consist of thicken-
ing of the cartilaginous and bony parts of Che 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 8ymj>tomatology are practically tlie same in both. Tho project-
ing spur is usually directed from below upward and backward along
IflliHAilSS Oil- TIIK ITASAL CAVITIES.
the !tlie of articulation Iwlwovu the vomer and the iierj>t!ii<]icoUr
of the ethmoid, I'hitt may he ^niall, or bo large as to impinge
Qm outer wall of tliu nuMkl cuvily. Tho Kpiir is covered br mi
mpinbriuu', its anterior portion ia cArtila^i
tl»e pngtorior bony, and tlio inferior part immtil-
ali'ly lijiok of tho cartilaginoue septum ia made
np rjf lidtii- of cxtrfiiK! hardness. These fi
tiona, bi'cimsp larger and exerting more
ugainflt till' out<>r wiill. are more liable th:in 9\i
(IpriationK of tlii) sepluTu I4) pxciie neuralgic paia
mil] varioiit) uiht-r iu-rvoiis t^ymptoras. Thoy are
frcfjiifhtly foiuitl in cases of hypertrophic rhinitiff.
*>n' 1 l"H3n ''^•^" ^^'^'*-'^' ruithiiii), «nd pcrsi&tcnt supra-orbitAl or
fiibit orHw^'K. Hn-'iiii^ occipital nt,'uralgiu.
^, l.!!:!'**^' <i.ri>io«*.i lUAo.vosis.— Tho diagnosis is eaally made by
boUjf of left iiiile. . ,, *,, ... ,
luspoction of the mires iiud the application of 1
prnbo, which dotctits the dliToreiici! in tlio dunaity of iiimple thickening
of the soft tissue, and that <if bony or cartilaginons tissne.
pROONOSts. — The obstrni'tion may be completely removed by aaita-
l>le operation, and niaiiy of tlio symptoms will be relieved accordingly;
hut the siirgoon HhoiiM ]iot He too oontident of the result, for ia a con-
siderable number of cases, some of the symptoms will remain.
Tkeathest. — Tho ex«os8ivc tisftuo must be removed by operulloii,
during which un eflorl ifhoiild be iiiiide to aavu ant much of the mucous
membrane as ]Hi>rsible. Before commoncing the operation, the septnm,
Ixith upon tlip nfTected side and upon tho opposite side, and all other
portions of the walls of the cavity liulile lu be toueliei] during the
operation should be tlioronghlyaniesthetized by cocaine. It will ho found
impossible to produce complete anaisthesia by appljing cocaine to the sur-
face near the nostrils, thoreforo when the operation is to extend far for-
ward a few drops of the solution (Form. 140) should be injected beneath
the mucous mcmbnine where it joins tho integuinuuL Ecchondroma near
the nostril may be removed by dissecting up the mucous membrane and
poring away the cartiliige with a knife, or cutting it with saws, trephines^
or drills. Jarris has devised a drill for cntting cartilage beneath the
mucous membraue, but I have not seen its work. C. H. Wright, a deD-
tist of Chicago, had made for me a burr which cuts cartilage very well
in adults, but it will not cut mucous membmne except under firm pres-
sure, and onfortunately does not accomplish much on cartiUge in chil-
dren. This, or other drills or trephines (Fig. 202) I use with an electric
motor. Tho burr may be made to penetrate tho mucous membrane by flmi
pressure while it is in motion; and then, by moving it slowly nbout, th»
excess of cartilaginous or bony tissue may be cut away without iujunng
tho nnicous covering. Any of the tleM^ which is not extruded doriug
the drilling process is washed away with a two per cent solution of oar-
d
BCCHONrtROifA AND ESOSTOSia.
5'j9
boUo acid, applied by a small syringe. Ordinnry dental burrs will not
cut cartilage. Trephines may be rnn directly through from the front
Fw. a'iJ.-Sjuui!*' K..MrK v>a nl'i-).
backward, and with care moHt of the mucous membrane maybe preserved,
bat more of it is destroyed than when a burr ie employed. For re-
Fm. i!tS. -Nasal &pi'i> CH ***«'>•
moT&l of ecchondroma or exostosis situated fartlier back, I cut the
mucous membrane along the Jnwer edge of the spur with Sajoua' knife
ri«. ttl.— tKOixs' Umal Saw 04»iw).
{Fig. 222), and bring the incision, in a curved line, forward and upward
to the anterior and upper portion of the maes to be removed. The
Fro. len.— Ikoau' FtAT NUAL S*w (iauurj.
mucous membmne is then lifted from the subjacent tissues by the back
of the same instrument or a spud (Fig. 2"2:i); a saw is passed beueatb
Fin. C9R.— SAJOr«' NmaL Baw 04 tdxe). Form \taei for clowiiwanl culUng.
Fro. ear,— Smoo' Najui Ba* (H 8ii«). rorm used for ninrardcuulDg,
the loosened flap at tho upper part of the spur, and a cut mado down-
vord on the normal plane of the septum until it reaches nearly to the
DlSSASm OF THE NASAL CAVITfSS.
lower part of the nasal fossi; a narrow saw is then passed beoeoth ihs
6\mr,tit\dt\cul madediruetly ii|twaM to meet the one from above. AJUir
the bone in cut through, it miiy he held by soft tissucfi.Hiid these are coi
by sciwors <Fig. aOO), to allow removal of the frttgiueiit. SometinM
stronger aoiiisor8,a8 shown {Fig. 2^8), will be needed. SubBoquontly wiUi
rn». MS.— iNQAL*' HuvT-Boxx SciasoBs t^itUf}.
bone forceps (Fig. 2^9) any eharp spicalae are cut off. In some inal
I find it preferable to out through the lower portion of tlie spur with
ft good-sized trephine. In others wliere the spur ib not largo, I une the
trephine, only removing one or more eorea as seems d^siniblo. Thia
latter operation is uaunlly made without first having removed the tnucona
membrane, and tho out ta made aa much as possible beneath it. Aiter
the bone is removed, the loose Rap of mncons membrane, which nwy
have been 8ave<l above, is pressed down smoothly against the eBptiim.
The patient ihen blows out tho blood; the cavity is frcelv duett^
with a powder of equal parts of iodoform au-l boric acid, and, while the
flap is held in position with the nasal spatnln (Fig *^30J, the naris is
packed, as recommeuded in the treatment of epistaxis, either with a
Fie.9».— Imuui'KiaALBpATrLAOiiisP)* 8e(so(th»eTKr]r(nKlDir}d^anirleof46*. UAdrofi
strip of hn'mostatio gauze or ptctiget* of lint. Tliis l:im{>ou tho pntient
is directed to remove at the end of sixteen to twenty-fnur houre. but
sometimes it is allowed to remain two or three days provided there is
no offeiifiive odor or pain. SulisequfUtly the wound is kept cleim and
as nearly antiseptic ua possible, and the patient is directed to use two or
three timee a day a powder coutuiuiug from twenty to fifty per cent of
iodol.
PERFORATION OF THE NASAL SEPTVM.
601
Ileiiliiig usually takes place in from one to six weeks, according to
llio size uf the wotiud produced, uud it is often remarkable that after a
fon' mouths, even when largo spars liaTc been removed, the mcmbrjiio
over the wound it]>|KSirs normal with im ciottrix thut om bo seen. II.
Uolliraok Curtis prefers to reinuve these spurs with the trephine
aluiio; Rofiworth uBuallv employs saws; others are in favor of dent::l
burrs. By using a trephine to cut the lower portion, wliere the bojie is
very hard, aud ii saw for the upper part of the incision when the spin- is
large, I am enabled to makt! the most eomiiletc jind e.'(i)edilious upcru-
tion. The niuin objection to operating with the trephine ulone h thut
after milking two or three cuts il will he found that ^utlii-icint tissue hns
not l)een removed, and the partji are so obaciirrd by bleeding that it is
difficult to complete the operation accurately; it therefore retftiires
much more time than with the k;iw; in the mean time the eflfetts of llie
cocnino are liable to pass away, and much pain will be caused. I'erfoix-
tion of the cartilaginous septum should always be avoided, and an open-
ing should not be mjtdo in the bony septum if e-ufltcient room can be
obtained without it; but often when there U u i^harj) deflection, togeilier
with the exostosis, it is impossible to free the nostril without opening
til rough to the other side. There is, however, no serious objet^lion to
this, providing it is more than an inch hiwk from thu nostril, anil the
opeiiinu In such CAses is certainly prefenible to a cavitv 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 upt-rtttion is
not repeatetl until the eschar is thrown off. James K. Newcomb, of New
York {Mcilk'ul J{tcord, August 5, 1803), who has recently gone over this
entire subject thoroughly, ooucludes tliat tlie method is wortliy of a
further trial, but that " whatever cati bo done by elcctrolysia can be, by
other means, accomplished more quickly." In most iustaneea cauteriza-
tion of the inferior turbinateil body of the opposite sido will subsequeully
be fonnd 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 jHrfeotly free and abont
one-third larger than normal, to allow for the partial closure which is
sure to take place during cicatrization.
PEUFORATION OF THK NASAL SEI»'rilM.
Perforation of the septum is often found as a result of syphilis, but
it ftlso not infrequently ocxurs, 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 qnito
eoa
DISEASS^'i OF TITK NASAL CAriTTSS.
A large piece of the cartilaj^nous septum to be expelled, witbont vnm-^
ing, in a person apparently in perfect health; and i have even seen sod
openings inrlepenrlent of any of the causes already mentionod, wbickj
have occurred without the patient's knowledge.
Treatment. — The treatment consists in making 8uita1>le applirfr-j
iions to heal any ulceration whieh may he preHent. It is not world
whijp to try to riose the opening, an attempt which even at bo«t col
•give little heneflt, and which wonid itsnally rcsnit in failure.
HiEMATOMA OP THE >'ASAL SEPTUM.
HftmAtoma is a collection of hlood in the septum indicated hy th?
formation of a lumor usually at the lower anteriur part, and projecting
alike u)>on both sides; it results from an eltuaion of hluod between ihe
deep Inyer of the mucons niembruiif and the underlying eartilage.
Etioloot. — Hare cases uf t^puntuiieous liEeniatonia have )x^^n ob-
aerved, but it Is usually due to fracture of the bony or cartilnginoui
«eptum by violent bluwti on the noHe.
Symptomatou>(;y.— The blood collects immediately or within a low
hours after the ctiusative aceideut, and causes a smooth, uniform tumor
of purple color, which hue somt'times extends to a considenible porttun
-of the mucous nietiibnme of the nose. These tumors are sitimted just
within the notitril^ arc* soft and ductnating, usually symmetrical npeu
both sides, and may l>e so largo as to protnide from the nostrils. More
commonly they cause simply an extremely thickened a])pearunce of the
cartiUigiuous septum.
l>lA0N'06is. — The tumors are liable to bo mistaken for inucoiu
polypi, hypertrophy of the turbinated body, ecchondroraa, or abscesa of '■
the septum. The esseutial points in the diagnosis are the symmetrical
ebaraeter of the swelling, the color, and the lluctuation.
These tumors arc distinguished from t'ttriihijittouH tutnorg by their
softness and symmotricid appeanmec; from nmvotts poh/pi by their urn--
form character, broad base, and color; from exfretuc htfjm'trophy of tho
unterior end uf the inferior turbinated body, by their location in the Sep*
turn, as demonstratt^d by the prube; from abscess by their color and by
the result of exploratory puncture.
pKouNOSis. — The enlargements sometiinea exist for a long time,;
but usuiilly, within a few days, they eventuate in absresg, the patteQl
rarely rooovonng without a permanent aperture in the septum.
Tkeatmest.— Cold applications to reduce the swelling and inflam-
mation should be made at tirst; if the blood does not become aluorbed,
aa sometimes happens, within three or four days, it is apt to beeome
pumlent, and the swelling must then be ot>ened upon one side at ita
most dependent part. Usually a single opening will drain both eide^
but au iueisioD oa each side may be neocssary.
FOREIGN BODIES IN THE NOHE.
603
AUSCKSSES OF THK XASAL SEPTUM.
Abscesses of the nnsal septum may be acute or chronic. Tlicy are
fouml in iLo aime poBilion as the hfcnmtoma just described. They
may result from the latter, or follow from simple infttimmatioti of the
parts. The svmptoraB, dinjfnrjsig, prognosis, and treatment are essen-
tially the same as those of hsmatoma of the septum.
FOREIGN BODIES IN THE NOSE.
Foreign bodies of great Turiuty htivc been found m the nose where
they are most commonly plauod 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>
fitnnee whore a child, during the act of deglutition, choked and coughed,
thus lodging in tin? posterior uaris a cervical vortebm of a chicken,
which remained there several months.
SvmptoMatoloov, — Foreign bodies sometimes renmin in the nose
for a long time without exciting any Bymptoms. Substances wliicli
nbsorh mcn«turo soon swell and obstruct the nostril, and beans, peas,
nnd other seeils may germinate. Irregular bodies may excite acute and
severe infliunniittion. lleuduche, often assuuiing a neuralgic form,
is occusiuniLlly present at un early period. The most characteristic
symptom is a more or less jirofuso discharge from one nostiil, which
becomes exceedingly offensive when the body is one which will take up
moisture and decom{>ue!e. I'pou inspection, thu nusal fo^u tisuiilly
appeal's tilled with secretion, but when this is wiped away the foreign
body may be seen, or felt with the probe.
Diagnosis. — The presence of u foreign body is to be distinguished
from exostosis, rhiuoliths, other causes of nasal obstructiun, and from
eimple catarrh, by the history, which may oftentimes be obtained from
the child or its playmates; by the occurrence of the diticharge from one
side only, which does not occur in simple catarrhal inflammation of
the nasal mucous membrane; by the olTensive nature of the discharge
in many instances; and by careful inspection or palpation with the
probe. As an illuetratjon of the difficulty which sometimes attends
the diagnosis, 1 recall an instance in which a long match had been
inserted into the nose and had l>ecn sought unsuccessfully by a phy-
sician. The mucous membrane was so swollen and the naris so filled
with secreliou 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
G04
J)ISJijlS£S OF TfJE NASAJ, CAVITIES.
quiuitityof tbis drug the swollingiB removed and tUa mucous memi
is Ixriiuinbed so tJiiit a carefnl exploration can be mado. A good li^lit'
is ulwa>'8 cKsetitiiil to a sntififactory cxamiDtition.
Foreign boilicB arc (li&liii^uishcil from )»>l;fin by their color, consist*
once, and mobility; from ej^vf/OHt'i* in the Mime why.
Prognosis. — Siniill huUies nia/ rciiiHiu fur a long time, even manT
years, without attracting attention. IW the accretion of chalkj d^
positM they inny become the nuclei of rhmolithe. Thoy are not ilan^r^
ous. but in most instances sooiier or hitor provoke an extreinely ofTensifv
diseharge.
Treatment.— Tho nas-il cavity should bo nna-Blhetized with ro<Mitic
!ind the substance removed with forceps, catheter, probe, hutiks. screws,
pufiterior nasal douche, or the linare; the latter I huTo found more lue-
•
Pio. est.— Olton' tirantciiKm FOR ItKHunxa FoHKiax BobiKsnK»iTiiRNAui.CATmiSA](9 Eam.
fnl than other inatnimeniB. The loop is easily passed by the sides of
the foreign body, and when tightened up<ni it the object is firmly held so
that it can be withdrawn. In one iusUiuco I extnicted by ibi3 means
n wild tooth from the floor of the naris which had caused a oaturrlul
discharge for sevoml yours.
RHINOUTHS.
Khinoltths are cretaceous nuu^Kcs of comparatively rare occni
which usually owe their origin to the lodgment in Oio naris of
foreign substance upon wliich pbosphute of lime is grudmdly deposited
from tho secretions. They are generally hard on the surface, but softer
toward the centre.
SvMl'TOMATOLonY. — Tho syuiptoms are similar to those described m-
due to the presence of foreign bodies, the most characteristic being ob-
Btructiou and a fetid discharge from one nostril. When pitmited in tb«
upper and anterioc portion of tho uosal fossa, they sometimes cause
swelling of the face. The symptoms come on more slowly ihun those rv-
snlting from u foreign body; but as the calculus coutiunallr cnhirges, the
obstniction finally becomes greater. The calculus is usually single, but
more than one may occiwinnally be found. It is geneniliv nfn grayish or
blackish color, with n rough, and more or less uneven though eometimes
smooth surface. Sometimes it becomes partially imbedded in the
mucous membrane, wbi«!h then is apt to ulcerate and bleed. The nte
of tho cdlculns varies greatly. W. N. Browne reoorvls u caEe(£lafiV
l/iirgft Medicu! JourniiU Iti^^) in which the stone measured one inch utd
three-quarters iu length, one inch in breadth, and nearly half an indi
in thickness.
MTA8IS NARIUM.
605
DtiONOSia. — A rhinolith may be confounded with osteoma or can-
cer. It IB (lietin^iiBhpd from osteoma in that it is moTtible ami cnn be
Iieiietnited by a shtirp probe or needle. Owing to the fnngoid, blood-
ing grannlations which Bometimos spring up from tlie edges of the
mucona membrane, where ulceration has occurred, and iilso to the offen-
sive diBcharge, it may be mistaken for rnm-fr, from wiiich it ia dis-
tiijguialutd by its slow growth, the romparative absence of pain, and by
inspection and ptilpation with the probe.
pRooKOBis. — lihinoliths may remain many years, cauBing much an-
noyance, but thoy are not dangerous to life.
Theatmeni. — Kbiuolitha may usaally be removed with polypus
forceps or the snare, or they may somctimee be crowded back into the
uaso-jiharynx, when tliey will bo expelled by the patient. H too large
to be readily removed, they should be broken down with the nasal bone
forceps (Fig. :229).
MYA81S ^AHHJM.
S^noni/m. — Maggots in the nose.
Myasis nurium is a condition very rare excepting in the tropica. It
is chanietcrized by deHtructioji of the soft tissues and occasionally of the
bone, with oSen»ive discharge, form ic:it ion, severe pain, iuBomuia, and
sometimes convulsions. It has been frequently observed in British
India, South Americ^a, and Mexico, but in those countries it is said not
to bo found in the cooler atmosphere of high altitudes. Very few cases
have bceu recorded either in Karope or the United States, A case is
recorded by D. N. ituukin (Transactions of the American Liiryngological
Assouiation, 18HS).
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 st-usations, with attacks of sneezing, soon
folluw, and subsequently truubleaome crawling sensations are experi-
enced. There is a sanioua or bloody disrhargo from the nostrils, and
(edema of the face ami eyelids may also appear; Bevere and sometimes ex-
oesBiTe, unceasing, pain is felt at the root of the nose and over the frontal
region. In this afTection the mucous membrane, and even the csirti-
lages and bones, may be destroyed, and the resulting inflammation may
extend to the brain, cansing convulsions and death. As many as two or
three liundrcd maggots have been ejected from the nose in a single case.
Upon inspection, the horrible condition imiy be readily detected.
Diagnosis. — vVU the Byiuptoms may be caused by 4)lher affections,
therefore the diagnosis mnst depend upon finding maggots in the nasal
cavity.
pKouNosis.— If neglected, a considerable proportion of cases will
erentuatly prove fatal.
606 DISEASES OF THE NASAL CAVfTIBS.
Treatment.— Chloroform has been found most efficient for destmc-
tion of the parasites. In some instances inhalation only, of chlorofonn
is sufficient to effect a cure. When this does not succeed, the patient
should be fully anaesthetized, and the nasal cavities thoroughly syringed
vith 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 XXXVI.
DISEASES OF THE NASO-PIIARYNX.
HHINO-PHARYSUITIS.
jSynOBj'.iiJ.— Post-iiaaal catarrh, retro-nasal caturrli, follicular discaeo
of the niiso-pharynx.
lihino-phiiryngitis consists of chronic infliimnitttion of the mucous
mtmbmno of tho imso-plmryiix, cb:micterizf'd by collection of vieciil or
ilryiug Hccrclioii, and u tcndcni'V lo liawk frc({UL'ntly and clear tho
throat, especiiiHy in the early morning or iifler uatiug. It is a very
oommon and wide<(prBii(I iifTcction, but xuenis cspeciuUy ])rcvuit;nt in
Americft, where it is found in all regions and nmong patients of dilTor-
ing age, sex, and condition; it is less frequent in warm and equable cli-
niutes.
Etioloot. — Beverley Kobiusou justly atiributcs it largely to cold
and damp Ktmosjihero subject to duddcu and great changes of tempera-
ture, but believer that it is a.\so due to a ttpec-jal dlatlie^ii? which lie terma
catarrlifil (N'iL*al (ruarrh, isjsu). ilackeiizici hellL-voa it is mainly due
to dust, and frequently to dyii{>ep8ia. I am satistieil that a uuld, damp
climate, an<l an exressJve amount of irritating dust in the atmosphero.
are tho chief of its prcilit^posing causes, and that disturbanei* uf the
digestire organs is a pronounced etiological factor in many instances;
but I am equally satiatJed 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 alTection is due to extension of inilannnation
from the naros or oro-pharynx. Hypertrophy of Luschka's tonsil
or even of the faucial tonsils nndonbtedly causes the disease in
some cases; but the cat^irrlial symptoms caused by hypertrophy of
Luschka's tonsil, or exnessire adenoid gi-owths in the.naso-phani-nx,
should not be confounded with tho result of simple inflammation.
Tornwaldt contends that it is often due to catarrhal iiiHammntion of
the pharyngeal bursa (L'ebcrdie Bedeutung der Ihirsa pharyngea, n. s. w.»
WiesbaiJcn, iKfi,"!); this is uniioubtecUy true of some cases, but not
of a large percentngo. Many cases are apparently caused by sub-
mnoous thickening at the sides of the iwaterior part of the vomer.
I am unable to explain the direct relation o^f this tliickening to the dis-
charge and chronic inflammation, but I am satisfied of \\» eti(dogical
relation from the fact thai its reduction will often greatly benetit, if not
J>ISEAS£S OF TBS NAUO-VHAHYNX.
completolf cure, tlie post-imHal aiturrli. Tobacco-smoking ia a com*
puratively frequent rauge, and the exrefutive n»c of alcoholic etimnlanti
miiT produpo congestion and inflammation of the mucone mombrone
liore as in other localities.
Symptomatology. — In slight catjcs the patient is merely trDublit]
with ft sensation as of something sticking in the naso- pharynx, bat
usually the secretion ia tenacious or dry, and difficult to dielodg»,
and gives the patient great di»oonifort^ causing him to hawk nod
make fret^uent eiTort« at its removal. Distinct articulation is fn^-
quently prevented, partially from obstruction of tlie iiaso-pharynx ami
partially from a mild form of chronic larvngitis which often roexisU.
Theee conditions are most annoying early in the morning or after eating,
when the patieot's efforts to dl&lodge the secretion may prodaco nauBea
or even vomiting. The symptoms are especially troublesome in da[ti|i
or chilly weather, or after uutchiug cold. Dull aching in the upper part
of the throat, and sometimes weight and pain in the occipit^tl region,
ore e:[pcricnced by some of these patients, but the hitter is apparently due
to the rhinitis rather than to the jiharyngitis. The sense of hearing ia
often obtundod, in consequence of extension of the inflammation throagh
the KuHtachiun tube.
Upon examining the pharynx, tenoctoug secretion will nsnnlly be
observed coming down from the naso-pharynx, upon tho vault of
which similar secretion or adherent crusts may be foiud. The tnu-
ous membrane is more or less congested and usually lias a relaxed
aiJpcaraiicc, often cxliibiting one or more enlarged follicles, esptn*i:;!ly
just back of the posterior pillars of tlie fauces; iudeedj, iu many in-
stancea this affection appears to be simply a chronic fvUirular inflam-
mation of the upper part of the ])harynx :iaK«ciatetl with a c?mihir condi-
tion in the oro-pharyni. Tho diseased follicles referred to appear as
email, oval or round, reddish gntnulutions, usually raised about tvo
millimetres, and from four to eight millimetres ia diameter. Snutll ero*
sions or ecehymotic S]>ot8 arc sometimes seen, and in youTi,^ subjects
adenoid growths in the vault arc frequently present. The K.mtachhui
orifices are often congested and swollen and sometimes blocVcd with
secretion. Varicose veins are often observed in the pbaryrx, and
the pillars of the fauces are usually congested and thickened. In ad*
Tanced cases, atrophy occurs, with accompanying dryness and irritiHJon
of the parta. Whatever the condition, there is apt to be a similar affec-
tion of the oro-pharynx.
PiAONfi)4is. — The diseuso may bu confonnded with adenoid growth!
or other tumors, or syphilitic disease of the parts. We can distinguish
atlenoifi and nlhcr (jrowths by inspection and pal|Mtion. and ^<y/iAi7iVi«
ffi^entt> by a consideration of tho history, and by inspection, which U
liable to reveal mucous patches, condylomata, ulcers, or cicairicoa.
Pbogxosis,— The disease may extend over a period of many yvan,
HHJNO PHAR YNGITIH.
COO
but is not dangerous to life, and^ contrary to the popular belief which ia
fostered among the laity by designing charlatans, there appears to be no
uudeuoy for it to extend downward and eventnate in palmouury iuber-
ciilosiis. When the ufffCtion Ims lasted for many years it is iloubtfnl
whether it is often cured, but in the majority of cases removal of
tbti naeal obstruction will greatly relieve, if not cure, the disease in the
n.iso-pharynx.
TiiKATMEST.— As a mejtns of prophylaxis the patient should be pro-
tected so far US possible from sudden changes of weather; he should
uvoid dampness and chills; summer und winter constantly wear woollen
undcrcluthes; keep the skin and digestive organs vigorous by the ob-
Ecrvance of pruper hygienic rules, and when exposed to nn excessive
:ininunt of dust in the atmosphere, protect the nares and pliarynx 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
(he nnsat disease which has caused it. Constitutional treatmont is indi-
Fio. ftU.— Puffr-yASAL Bntisas c<^&>U«>.
cated for debility, and faulty digestion must be corrected by appropri-
ate treatment, as has been so judiciously insisted upon by Heverley
Rubinson (I'ranaictions of the American Tjiryngological AssiHiiation,
Vol. X). In the direct treatment of the niwo-pharynx, cleanliness
is of first importance. This may bo accomplished by means of the
hiiniii douche, nusiiJ insuOliition, the postnasal syringe (Fig. ^'i'Z), or the
free use of ujxsal or post-nasal atomizers. The salicylate wash (Form.
187) ia an excellent detergent application ; but any alkaline w.ish, ns. for
example, sodium bicarbonate or equal parts of sodium bicarbonate with
sodium chloride 3 i. ad 0 i. of water, or Dobell's solution may be nsed
instead. It should alwnys be borne in mind that with the nuBul
douche, and to a less extent even with the other methods of cleansing
just recommendud, there is some danger that fluid may pass through
the Eustachian tube to the middle our. This niay 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
mode. The soliitiou should always be used lukewarm.
The parts having bucn cleaiij^ed, Mackenzie specially recommends
the insufl1atii)u of luitriugunL {wwdurs. The old-time application of a
solution of Bil\ernitrate, varying in strength from ten to sixty grains to
the ounce, will hi; found beneHcial in many cases; and astringent or
atiniulatiug sprays, either aqueous or oleaginous, are often desirable.
39
CIO
DTSBA/iES OP TUB yASOPOARYNX.
I
When there ore enlarged follicles without great congestion, ami whero
the ]>iirLs remain moist^ I have scon great benefit from the iu^nfllation,
two or tliree tinier per week, of two or three grains of ii powder con-
sisting uf berbcriuo muriute cnc part mid tiugar of milk or acaciu two
parts. For excessive secretion, eitlier lieru or in the nures, I hare found
lerubene buiitficiiil in the proportion of about ten minims to the ounce
of liquid albolene, conibinod or not with other subetuuccs rs seems dc»*
sirable. If the parts luivu a teudeuey to dryness, after they have been
thoroughly cleansed the aj>pliciLtion of an oily spniy containing from
two to six grains of carbolic acid to the ounne may he mode by tlie
imtient twice daily hju.!k of tlie palate, or in wise lie cannot do this &
weaker spray may be thrown through the nose while the head ia held
backward so that it will run gradually down over the pharyngeal w»U-
Indeed, the same remedies are applicable hero as to the nasal cavities,
it being remembered that the naso-pharyux will tolerate advantAj^eouslj
applications from llfty per cent to one hundred per cent stronger than
the nasal cavities.
THROAT DEAFUESS.
Morbid changes in the naso-pliarynx, particularly when near th«
orifice of the Eustachian tube, frequently involve the hitler and extend
to the middle e-ar,atrecting more or less the sense of hearing. ProbaUf
most v&ses of deafness are uf tlii^ nature.
ETloi.tMiY. — The diseaee may depend upon a paretic condition of the
Eustachian tube, or chronic inllanimatory thickening of its lining mem-
brane, or any morbid state of tho nneo-pbarynx which gives rise to ob-
struction of the Eustachian orifice. Edward \\'oakes considers tlii*, or
motor {Hiraly^is, the fundamental cause (Diseases of the Kose). Ue
ulso attributes the deafness to exaggerated folds of mucous memhrane
at the orifice of tb,; Eustachian tube, and to folds projecting from the
sides of the pharynx, and to partial obstruction of the nasal cavity bjr
exostosis, or hypertro]>hy of the turbinated bodies; whereby during
inspiration, but esi>ccially deglutition, the air is rarefied in the tym-
jwinic cavity, jiroducing depression of the drumliciid. •Pcrsislfncf of
this condition eventuates in permanent collapse of the membrane and
resulting deafnesit. One of the most fn-tiuent causes of throat deufnrsa
is enlurgt-ment of Lusclika's tonsil. Atrophic rhinitis Is aUo a naxi«c;
tho affection has also been attributed to syphilis, diphtheria, rheuma-
tism, progressive muscular atrophy, chlorosis, and extreme ann*mia.
Svwi'ToMATOMKiY.— .'Vccording to Wuber-Llel, the chief featnre of
the complaint is piralysis of the tensor jiahiti muscle (Mackensie;
Diseases of the Throat and Xose^ Vol. II). In severe cases there is col-
lapse of the Kustachinn tube, the air In tho tympanic cavity become*
rarefied and the tympanic membrane yielding to the pressure of the
THROAT DEAFNESS.
nil
(h'natT (lir ou its external Burfticc becomes abuorntally concave {drawa
in) and as this movement of the drumhead is necessarily traiisitiitte<l to
the tdiaiii of ossicles, the foot-plate of the stapes is abnormally pressed
iuio the oval fenestra. Secondary changes soon follow, passive conjjes-
litjii of the tyuipaiiic cavity lends to trophic chaTig(\s of a more or less
cirrhotic character, consisting at finst in the groM-tli cjf a low form of con-
nective tissue, with subsequent atrophy. Adlieaion takes place, tho
stapes becomes fixed in tho fenestra ovaiis, and the labyriiitli becomes
the seat of disuase. The patient often roniplains of tickling' or senitt-h-
tng scnsiitioQ^ in the throat; of snapping sotnuls heard during maslica-
cion or deglutition; of fatigue in listening, and ilifficulty in hearing
during general conversation, though be may readily underf^tjind ono
[it'i-soa talking alone; and often of noises in the heml and giddiness.
Ducxof^is.^ln the mildest form, according to F. C. Ilotz, pror
fessor of ophthalmology, Chicago Polyclinic, the tympanic membrane
is of nornnil color anil hrigbf-nesH, bnt abnormally concave (personnl
letter from F. 0. Hntz, Jnly, ISIH). In the medium variety, attended
by acntc InHammation of tlie middle ear, the membrane is congested ac-
cording to the degree of intlammntion, and the injt^ction may be limite<l
to a small streak along the malleus or may o{;i;upy tlie upper tlaccid
portion only, or It may spread over the whole membrane. The Eusta-
chian tube is obstructed, and tlie tympanic cavity contains more or less
setireiion, tlio pro«pnt*e of which is in<licated by characteristic riilea
heard tlirougb thii ausculUiting tube while insufflation is made through
the P^ustachian catlieti^r. lu the must serious variety, the drum mem-
brane may bu bri^dit and clciir or dull and opaque, its movements may
be impeded indicating sclerosis or anchylosis, or they may be excessive,
indicating airopliy, and Che Kustaehiaii tubes may bo either closed or
uiiusually patent. Tho drum cavity may bo either dry and empty or it
may contain inspissated mucus, and we must distinguish by the tuning-
fork test whether tlie deafnesa is due to changes iu the middle ear or to
lesions of llie internal ear. If the patient hears the sounding-fork bet-
ter when placed near the external ear than when touched to bis fore-
head or .held between the teeth, we must assume that the internal ear is
invoh'ed; but if the forkisheani better against the forehead orbetu'ecn
the tceib, we conclude that the chief cause of deafness is located in the
middle ciir.
Phoonosis. — In tho mild variety tho prognosis is favorable provided
the congestion and swelling of the pharynx and Knstachian tube can bo
removed by o(T;isional insulflation. In tlie 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 bearing 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 fnternal
ear is affected : but even iu these cases the prognosis is somewhat mora
G13
DISEASES OF TTIS NASO-PIUnYNT.
favoniblo if there ure rAlefl, indicating the presence of mucus in 1)»
tympiinic navitv, or if, lu aonietimos biippeiie, thoro is murketl anil fre-
quent varialion in Lbe heuring jion'or. In tho inajorily of cases no im-
proveineiit cjiii 1)« expected, aiul wc ure furlunato if by treattnent we an
chook the ouvrard progreHs of tbu diseuee and euve ihe putieut from »U
solute deiifnesB.
TuKATMKST. — Our first effort should be directed to removing
cuUBc uf the diseuac. Obetruetioii uf the uaso-pbnrynx, or of thu no
by the various forma of inflaniDiation or exuatosis or tumors, ebooM
removed and the inHammatiou vnhdued by the metbotls already vq\
gested. For the chronic thickening; and congestion of the rhim
pharynx, with extensiou to tho Knstiichmn tubes, tho frcqnent npplica*]
tion of strong sohitions of silver uitrnte, varying in strength from for
to one hundred and twenty grains to the ounce, luive been must bigbl]
reconinieiidt-d, and tiic various alteniLivefi, astringents^ and &ticnuInDt
already recommeuded may U; tried. In a considerable number of
:tj
Pui. SSK.— CCRtts' VAPomucit. For ludatloo of tlt« fiumachian tubn aqi] m\M\^
bottle Bbould ly> btrldlo iIm IiiuiiI wlUi ttw Umtntt nkinipifaln Uix kIasi inilh W
lUMrlb. UiD (tikunb cotnpM^Iy town <.>t)B and U>e kUm biill> foiiiKij' M* Um<
rtjtiic band icrn^r" ^^^ niblnrr boll, umI stmaltiuipooaly wfUi tin* nifiit rniirirliill> r
Uio RuUttrnKi.n uuinbtfrtir iireaMtm Utwa Utetmlb will lntliiT>*11i>- iiililtHi* rur "
o(Utiii|[A Kwalhivr ot uau^r. Tills mKluxlnt tn!Atin«ut ul llu: KiiMiu-tilan tui
tadllM.*Ukrr, chlorofurm. e1c..(lro)>p>->l upon Uw fipontre ot Un? Tn|>'Tl7iT. Ig r<
efllcackKUi by H. Holbruuk CurUn. By muoriug U10 apuuj^v, Uis liumuiieBt .1 .
pow-dcT bloww.
I have obtained much benefit from spraying into the nasO'pharynj and
Kustachian tubei), while the nostrils are held, a i-ohition of two to fifv
grains of menthol to the ounce of liquid ulbolcne. Thi« may be readilv
done by tlie Davidson atomizer Xo. fUt with the long tip (Fig. Ht<i), and
there is no danger in n8ing tifteen to twenty pounds pressure, for t^
palate will yield before injury will be done to the drum membrane, .b
stated by llotz, in addition to the trealmeut of the pb&rynir, in uiU
cases, when the chief trouble is the iiiBuHifieut ventilation of the
panic cavity ou account nf the catarrhal swelling in the EuaOichian tol
it ia only necessary every two or three diiva to ftupply tho drum cavil
with fi:esh air by means of Piditzer'a nietlKMl. IJiit when the tympftnit
cavity itself is the seat of tnitarrbal changes the nse of the Knstacfaii
catheter 18 indispensiible for the eflicient introduction of suitable reine*'
ItYPSHTROPRY OF TffJS PUAJtYNGEAL TONSTL, 613
diBS. Whoi) the auscuUnting lube reveiiU the presence of mncus in tho
Kiistacliiau tube and tympsmic chanibor, wiirni solutions of boric ncid
(gr. X. ail 3 i.) ore very serviceable. Two or three drops of this are put
into the catheter and blown iuto tho eavity by means of the air-bag. In
the atrophic forms of otitis media, stimulating vapors are recomineudedr
m of ammonium muriate, eiicatyptol, or beu2ot.
In caaea of Bever4>r grade with acute inllummatioa, be specially
recommends hot solutions of cocaine four per cent, frequently dropped
into the external meatus, and warm couipreases covering' the ear and
mastoid region, together vrilh careful insuQlutioiis through the Eus-
tachian catheter to ventilate the drum chamber and clear it of accumn-
lated mucous secretions^ and at the same time spraying this cavity
through tho catheter witli solutions of boric acid, eucalyptus, or other
suitable remedies. In this variety, rapid and copious secretion into tho
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 nse of iron, strychnine, and phos-
phorus, and suggests that in the later stages nothing remains but the
doubtful openitiou of paracentesis of the tympanum or tenotomy of the
tensor tympani (Diseaeea of the Throat, Vol. II).
These cases are most unpromising, and it is only by carefully adapt-
ing the treatment to the requirements and tine peculiarities of each
individual patient that wo can hope to prevent even absolute deafness.
The details of treatment are njore properly set forth in works on diseases
of the ear, uud the treatment itself should be carried out by an osperi-
enced aurist.
HYPERTROPHY OF THE PHARYNOE.VL TONSIL.
Synonymt. — Hypertrophy of Luschka's tonsil, adenoid growths ia
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 tho voice, and in many cases partial
deafness, with catarrhal syniptumii and more or less deterioration of the
general health. It is particularly oleerved in damp clirnat<?s. It com-
monly occurs in children, but is not infrequently observed in young
adults.
ASATOMKAL AXD PaTIIOLOOICAL C'HARAtrTERI&TICS. — The ch&ngCS
in tho glandular tissue closely resemble those which are frequently wit-
ueesed in the faucial tonsil. The gland is of a grayish or pinkish color,
though sometimes even of a bright t<h\ hue, and the surface often hm
a lobulatfd apjiearance. Kulargeil blomi vesselti are not present upoa
the Borface, an la many other forma of abnormal grov^h. The ti^ue
614
DI8SASES OF THE NASO-PHARYyX.
may b« soft and friable (Fig. 'm\) or exci-f^Jingly firm. Jl coubuu o£
lyiiiplufid structure aud iucrtaii^d conut^rtive tiseu** giinilur tu tliM
found in bj^icrtropb)' of tbe fancial tontul. The efluct upon rc«piraUou
and thu general bealtU depends upon the itize and the nniouQt uf ob-
struction.
Etiology. — Heredity evidently bears some part in tbo etialug> of
the affecition, ulttiougl) etatistice have not yet proven tlic point ; fre-
quently several children in the same fuuiiiy will
be found afloctod. It nppears to be due* in matt
cases to the same causes as enlargement of tbe
fauciol tonsil. The exantbcmatous difiunsesand
diphtheria are common caitses, and frequent
colds, as well as the strumous and rhenmalic
diiithc8**8. appear to be predisposing factors.
MePoniild (Uitsoosea of the Nose, 1890) utlribntM
the majority of cjisoe to obstruction of the naai
Fw. »i.-KBO(o«»ric v«w i»assa)ies, and consequent rarefaction of the air
or VMrTATioKs iM rnx VAirLT ill the niiso-pharyux during respirution. This
or turn P«*imr« (Ooi»). theory, however, would seem to be oppoeed to
the fart that nearly all cu8<m of cleft palate are al£o affected by the dit-
ease; it cerLiinly dot's not correapond with niy own obfterviitions, al-
though it ig true that in many cases anterior nasal stenosis does esint.
Symptomatoloov.— There is nsually u history of mouth-lireatliinp,
which has lasted fur several mouths or years, with all its attendant
aymptoins. During this time the pnrentti have been continunlly di»-
turbcd at night by the loud snoring of tlie patient. The child isnsiially
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 iloes
not wear off for several hours. Spasmodic cronp ia sometimes itp]iurently
caused by tbis condition. Nasal or post-nasal catjirrh and partiiU deaf-
ness are not infrequently present, and it is common to find that thuM
have conie on after diphtheria or one of the exanthemaUins di«ea«A.
The deafness appears to be due to obstrtictiou of the Eustachian tube by
the bypcrtrophied gland, and in some cases to gradual extension of
inflammation to the middle ear. Acute earaches arc frequently t?auMd
by thi^ affoction. The deafness is sometimes outgrown as the gland
atrophies during advancing life, uud it may ofteu be cured by removil
of the ahnornial tissue, but if allowed to persist for a few yeans it is likely
to beironie iiermanent.
The voice is thick and indistinct in proportion to the iuterferenc*
with nH.sal resonance, and it becomes im|>oB8ibIe for the {>atient to sound
the letters m or n, esiieciallv when occnrring before a vowel, t and 4
being sounded instead. In such casos the voice sounds as thimgh ths
jiatient had a i-old in the head. Wroblewski of Warsaw [hiti:rnolk\nak
KUnischc liuuilnchttu^ Vienna, A nnutti of the Vniveraal Medical ticimcnf
i
HYPKRTROPHY OP THM PifARYXtiEAt. TOXSlt.
AM
189S) fonnd adenoid growths in orer fifty-KTen per cent of on« buiidrad
and sixtT deaf and dumb patient«. Shortneic of liivath tipon fxertion
is oft«n noticed, and where children nre trained to keep the mouth
closed we may frequently observe tiatehing or sifEhliig respiration at
intenrals, an effort to compensate for the ennstant Uetieieiicy of air; and
it is often neccaaarj- f or these patients to rlenr out the mueus from the
naeo-phar^'nx by the act of hawkiug. A barking;, reflex i*oujih i& »^n)e-
titnee present, and occasionally a spiisniodic affection simnhttinji; whoop-
ing-congh. Often a peculiarly dit>ajfreenblc na^l screatns becomt« a
fixed habit. Occasionally^ though not in the majority of casee, rhinor-
rhtpa ia present.
The mucous membrane of t:h« nostrils and anterior inual cavi>
ties is found abnormally swollen in some cases, and in tlio majority
the fancial tonsils are also enlarged. The uvula, pillarv of the faucos,
nnd edge of the palate are genenlly slightly coiigeiited, and frothy or
muco-porulent secretion is found nj)on the pharyngml wall dropping
down from the niiso-phurynx. lu many cases the phiiryux is rriltued
and the follicles are suollou, as in advanced enst.^ nf follicular pharyn-
gitis. The follicles, which arc liable to bo paler than the surrounding
mucous niembmne, usually incrciisc iu size towan) the u)>per part of
the pharynx, until just above the edge of the palate they become eon-
timious with llie ghinihiUir eiilargeiiieiit, lu jiottlirior rliiuoscopio ex-
amination we kIiouUI observe eiipeeially the poKli-rior pluiryngcal wall,
the vault of the pharynx, and the choanie. Irregularity of the npper
ontlinoB of the latter are among the most easily recognized signs of the
d israse.
Upon the pharynx the growth has a cushiondike appearance, more or
less nodular upon its surface, hut in rare instances it hang^ from the
vault in soft, pendulous musses resembling condylomatous warts. In
color it is nsnally 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, wliere atrophy has taken phice^ the remains of the gland may
sometimes be seen as small excreBcenoes. Palpation is often desirable in
adults to determine the consistency of the growth, and it is frequently
essential in children because of tlie difficulty of rhinoscopii> examination.
In pcrformini; it, a gag having been placed Iwtween the tet-tli, Ihe fore-
finger of the right hand should l>e carried back to the pharyngeal wall
and then turned upwanl behind the palate, where it at onco detects the
abnormal growth. Th'use unfamiliar with the normal feeling of the part
should ul first search for the septum and carry the exauiiimtiou from this
backwanl and upward along both sides, t^litjht bleeding usually follows,
though the examination is not H|>ccially painful to the patient, Chronio
pharyngitis, rhinitis, or luryngitii* will hn fonnd prosent in some eiUNMit
and occasionally deformity of the thorax will have resulted, ai shown in
the pyriform chest or pigeoD'brcast alroiuly referred to in sjwaking of
hypcwrtrophy of the tonsils.
610
DISSASSS OF TliR NAHf^PItARYNX.
DiAaxosis. — The nffection ia to be dlstiuguiEbed from misiil inucuvs
polypi .ini] nbi-oi(] tumors by inspection uud ptilpulion.
We se](lom find niucoint pnh/pi ut no early lui ago as hypertrophy of
the pburvngeal tonsil; they urc of a Iighti>r color, scnii-tninslacvnl,
antl usurtlly bave (.-Diirpiiig iiltobs their surface blood vestielB, wbinh ure
not soon in this diiM?ase. They usually spring from the naiUil caTities
and may be readily detected by anterior rlunoseopy.
We thtHjifirijtd tumors much harder than the bypertrophied glandular
tissue; they are frcquetUly attended by severe epistiixis, and, upon being
touched, blel^d easily i.nd profuaely. Thoy are naunlly of a bright red
color with blood vt-swls appnrent npnn the surface. When hirgc, Ibey
CiiuBC distortion of tlie neighboring parts. \one of these signs are ob-
Berveil in hypertrophy of the pharyngeal tonsil.
pRoosoais. — Probiibly in Hcventy-five per cent of the cases the
glands if left to itself, would atrophy at about the twelfth or fourter-iiih
year of the pationt's age; but in the mean time irreparable mischiuf
to the ear, the voice, or tho general beiilth may result. In the re-
maining cases tho gland gradually diniinishe? in size, and disappears
before middle hfe. M'hon tiio uftectiou has existed fur a long timo> the
hearing may be permanently impaired, but usually removal of the gland
greatly benefits this condition. The voice ia not always perfectly re-
stored, because a person having learned to talk with an obstruction in
tho naso' pharynx may require a eoiisidcriLblo 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.
Trratment. — Internally, particularly for anamio children, I have
occasionally found the syrup of iodide of iron of value. Sometimcff
other preparations of the iodides will prove bciieGcJal and probably
calcium chloride might cause some rediictiun of the gland in some in-
stances. As a rule, however, medicinal treatment ia 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 tlicre are no coutra^indicutious tv o|>eratiug even on young^
children. lu a few patients whore friends have objected to uu operation
1 have employed chromic acid encceasfuUy. In using this caustic 1 fuse
a few crystals on the end of a flat nhimininm probe and pass this throngb
the nostril to the enlarged pharyngeal tonsil, whore it is held for two or
three seconds. Previously tho nares may be oiled to prevent the {M»«ible
contact of any of the acid with its mucous membrane, and a small amount
of cocaine may have bceu applied to the iiarea 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 lereral
hours afterward, but it is uot sorere. Tho applicatiotu may be repoated
UXPSRTnOPHY OF TBE PRARYNGJSAL T(J^t<IL.
B17
uncf in frnm three to five daya, being made through the opposite Doetrlls
alLuniaU*!}'.
Tlie giilvuiio-flimtory may bo used to destroy tho prowth, a bent
elecLrodt' bi-iiig pa^iiiH) uj) bt-luud tbe jmliito, hut the itiethiHl i& painful,
tedious, and uUogflUer not very satisfactory. Scraping off tbo gland by
means of a long finger-nail or varifuis forms of curettes is in favor with
some operators and may in certain ttises answer an excellent purpose;
but usually the operation is leea complete than when performed by
Loewenberg's forceps, and therefore re(airrenoe Is more likely to tike
place. licraaomt'iit by nioans of a iMsnt. snare is praetiseil satisfactorily
in some cases where the growth is very soft. Some operators prefer
scissors or putich-liko forceps, but they are both open to some objections.
The scissors-like instruments which I have seen may he sntisfnctoi-y
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 he 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 modifit-ations, espe-
cjully that siiggesled by Jolin N. Mackenzie. I have h;Hi a similar in-
strument made with shorter blades, for openiting upon young children.
In performing tiie operation upon adnlts, it is often sufRciont to an-
esthetize tho 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 tho palate, and a similar
solution by means of a syringe with a long blunt noxzle, to the upper
part of the gland through the narcs. Tho application should be re-
peated about once a minnto until the part is fairly anesthetized, whluh.
Fm. Wf.— MAOESMSS'a UtmincAttox ur LuRwuiBuut'i Tokcm.
Willi take about ten minutes. A self-retaining palate retractor should
then he adjusted and tho patient may hold tho tongue with a depressor.
The forceps are then inserted with the aid uf the rhiuuscopic mirror,
and thus one ur two bites may be made accurately, but subsequently tho
blood obstructs the view and tho remainder of the ajwratiou may bo
postponed to another sitting or completed by the sense of touch if the
patient will permit. Usually, even with cucaitie, after two or threo
618
DISEASES OF THE HJASO-PHARYNX,
bit06 have been luade^ patients prefer to buve the rcDiaindor of the op
«rution done nt onothfr time. Two or three sittings, liowcver, will be
eiifficient in the nmjoritv of tliese vn»QA. AVht-n un uiiiesthotio in objected
to, or if for txny n-a'-uii a rompleli; o|i*!ralioii will not be permitted, a
eingle, Urge excision may be recomracuiled when the gland is Boft
ThiB, in tho oaso of oitlier rhibirpii or iidnU«, will gonrrally give mach
relief, lu children cliloroform or ether should he aJuiinistered. ehluro*
form being preferable. When anEesthesia is complete, the child should
be turned upon its ubdonien and fuec. tite mouth coming ot-or the side
of tho Utble. A gag aliould tlien Ih* in^serted to hold the teeth apart.
Honrotin'it tra? ix the nitnplent one that I Itave lu^en for 1hi» pttrpoM*. tiul
Kometi(ii<»i Aliiit^'lmiirs will be fount! preremble, especiully for tur^^e children
<FiK. 113).
The eurgenn standing at the right side of the table, facing the
patient's head, pa^sea the index finger of his left h:ind behind the paUte
into the naso-pharynx, where it ia retained as a guide for the foroepa.
The forceps may then be passed along the dorsal aspect of the dnger
and applied accurately to the growth. Thus ]>icce by piece the gland
is extracted, the forceps being guided each time by tho Cngvr until
every part haa been extirp:*ted. Cure should be taken to avoid seising
the posterior e<lgo of the vomer or the projecting end of the Enst»-
ehian tubes. Tbo latter often feel to the nneducated finger like ab-
normal growths. If care is taken not to tum tho forceps sidovays,
tliere is but little danger of doing damage, providing the operator is
familiar with the noriniil condition of tho parts. Sometimes mascoi,
located just hack uf the Kutituchiun oritice^ are liable to be overlooked,
but the most common difliculty arises from aniall pendent maasei
which hang just back of the choanse and are liable to be crowded for-
ward b)' the linger into the posterior nares. It is eometimea quite diflR-
cult to get tho finger iu front of this maw and push it back whfeK it
may be caught with the forceps. Some o[ienitor5 attempt to scrape ihi*
portion of tlie growth awiiy with the flnger-niiil, but this effort ciin oulv
be partially succesAful. When I find dilhcuit}* in removing this part with
tho poBt-nosul forceps, I employ a straight nasal forcejia with cntting
edge (Fig. Sl^O), which I puas through tlto nostril, and guide to the proper
point in the vault of the pharynx witli my finger still retained behind
the ]udate. In this manner a piece which might otherwise be difficult
to catch is very readily remove*!. This procedure also enable« na to
determine whetiier the n:tsal foasa? are free, or if they are not to break
down any adhesions or slight bony obstruction. With the patient in the
poditioii just nH!ommeude*l, there is no necessity for care iu swabbisg
out the throat, as the l)l(>od cannot run w/) the trachea. With tbc
patient on his back and the head thrown far backward, oe reoommen<Ied
by some English surgeons, it is neceasary to swab out the throat and
HYPSHTROPUY OF THE PHARYNGEAL T0N8IL.
r.i»
naso-phan'nr frequentlj to prevent blood from getting into the air pas-
sages. There is usually coTiaideraMo hlewJing, but fhia atopd aa soou as
tlie oj>eratiun is conipIeteO. If undue lieniorrbitge sliotild occur, the
Tuult of tlie pharynx mav be packet] in thu iitiual way or, as I prefer,
with » long strip of g:iuze whirh is pu^cd tliroiigb the narca. This strip
is saturated with a thick solution of tannic and guUic acids, as recom-
mended for checking hemorrhage from the nares. Tliis nhonld be
pushed back through the nares, and packed np behind the palate with
the finger, which is inserted through tht* month. The nnrea should also
be packed, and the gauze brought forward to the nogtril to prevent the
packing from falling into the throat. This packing should be removed
within from twelve U) twenty-four hours, to avoid the danger of exciting
inflammation of the middle ear.
When the operation id completed, the month should be wiped out and
the nostrils squeezed to press out what bicod is pcss-ihle, 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 tu keeji him as much as possible
upon the face till he haH thoroughly recovered from the chlurofurm.
This latter suggestion, however, is not very imjwrtant, and it is seldom
followed. The patient should bo 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 1 neually have insufHatians made through the nostrils
two or three times during the day, of a powder of two jKjr cent of
cocaine, lifty per cent of iudol, and sufticient xugar of milk to make one
hundred parts. A simple detergent alkaline spray is not objectionable,
but washes should lie avoided for fear of injury to the middle ear; even
Rpniys will sometimes find tlicir way np the EusLichian tnbe, and there-
fore, unless by the odor there seems to be n special indication for themt
I prefer to nso the powder in connection with an nntiseptic oily spray
oontaining thymol gr. J, oleum caiyophylli I'liij., toliquid albolene 3 i.
As a result of the operation there is nsimlly a little soreness of the
parts for a day or two. but not suWcient to interfere with swal-
lowing. There is sometimes slight elevation of temporatnre; the im-
provement in brciithing is marked nitd 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 bo expected within a few days or weeks, but
reooveni' from alteration!! of the voice is sometin^es less rapid. Some
danger of otitis media exists from the liability of blood or other fluids
passing into the Sustiichiau tube, but thus far no pernuinenlly bad
results have been observed from it. In case it should occur, the con-
tinuous nse of hot \vater In the ear, or hot water with glycerin and
opinm and dry heat pxternnlly, are the best remedies that can be
employed.
In some cases nasal obstruction will be found to exist after the opera-
t
620
DISBABBS OP TBS NASOPffAJtTSX,
tiun, and it must recpivo appropriate treatment subscqueutly. The fiofll
resuUs of removing the liypi-rtropliieil plmryugL*uI tonsil are tbe meet
Batisfactory of any witli which I am acfjuiuuted in tlif iloniain of special
surgery. Tliu operation ahouUl not bu rccommeuded unices the dw-
oased gland \s large enough to interfere with nasal reBpiration, Bt Irast
when the patient has a cold, or nnless it affects the Rense of bearing i.iy
pressure on the orifice of the Eustarhian tube. In cases suitable for
the operation, tlie patient's general condition undergoes a rcvolaiion
for the better, which nften astonishes oren the phyBician, and gives the
friends most unbounded siitisfaction. In a child of from three to six
years of age it is not unusual for a gain in weight of from twenty to
tweuty-Gve i>pr cent to occur within five or six nionthB after the gland
has been removed. I have never Been 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.
RETRONAaAI. FIBROUS TUMORS.
Fibrous tumors of tlio naao-pharynx are cliaracterized by obstnis*
tion of the noee and dyspnuDa, frequent epistaxis, and, when large, by
great disfigurement known as frog face. They usually occur tu
young adults, sometimes in infants, but seldom after tlie twenty-fifth
year of age, and they urc much more common in men than iu women.
The affection is so rare that in over five thousand records of priTila
patients suffering from dlseatie of the throat and nose I find bat aix cuses
Anatomical and Patiiolootcal Characteeistics.— The growtht
are generally smooth, hard, and unyielding, red or purplish in color,
and sometimes ulcenited or bathed in a sanious secretion. They may
spring from the periosteum of any portion of the roof or lateral valb
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 cerviciil vertebra). In character they arc like fibromata in
other localities, but occasionally are composed quite largely of ereotila
tissue. They are oxceediugly dense, destitute of elastic fibres, and the
blood vessels in their interior arc small, while those in the investing
membnino are larger, and have brittle wallt; which render them pccol*
iarly liable to bleed. The tumor is usually single and attached by a
broad pedicle.
Etiolooy. — The etiology is unknown.
SYMnoMAToLonv. — The patient first experiences a sense of obstruo-
tion in the naso-pharynx, and finally one or both nasal paaauges become
occluded. Many oomplain much of fatigue and droweincss, probably doe
to imperfect flOratton of the blood. Later, the symptoms depend npon
tbe direction which the tumor m;iy take in ita develupmeut, IX it
extends toward the throat, it interferes with deglutition; by preesu*
RETRO-yASAl FISROVS TUMORS.
621
upon the Kiistaohian tulic, it m:iT excite inflammiition of the mictdic car,
with more or less pain iitul <)enfness, Wlicti it projoctg forwar<I» the
nasal bonps may bo fiopiirateJ, tlie eyes pnshu*! upan, and tlic ItiiIko of
the nose lUittenei], giving thocharactmstic deformity ahoudy mentioned
as frog face. Pressure upon tho lachrymal Uueta ciiiieoa epiphora.
Sometimes the tumor extoiuU into tho mitrum of ITijrhniorc nnd gives
rise to swelling of th<f cheek. It may perforate and fill ihe sphenoid
cell)', and eometimoB, rs in one inefcincc I have seen, it may canso
absorption of the bnsc of tho skull, pressiiro upon the braiu, and fatal
meningitis. The fillin^r ^p of the naso-phurynx interferes with urtieu-
Iiition, giving a nasiil tw;ing to the voice, ami, if tho tumor ia largo and
extends downwanl, great dyspnoea may occnr. There is usually profnse
purulent or muco jnirulent aeeretion, sometimes ofTensive in character;
nnd opiBtiistiK, frequent and i-nmetimep chnjperons, is a common symptom.
Dysphagia may bo present. Uy inspection of the anterior and posterior
uurcs, (ind palpation with the finger, the charaeteriBtics already pointed
out may be readily detected.
DiAiiSOsi.s.— Tho growths are liable to be mistaken for mucous or
fibro-mucuus polypi and sarcomata. From the latter they can only be
distiuffuislied by a raicruseopic; examination. The essential points in
tlie diagnosis are tho age, sex, smoothness and density of the growth,
and frequent epistaxia. They are distinguished trom muentts jxtii/pi by
their color, density, and tendency to bleed. Fibromata are distinguished
from ^fibro-tnucoita polypi or tumors, tho latter being loss dense, )iaving
less ti'ndeuey to bleed, uud by n»icriiscopic examination. We might pos-
sibly mistake hypertrophy of Luschka's io/ml for tibromata» from which
it will be differentiate*! by the ago 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 regeUtions in the vault of the
pharynx bleed easily, are soft, irregular, and occnr at an earlier age than
tibrouB tumors,
Pitoososis. — The growths teud steadily to increase in size, and,
nnless recognized and remove*!, will prove fatal in most cases, in the
course of four or five years. Kvcn when removed, there yet remiijus a
strong tendency to recurrence, but fortunately, if they can be kept in
check until the patieat -hae attained tho uge of twenty-five, there is a
tendency to spontaneous arrest of development.
Tkhatmknt. — If jKjssibli', tho tumor should bo romoved through tho
natural passages by the fcmsour, galvano cautery, or by electrolysis.
When large, it may be necessary to adopt tho more severe meiisures
recommendeil by Dupuytren, Kougc, Jjiingenbeck. Chussaignac, (Hlier,
Lawrence, Palaseiuno, or Knmpolla, which consist of various opomtiona
for exposure and removal of tho tumor through the face that are fully
described in tho textbooks on surgery. I have never seen coses in
which those mutboda wcro necessary, nnd the experience of Lincoln
6^2
DISKASBS OF THE NASOPHAHYNX.
(Transactions &f the American Luryngological ABSoclation, 1883), u
wull as my own experience in two oases, eliow that even largt* tninon
may bi; PxtiriKttctl throngh tho nares and naso-pharynx with eteo
better results tlinii are nhtnined by external o)>emtion8. Tbe sim-
plest operation, and one which is sometimes attended bj 8uoce66,cons)5U
of olActrolysis, which is performed by passing one or more needles
conneoit'd with tbe negative pole into the tnmor from behind the
[Hilato or tbroiigb tbe nares, a single needle connected with the positiTO
pole being introduce*! in a simitur manner. A continuona current M
strong as the patient can tolerate shonld bo used, and the operation
continucii ten or fifteen minntes, and repeated about once a week or
less frequently according to circumstances, until the growth has been
dissipated.
Ligatures have beeai employed for th« removal of these growths, bat
they are less satii^tuctory than tho ^'craseur or galvano-caulcry. In nil
cases when ligation is practised, a thread shonld be passed throngh the
neoplasm and brought out at the mouth so that upon Bc|Mration tho
mass may bo removed before it fails deep iiito the throat aud cat
alnLnguluiion.
When a strong ecr&seur of sufficient power can be passed aboot
tumor, it may be readily and aifely removed by this instrument, but ibe
chances of recurrence are grejiter than if the galvano-cauiery snare is
n8ed. Kvulsion by strong forceps has been pi-aetised in some crises, bat
this method is not generally apphcable. The tnmor may bo cat
away with a curved, blunt-pointed bistoury, curved scissors, or stroug
cutting-forceps: or it may be removed by the gouge. Any of ihc«6
methods are a|>plieuble in some instanccB, but they are apt to be at-
tended by profuse hemorrhage, and if much force is used the resulting
inftammatton may prove fatal by extension to the brain, as in two of
Ollier*s cases (Spillmann: Dietionnaire Encyclop6die des Sciences m^i-
cales, fig., neconde serie. Tome XIII).
When the tumor is pedunculated, it may sometimes be secured in
the loop of an ecrasenr, but more easily in a loop of steel wire tised
with the ordinary smu-e; usually the tissue is so firm that it cannot be
cut with the cold-wire snare in common use. Tho Xo. 5 piano wire
used for mucous polypi is liable to breaks and wire of larger size cmU
the tissue nmch lec^s e:i£ily, so that it cannot be drawn throngh the
pedicle excepting with a stronger and much more powerful instrnmcnL
The galvano-cttutery 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, 1
jwsa two soft catheters througli the naris, endeavoring to carry one on
either side of the growth, and bring them oat of the mouth. Into the
ends tlutt are brought out of tbe month tbe ends of a piece of platinnm
wire about three feet lu length are introduced and pushed on until thoy
RETliONASAL FIBHOUH TL'MORS.
623
come out of the nogtril. I attach a thread to the wire loop to ennble
me to draw it backwai-d in case of failure on the first attompt to place
it about the tumor. Tho catheters with the wires protruding from Iho
nostril are now drawn upon and the loop, passiug back into the mouth,
is ciirrit'd witli the finger or with the aid of a poat-naail snare-appli-
cntor (Fig. 23(>) up abont the tnnior, where it is drawn firmly into
place. Tho catheters are then withdrawn, and the wires intrusted to an
asaistant, who holds them carefully, to prevent tlieir Ijccuniing crossed
in the naris. The ends of the wire are ihen slipped thruugh the tubes
of the galvano-cautery (''cntseur atid fustened to the ratcliL't on tlie handle.
It is deRirable to have the distal ends of itiia electrode i^epnrateil about
a quarter of an inch or even more, so that it may be tlie more readily
passed upon either side of the tumor. Aa the inittrumenl is pushed
into the noeoj the ratchet is turned to tighten tho loop, which is drawn
Pia.SM.— IxoAU' Po«rKAilAL8!rAMAprLTrATo«<M(>ise). For mmorsin nruw-phwynx. Th*
trirv biop b Itrlil In tii<lrh>'« al I> liy Uip alUli-M R. i\ w liK-l> an< lield Hniit}- b>- Uipcvn A. A«tlirli>op
in ouTled behind ili« fNiLair. itii* IjAiIt^ an* 0|K-nf 4 >k> that th« win IncIoM* tiK uinKir; It l» ItKn
tl^liuwrd. the MUL im IihuwtlcI, iIu-hIUi^ It, CI nrv ilrawu allKliUy backward. oaA Uio win i» n-
hwfed uul left In poiiuuu wliito Umi ap|>Uc«tor i» wahdrawn.
tight upon the pedicle of tlio tnmor before the olectrio cnrrent is turned
on.
At it is very difficult to adjust the platinum loop properly with
the patient under ether or chloroform, I have iu recent cases relied
tipon the anesthetic effects of cocaine ; but its bennmbing effect in
this locality is not sufficient to prevent considenihlo pain during tho
burning otT of the growth; therefore, when everything ia in readincse,
] tell the patient to bear (he burning as long as poi-sible, and that I
will stop the L-urrent as soon as he requeets it. The current is then
turned on and the rulchet tightened at the same time. The patient
will enrliire the pain two or three seconds, then the circuit ia broken
anti he is allowed to wait two or tbn>e minutes; as soon as he is again
ready, the circuit is again closed anil thus tho process is contiiuied until
thu pcdick is bnrned through. Tho tumor is thou seized with a pair
of post-nasal forceps and withdrawn through the mouth. TItoro is
litUo or no hemorrhage frum liiis operation.
Whenever as the re«uU of an operation hemorrhage ensues, it may
be necessary to plug the posterior naree. For this purpose I have
634
DISlCAS^a OF THE NASO-PHAHYHX.
fonnd most 8nti6f:iction in parsing through the naris a long strtp ot
gntizo, rcndprt'd gtyptic by saturation with tannic and gallic aciUs^u
recommended in the trefltment oi episiiixis. The guuze is ]iuslic(l bwrk
vith tho probe through the uaria to tlie naso-phiirynx, iwiU there it i»j
packed into Uie vjiull, with tlic finger fiirried up boliinJ the palat
Fiimlly. tiio narie itiielf iii completely Glled tu prevent ttiejOug from fall*
ing into the throat if it ehottld become loosened. Tho tampon ebouldi
i>e removed viithin from twelve to twenty-four hours, by traction upon
tho end protruding from tho nostril, by which the Btrip is gradu»JJy
unfolded. In case clotting of bloud has rcudered the tampon hard, and!
bound its folds together, it should lie softened by gently inje**ting into
the nostril a warm solution of sodium bicarbonjilo. Should recurrence
of the tumor talte place, it Rhonid be troutod while it ia yet small by the
galvanoH»utery or by electrolysis.
RETRO-NASAL FIHRO-MUCODB TUMORS.
Hetro-nasal fibro-mucoua polypi are smooth, more or less ovoid
tumors, varying from two to ten centimetres in diameter. They cbu«
obstruction of tho posterior narcs, especially in ex]iiration, with ooi
quent inability to blow the nose. They are lesn frequent than tb«|
fibrous tumors.
Anatomitai, and Patholooicai, Chai{A(TKki8tic8. — The growths
originate near the posterior opening of the dubaI fossae and are more or
less fibrous or mucous according to their position. Those growing
V
Fio. asT.— Rrr(io-?tAK«L Fimio-MOTtPtTi Tcmn.
largely from tho retTO-nasal space are mostly flbrons, those from tbv
uarca, ns a rule, are chtetly muoouti, iu chanictcr. They do not isiuse so
much presiiure as Dbruus tumors, and do not dii^place the bony structures
like iho latter.
Ktiology. — The etiology is unknown.
Sysiitomatoloot.— The growths develop slowly, and arc attended
by tho well known symptoms of nasal obstruction.
D1AONO8I3.— The retro-nasal flhro-mucous polypi are to bo distin-
guished from fibrous and mucous polypi and malignant growtlis. Thry
differ from jUnatf lun-tir.* in that they are leias deuac« they do not do-
MALIQIfANT TVilURS OF TBE NA80-PHARYNX. B25
I Btroy the bony etructureB, and they ore not ftttendod by frequent epi-
f Btaxk They are disLinguishcd from vtucmu! pvhjpi by their greater
dctnsity, their dnrlcer color, mid by their size and position. They are
1 distinguished from maUynn»t ijruwthn by the history, absence of puin
and heraon-hage, smooth surfnco, and less degree of density.
PROGNOsts. — The tumors grow slowly, and when removed have lit-
I tie tendency to recur.
Trkatmknt. — Tf not too 6rm, the tnmora may be safely torn away
with post-nasal forceps, but they are best removed witli tlie Bteel wire
^cniseiir or galvano- cautery applied as reeommended in speaking of
fibromata.
RETRO-NASAL CARTILAniVOrS TITMORS.
True cartilaginous tumors of the retro-nasal locality are bo rare as
to barely need mention. Only three or four cases are on record.
MALIGNANT TUMORS OF THB NASO-PHARYXX.
Malignant tumors of the noso-pharynx are comparatively rare ; they
are characterized by symptoms of ntisal ol>struction, with abundant dis-
charge, fre4)ueut epistaxis, uiid often by severe pain.
Anatomical anu P.vrinaoiiic.vL Ciiabactehistics, — The growths
are usually more or less pedunculated, somewhat pyriforni in slmpc,
and they hare a nodular or lobulatcd surface covered by mucous
membrane. They appear to be mostly of a sarcomatous iiatnre, and
often contain mucous or fibrona clfmenta to a considerable extent.
Microscopically they arc found to contain the usual round or spindlc-
shapcd cells and sometimes c::trtilaginDus cells. In common with malig-
nant tumors elsewiiere, thi-y are characterized by rapid growth, speetiy
recurrence after removul, and tendency to form new deposits in other
organs.
Ktioi.o(;v.— The etiology is unknown.
SYiinoMATOLooy. — The tumors cause the common symptoms of
nasal obstruction, with more or less discharge and bleeding, and oft«n,
but not invariably, scvltc lancluutiug puiu shooting toward the ear uiid
most troublesome at night. As th« tumor Increases in size, dyspuoa
and dysphagia may become pronounced. It may be readily Been upon
rhinoscopic ins|)ection.
UlAGNOSi.s. — The malignant tumor is to be dtstiuguishod fromothrr
retro-nasid growths by the features mentioned in Hpcaklng of fibrous
and fibro-mucous polypi, and by microscopic examination.
Prto(iN(mis.— The tnmora grow rapidly and terminate fatjilly, usually
within from four to six months. Recurrence is the almoat constant rule,
Tkeatmext, — When seen in the early stjige, if possible, the growths
should be thoronghly removed by the steel wire or galvano-cantory
snare; but more serious oporations cannot be advised.
40
626 mSSASBS OF THB NASO-PHARTSX,
CYSTIC TCHOBS OP THE XASO-PHARYXX
Cjstic tumors of the naso-phairnx are of rare formation: onlj a fev
caaes hare been reported in this conntrr, by Lefferts, Clinton Wai^uer,
and myself. They are characterized by the nsual signs and symptoms
of nasal obstruction. Tliey are most readily removed bj emlsion
with strong post-nasal forceps, and show little or no tendency to recur-
rence.
Diseases of the Thyroid Gland
and cesophagus.
CHAPTER XXXTII.
DISEASES OF TllE THYROID GLAND.
GOJTRR
Symnifm^. — BroDchoce1o> Derbyshire neck, strnma.
Goitre consists of an enlargement of the th}Toid gland, trbiefa may
be vaiiciiliir, parenchynifttous, or cystic
Anatomical and Patuolooical CuAHACTERisxrcs.— Iu the vas-
cular variety in some cases the veins, in others the arteries, and in still
others all the bluoil vessels are enlarged, elongated, jind tortnnns. and
the walls may be greatly thickened, so that the rBssuld themselves ninke
up a large part of the incr^iscd size of the gland. In the parcnchyin-
atons variety the glandular structnro itseU is increased, sometimes the
nlveoli are mucb enlarged, and the tumor is made up in great purl of
colloid mat«rial, while in other cases the alveoli are smaller and the
tumor is composed largely of the solid stroma. In many instance*
the goitre consists mainly of true adenoid growth. In cystic g<»itre
there may be one or more large or small cysts, usually combined with
hypertrophy of the parenchyma to a greater or lesa extent. As n rule,
these cysts contain tenacious, ropy, albuminous iluid, often more or less
tinged with blood from rupture of viiricose veins into them, and of
various shades of colur iu consequouco of the amount or condition of
the blood which has been thrown out. Sometimes their contents are
entiruly serous ami in otiier cases entirely hemorrhagic in character.
Theaegrowthssomotimes attain enormous size. They are more frequent
in women than in men, and are most apt to occnr 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, Kngland, and in certain limited bnt not well defined areas in
the United States.
KtioU)OY. — 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 meiitttruatioii, or due to violent
efforts, fioitro is sometimes hereditary. It is often attributed to the
drinking of snow and glacial water, water imprcgnateil with chalk, or
to bad air and bad surroundings and defirjont sunlight; but the preva-
lence of the disease iu placus differing from ouch other widely in atmo-
DISEASES OF nrs THTROW GLAim,
•pbere. («mpentai¥,andearToaDdings, and in some* of which tbi
ing-vater cannot poeaibly aecoant for it, shovs that ve are still in tbv
4ark regarding the etioIo<^.
STMt*ToxA'n]U>UY.— The symptontt depend npon the amonni ofpna-j
sore exerted upon surrounding stractores. Tho exlnnt of preasan
not nece^arily commensitntte with the iize of the tumor, whirl
thoQgb small, maj send prulongations downwanl and backward ll
press upon the trachea or the pneum (gastric or recarrent hir^ngal
nerves and canse nlteration of the roice, and d> >. luob roav
slight or seTere. When dvspncea is severe, ic of" ^ uu in parox-^
)rgms due to acnte congestion and swelling of the alrvodj narrowed tobfw
These uttncks are sometimes speedil5 fatol^ and though the patient nan
recorcr from one utljck he is liublr to others during vhich Che danger il
great Pressure u[N>n the bmchial plexus may catue puin, numbni
or eren paralysis of the arm; but there is seldom any pain referred
the enlarged thyroid glaud.
I>iA<jNo.<is, — There is uKiially no difliculty iu the dlugnn^is ext'eptingj
in rare cases, where small goitrce press i>usttTior1y, cautting diftirully in
respiration, while the external growth may be hardly perceptible. IVcsnare
u|>on tlie veins causes turgescence and Uvidity of the face, with promi-
nence of the superficial Teius over the tumor, and passive hyperTpmia "f '
the brain. There is occasionally, though not often, pressure upon tfaej
ti'ti'jphagus, which then Cdnses diWotilt deglutition. The ^hmd. whirh
is connected with the trachea, rises and falls during deglulitinn unlfw
too large; the skin over it is freely movable, and the tumor is notj
attached to the jaw and does not involve the surrounding iwirtg. Thsj
size varies from flight fulness of the neck to an eDormous gmwth. Tb*'
surface is sometimes even, hut often nodulur, and in extreme cases Io!m-
lated. The libro-cystic variety, which in must common, has an irregular
surface, firm to the touch, with here and there soft i^pots over the cyst*.
■ It is distiugnislied frt>m tumors of other portions of tbe nn^k liy its
position and niovemt- til^ during tho act of swallowing. It is dist inguinbed
from erojthffuihnic ffoHre by absence of the ophthalmio and cardiac signs:
and from vitilujnani lunu/n by comparative absence of pnin, and by n»t
being adherent to other tissues and conse«iuently moving beneath the
skin anil with tbe deglutitory movements of the larynx and trachea.
I'kooXOSIS. — The tumor usually slowly increases for many years,!
but is always a source of danger, as, from sudden swelling or ateadjj
pressure, with acute iuflaniniation of the lining membrane of tho air^
passages, it is liable to cause strangulation.
TitRATSiENT. — It is nei'essary to rem^nber that endemic nauaes pisf j
a prominent pan in the etiology of goitre, and therefore removal to
some other locality may be the most important mtiasure in effecting a
care. If the tumor is small or of medium size, it may often be disii-
pAted by iodine iu some form. The tincture of iodine may bo applied
eOlTRE.
G31
locally to tlie neck, and tho remedy given internally in the form of
pntoesium iodide in doses of from gr. v. to gr. xx., or tho tincture of io-
diiiO in doses of m v. (o xx. iiuiy be adiniuistered in capsules, which are
taken willi a large dniught of water, three hours after ench riienl. Tho
internal use of the remedy often fails, and then injectiona have been
praetised in isome «i9cs with excellent results. Here again iodine
may bo used, but it is important that the aulntion should be thoroughly
aseptic; for this purpose I would recnmiueud the aqueous solution pre-
p«re<l by J. E. Clark of Detroit for tl»e treatment of tnhercuiosis.
Ilypodermio injections into the tumor, of carbolic acid in doseg of tI|, xv.
tn Is. of a three to five per cent eohition, are sometimes followed by
excellent results. Tliejie should l>e given once or twice a week according
to the irritation they produce. Injections of iodoform according to the
Jlowtig-ifonrhof plan are said to be safe and efticacioUB. This method
^Consists in iujeeting into the gland, with nntiaeptic precautions, about
once a week, from one to four grains of iodofonn dissolved in etlier and
olive oil seven parts escb. Five to ten lujectioneare said to be necessary
for a cure.
In the cystic variety, Mackenzie recommends puncturing tho cyat,
drawing off its contents and injecting the sac with a solution of pcrchlor-
ido of iron, .'S ij.ad 3 i,, which is to. he left in for three days; the eanula
being corked and Iicld in place by a strip of tape passed about the neck.
Tho cork ia thou removed and, if suppuration has oct^urred, the cyst
should be tltoroughly washe<] several times with an antiseptic solntion
{Lnurlou Lancet. May Htli, 1872). Obliteration of the sac accomiwniea
the healing process. If the iirst operation i9 not succesflful, it should bo
repeated until a sufficiently high grade of inflammation has been induced.
Electrolysis is sometimes a \ery efficient means of curing these
cystic growths. It may be practised by inserting iiito tho tumor suita-
ble needles at a distance of an inch or moro from each other and passing
through them a galvanic cunent as strong as can be borne by the
patient for ten or liftoen mitnitus at each fitting; to be repeated at in-
tervals of five or tun days until Lliu cystdisappeiu'S. If tho tumor presses
upon the trachea so as to interfere seriously with respiration, tracheot-
omy should be dune and a long, dexiblo canula introduced and worn
while the danger remains. Owing to the success obtained during tho
last decade, partial extirpation of the gland is an operation which meets
with considerable favor among general surgeons. Total exttrputioa
is a dangerous operation, very liable, in those who survive the immediate
filfectfl, to be followed by cachexia, sirumipriva or niyia>dema, there-
fore it cannot be recommended. The operation itself is fully described
iu recent works on surgery.
^ lOnymg. — Uravea' iliseuse, Basedow'
Exoplithulniic goitre is u ili»ctuc of the sympothctio nerroua 8}'Eitem
characterized by cnlurgcuicut of the thyroid gland, prominence of the
eyo8, disturUuuco of tho uotion of ttic heart, and deficient chest expan-
sion, tliough one nr two of thc-ije H)'inptorns may he abgeut. It ia fully
doB(;rihmi in tf xthooka (in practice, and, as stated in the previous edition
of this work, it Uelongii to tlie doniuiu of the neurologist rather than to
the flpocialist on diBcasea of the throat and chest. It ia mentiouud hen
because tlie Inrytigologist is sometiiiieB consulted about it and to call
attention to tlio i-enmi-kable ollecta sometiniea 6xcrtc<l upon it by tlio
administration of the tincture of struphanthus, which has proven oura-
t Lvo in several reported cases. Daniel K. Drower, of Chicago^ has treated
three caecs by this agent succcssfnlly. 1 have cnrvil two cases by tb«
ndiniuistratioii of ten-minim doses of tincture of strophantlitis three
times daily for a period of several months, combined with repeated
injections into the ginnd of thirty minima of a three to five per cent
eolutiou of carbolic acid. In some cases it seems to be of no value.
DISEASES OF TIIE CESOPHAGUS.
lESOPHAGlTIS.
ACUTB <E80PUAGIT18.
Aoate oesophagitis ia a comparatirely rare affection of the mucous
membrane lining the cesophugua, cimru uteri zed by {Miinful doglatilioiu
Tlie inflaninmtion may bo either circumscribed or dilfused.
Ktioi^uy. — ^(Esophiigitis sometimes results from simple exposure
to cold, in wliieli cuso it is generuUy rheumatic; it may be induced by
the use of extremely hot or irritating foods, or by iced drinks, piirtieu-
larly when the subject is wurm; it maybe ctiused by irritating medi-
cines, foreign bodies, or the piissagc of surgical iustruuicnlfi; but must
frequently it results from swallowiug very hot or curroeive sub«tancn.
It is sometimes ussociitted with diphtheria, pueumouiu. scarlet fevor,
small-pox, dysentery, cholera, tuberculosis, pyieniia, or cancer.
Symptouatology. — In mild cases there rany be simply a sense of
oonstrictinn in the oesophagus; but in those more eevere, puin. vbich
in the acute disease may be increased by prcsaure, is felt deep beneftlh
the sternum or in the back, between the acapnias. This pain is expcn-
onced upon deglutition even of saliva, and is much u;^'gnivaled by «w»l-
lowing solids, llysphagla or upliugia renult.-t fruui swelling or spoara
'«t the cesophagua during ntluniptcd deglutition which may canse
i
<ESOPHMUTtS,
033
regurgiUtion of food and Tomicing. The vomited nmtt«r consisti of
gluiry, sometimes blood-8t»inod muoue, together with the food that
hua bueii swhUowwI. There is fover, with intense thimt, m>mmunly
accomiKinieil in. children by convulsions. Somotinieit involvement of
the larynx onuses libardcness, and cough may bo prodticod hy ttie not of
swallowing. By auscnllation while the piitient id swalluwlng lliiid, a
pecuHiir gurgling sound nuiy bo lieard ut tiiu aeiil of inllitinmiilion pro-
vided it has caused unrrowijig of the tube.
DiAOSOSis. — The diagnosis will depend upon the history, the sent
of the p/iiii, the lime of its occurrouee and the presence uf dysphngia.
PuooNOSis. — In mild eases the diseitEe ueuitlly Bubsidod wiiliiii lliroo
or four days; in those more gevero it may lermiinite fiivoruhly within a
week or t«n days, but where there '\* extennivo inflnrnnmtion ihn i>njg-
uosis is gniTe. When asBociated with diphtheria or Bmrill-pnx, it in gen-
erally fatnl. Phlegmonous inftammation of the (eaoplmgun may eiiiiso
death within two or three days. Where recovery ocoors, the walln of
the tube usually remain more or less thickened, and if the inflammiitinn
has been severe a stricture rej^ultx.
Tkeatmext. — In mild cases, demnleents should lie employed, and
freqaent comparatively large doses of hismnth snbnilrate are rnlnnhle,
given in powder and with as little fluid aa possible. The food should
be liquid. When swallowing is impracticable, food chould be given per
rectum. In the early stage, the sucking of ice, and the ap)ilieation uf
cold compresses externally, are useful. In cases resulting from an im*
pacted foreign body, the cause should be removed. Id those retnltuig
from the swallowing of ucids or alkalies, weak chamical antidotes
ahoald be administered in the beginning.
CBROXtC (ESOPHAOITIS.
A chronic inflammation of the mucoaa membrane of the cnophagus,
with more or less thickening of the wmlU, is characterized chiefly by
diffienlty in deglutition.
Etiuloov.— Chronic oeeophagitia nmaOy reaolts from the acute dta*
case, from the excewive ate of alcohol, from syphilis, or from impaction
of foreign bodies; bnt it may be due to extension of inflammatioa from
Dcighboring pans, to pressure of aneorismul or other tumors, or to pro-
loDgad congestion occasioned by chronic pulmonary or cardiac afTertionii.
SniFTOXATOLOOT. — The lymptoma reaembla those of tbe acute di**
Mi^ thaagh they ara leaa prooimnced.
DlAoyoaia. — The diagnosis depends npon the blsioryand «'
Tha SBiinda obtained upon anscnllation while th« patient i« «■■.
are ape to be more pronoanced than in the ami* affeetion.
Pioososiii. — The aif'- dly ext«ikb 0T«r • eoiM;id«nibto Hum,
•ad is liable to eventuate: . ire,
TBKATXcrr.— The eanae should be removed if possible, end any
rZA DI.HEAHEH OF THE tESOPHAGCa.
Mtivjcialed Jueaw ehoald receiTe appropriate treatmcnC JjoeaHj tbe
nm of Mtrlrigenu or ctimnUntf, applied bj means of a soft sponge at-
ta/^faed to a whalebone, ha« been foDcd benefictaL For this pajpoee,
lolacioM of alam, zinc falpbate, or tannin, varring in stren;^h from
ftr. I- to XXI, ad 3 L, oreilrer nitrate gr. r. to i. ad ; i-, maT be employed.
S'^lations of iodine are abo recommended. Any of these in small qoan-
titT, not more than i^l xr. to xx. at a doee. and in Teak solntion, mar
}ft: brooght in contact vl'.h the part£ by the act of deglotition. As the
inflammation sabeides, b Tigieg shonld be passed at interrals of one or
tvo veeks to prevent the . -nnation of etrictnre, and in some esses this
procerJore will be found beneficial for orercoming a persistant low grade
of inflammation.
8TRICTCRE OF THE fESOPHAGUS.
Strictare of the cesophagns consists in a narrowing of the tnbe, occa-
sionally congenital, bat generally as the resnlt of injarr. It occurs most
frefjuently in children or young adults.
Anatomical an'd Pathological Characteristics.— The thick-
ening usually involves the mucous membrane and connective tissae.and
sometimes the muscular walls also. It occurs oftenest at the upper,
narrowest portion of the tube, and next in frequency near the cardiao
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
sciit 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.
Ktioloov. — Stricture is sometimes congenital, but usually it results
from acute or clironic inflammation most commonly excited by swallow-
ing of hot water or lye, or the result of rheumatism, syphilis, or cancer.
Symptomatolooy. — Kxcept in traumatic cases, the symptoms usually
come on gradually, the i)atient 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, evea
these cannot be swallowed. Sometimes the bolus is regurgitated imme-
diately after it has bcL-n taken, perhaps covered with mucus, pus, or
blood. When dilatation of tlie oesophagus has occurred above the stric-
iro the food may be retained for some hours, finally to be regurgitated
SrniCTURE OF TUB tSSOPHAQUS.
fl35
more or less decompoBPcl und softened. The p:itR'nl is iistmlljr much
depressed and very nerrotiR, and this lidds to the tendency to spasm of
the tpsophagns, which not infreqnpntly tukcs plaro dnrinj;; deglutition,
Piiiu at the scat of the strictnro is sometimes cxiH-rienoed, and oceusion-
tilly dyspnoea is complained of; this is espccitdiy lilsely to occur in oin-
ceroui) slrieturea involving the recurrent Inryu(;oiil nerve. Usuidly
nothing ran he disoovered by liiryngoscopic e-xaniiimtion, l>nt hy oare-
fully passing o-soplmgeal bougies tlie location and degree of strictoro
may be detennincd.
DiAoxosis.— Stricture of the oesophngus is to be distinguished from
iuberculitr hiryngitie>, fruni tumors of tijo ptmrynx, htrynx, or (Dsopbagns,
from Bpasmg of the (usophagus, from pnriilysis of the pharynx and
<pRophagiiH,niid from the presence of foreign !>odit>3. The diagnosis is not
nsiially difticiilt; the esBcntiii] potnr-s are tlic history, and presence of
dysphngifl, and regnrgitntion of food. By nuscultation the scat of the
atrietnro may frequently be located when the patient is swallowing^
owing to the fl<nind riiu?pd hy the ascent of bubbles of air just above the
narrowest portion; but the degree of stricture c^u only he accurulely
determined hy the pnesnge of the »vsophageal hoiigio. For this purpose,
gniduate<I dilators mudc of the same material as llexihle cjitlioters are
the saiest instruments; but surgeons usually employ an olivarj- bougie
finnly attached to a long whalebone rod. These olivary bougies shoulu
be of several sizes, about one und a htilf inches in lengtti, and eojiie»l
ut both ends; and when the instrument lias oneu passed the stricture,
it should be carried down to the stomach to determine whether other
strictures exist. Great care i^hould always he ui>ed in its passage, for (he
walls of the u^soidiagus are often thin and friable or ulc?eruted, and there
is liability of i}erfuration with fatal results. Upou lur^'ngoscopic exam-
ination, stricture is readily diatiuguished from /ubercufar hrffii;/i(ijt and
iumnr.t in the jihartjus. By passage of the bougie, it is dislinguislicd
from tumors of the (psnphaffHft xftamt, parah/sis or foreign bodies. It is
flometimcs difticuU to determine whether the stricture is the result of
simple chronic catarrhal itillanimation, or whether it is of maligtmnt
origin, but in advanced life cancerous disease may always be suspected,
and a ditfercntiul diagnosis may usually be mode by examination of tlio
regurgitated matter.
PttOciNOSls.— Xon-malignant strictures may continue for many years,
but those of cancerous origin arc ahvuyB fatal, usually within from eight
to eighteen months. Striclun^s due to simple Inflammatian, if not too
narrow, may often be furod by persistent dilatation; if not relieved, they
tend to interfere more and more with nutrition, and finally, sometimes
after many years, thoy may oanse death by inanition. Occasionally
death is the result of abscess caused by the pressure of fowl in tho dila-
tation above the stricture, or of tubercular defeneration, or g:ingrene
Tesuitiug from tho reduced condition of the system. Pressure upon the
636
DISEASES OF THE (ESOPBAQVa
recnrrent nerve aometiines causes paralysis of the abductor mueoles of
the vocul cords, with diingcrtius or even fntul dyspiiiea unless tmcfapot'
omy is promptly (wrforined. Uluenition may ocniir into the trachen, the
bronchial tubes, or into one of the adjacent large vesseU.
Treatmknt. — When resulting from chronic catarrhal inflainniRtiotif
rhenniutiBni,or syphilis, the administration of the iodides is ooi-usiomiUy
followed hy relief. In ni:th'gMiuit tniscs, opititcB must he given to relierti
pain. When food in sufficient (pmntity »innot he talten, nntritire en«<
mata miiBt bo employed. Dilatation ifl indioitted in till suitable eoses.
In those of malic^nant nature it inu^t be practised, if nt nil, with tlie
greatest care, but as a rnic it is inadrisable.
Charters J. Symonds, of London, in seventeen eaees of mnligncnt
stricture of thu ceaophuguis has successfully Uiicd, for keeping the stric-
ture pervious, a gum clastic tube four to sis inches long {Lotnltm l^n*
cfff March. A]iril. 1889). This is funnel-shaped above and oloeed at
its lower end, but has an opening just above the closerl extremity like
an ordinar}' CJithcter. This tube is introduced tbrotigh the stricture,
DfMn a whalebone staff, and has attached to its upper end a strong
silk thread winch is fastened to the ear. It may be left in xilu for
weeks or months, allowing the [lassage of liquid food, without hast-
I
iM«n.i.n*i>*« m M w '
c::^
FM. ttS.— AAKDft' iSMontAOtrtnmm.
ening the inevitable progress of the disease. In other cases dilate
tion should be attempted by the gmduuted bougies alroudy doscrihed.
and the opemtion should be repented even,' two, three, or four dajra
according to the amount of irrittition produced, time aitra}*8 being al-
lowed for this to subside before the next operation. When an iustru-
mcut bus been passed, it should be allowe<l to remain for a few second*,
OS long as the patient can tolomt<> it. and theu wiHidrawn and followed
by one of a size larger. Thus the largest instrument that can be jMiacd
withoat great force should be used at each silting; at the next an
instrument a size smaller than the one previously introduced should
be first used followed by one or two htrgcr sIecs. If the dilatation
proves successful, bougies should be introduced from time to time with
diminishing frequency, and the ifUtieiit shouhl bo Uiught lo jK-rform the
operation himself, which must be repeated at intervals for several
months or jrassibly yciirs, tlic cure usually recjuiriiig u treatment for al
least six to eighteen months. ^N'hcn the ftricturu is very narrow, an
'or iucisii
i
SPASM OF THE CE:sOPHAOUa.
637
membninc to allow of mora rupid uiid perumnont dilatation. Tl c bulb
IB to be introduced beyond the stricture, tbe knife slightly protvuduU,
uiid the iiiHtrumcut wlthdnmn. The operation \e uttcDdcd by great
duiiger, and Is liablt- tu be it direct cuu&e of dmith in iibout tliir'^y-livc
per ceiit of the cases opi^'rated upon. If this upBration is udupted, tM'O
or three slight iuciKiuns should bo made at ditTerent parts of the stric-
ture, gmduitl dilutntiou being practised subsequt-ntly. Eilerual uMoph*
agotoniy and gustrotomy are recuninieuded iu spt-cial cases, but they
come more properly within the dumuiii of general surgery. Electroly-
sis has also been recommended in the treatment of stricture, but the
close proximity of the (esophagus to the vagus nerve renders it hazard-
ous. A. Fort, of Paris, lias practised it successfully in several instances,
and appears to have obtained considerable bcneSt even in malignant
cases.
COMPRESSION OP THE (ESOPUAGrS.
Compression of the ceeophagus results from the pressiire of mediasti-
mil tumors, which may be carcinomatous, aiieurismal, or purulent. It is
sometimes caused by enlargement of tlm bronchial or thyroid glands,
and may bo occasioned by pressure of the fluid in pericarditis. It is to
he distinguished from true stricture, by the process of exclusion. The
prognosis and treatment will dei>end upon the etiology.
SPASM OF THE tESOPHAGUS.
Synonyms. — Cramp of the oesophagus, uesophagismug, sponoodlo
stricture.
Spssmodic contraction of the lesuplmgUB issumutimes associated with
a similar condition of the pharynx. It is characterized by paroxysmal
inability to swallow, wliii'h may come on suddenly and as speedily dis-
appear; or it may continue for several hours or ut irregular intervals
for days or weeks. It is most frequently seen in uer^'ous women, but is
said to occur at all ugee, and judging from my own experience it is not
infrequent in men ])ast middle life. It may bo associated with disease
of the ipsophngus, hut iS usually independent of it.
Etiohiov.— 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. Tlio affection is at-
tributed by Cohen to rheumatism, to acuto disease of the stomach,
heart, lungs, uterus, brain, or spinal cord, and to hysteria and hydro-
phobia ( l>i.sejises of the Throat).
SYUttoMATOLOO Y.— In many instances the spasm comes on suddenly
and may as speedily disapj>ear, but in others the constriction remiiins.
or at least the patient supposes it to remain, fur many houra or even
days, so that he is afraid to swallow food. Whea sudden, it is usually
fiSR
DISEASES OF THIS (KSOl*lIAGUS.
foUoweil by prompt regurgitation uf any food tUut the {mtioiil titl«mfpu
to KwaHuw, iind sonu'timcK by spusm uf thu air pafistges, |Kilpitatiofi of
the liuart i>r syncope. The iliniruUy \& usually intermitteitt, bat oi-c»-
sionully, iis lieforo tnentioii«il^ thu coriBtricliaii renmins fur iiuiny boun;
indeed, when oecnrring' in a loir position, it liotnetitnce contiiiuee ao luug
thftt food mny be regnrgitfttod in .1 softonml nnd decomjKising condition
some hours iifter it bus bct-n awullowcd, owing to the occurrence of dits*
tation ill the lesophngus nboTC tlio constrictioTi. Tlie seat of the diffi-
culty nmy be referred by tbo patient to luiy portion of the nigophagot.
JJiA(}N*ci4i8. — The diiignosit) is based npon the intermittent chiiracl«r
of the dysphagin, and exploration \rith oesopbage:)! bougies, the passage
of whi(ih \& not often greatly hindered by the Bpasmodic contrac-
tion. U is most likely to bo confounded with organic striutare or
paralysis of tlie Oisophugus. Jt is distinguished from oryttttu- xirieiwr*
by the history luul the reiidy pussage of the bougie. It is distingtiished
from prti'o!i{g\it by tho history, pnni]ysifl usnally following diphtheTia:
by the sudden regurgitntion of food, which nfti'ii takeg plitce in spiism
but is not common in puralysis: by it« intermittent rbamclcr: and by
the introdnctinn of the bougie, wliieb pusses readily in paralysis, and
is more or less obstructed in spasmodic stricture.
PiiOGNosis. — The spasm is usually transient, and tho liability to re-
currence may diaippear after 11 few days or weeks; but in some In*
stAuces it continues for a long time, and I have seen puiieuts who bjiTe
been unable to swallow fuitisfacturily for three or four years.
Treatment.— Anti-spasmodics, as bromides, unmphor, valerian, and
asafcetidtt, are frequently of benefit, and in most instances such tonirt
as iron, quinine, stryebuiue, and arsenions acid are necessary; but ibr
repeated passage of an orsophugeal Imngio will give more relief than any
other measure. ITsuallj it is necessary to repeat the opemtion only
three or four times.
Boi-^otti reports a case of a>»ophngral fi|HLtn) in a n-onian tbirty-ons yetn
old. which eunUfitied unint<>riupte(lly foi- five hundred ami thirty ilaj-s, mrely
permitting the pa.iHuge of the oouiid or hquid foiKl. Cure was cirected within a
few Uaj-a by the use of Veroeuira oesopha^jeal dilalor^(CV-wfran>/rtlfi /flr kHni«J*t
Medicin, l»8tt).
PAKALY8IS OP THE (ESOPHAGUS.
Paralysis of the ofsophagiis eonsista of loss of muscniar power, ehw*
acterizcd by difficulty in deglutition. It is said to be very common in
the insane, and it is comparatively fretjuent in old age or iu tboM
broken down by poor health, and also as a seqnel of dii)htheria.
AVATOMIC.Vl. AND PATHOLOGICAL CHAKAtTKItlSTICa.— Tbo 1f<fliOM
may consist of changes ut the nerve centres, such as hemorrfaafs
into tho pons or the raedqik, or tumors of those organs, bulbar pa-
PAHA LYSIS OF rUB (ESOVitAaCS,
1139
ralysis, multiple sclerosis, ccrcbrul atrophy, and progrpMivo Incomotor
ataxia; or of presauro upon tlio nerve ns in tulK-rculitr i'iilui'g«<meni of
the pharviigeiil lymphatic glaiulsj, or syphiUiii" oiil.tfjit'niotit of tho cvr-
vicjil vertehne; or there tnuy be sitnplo uitisiHitar Wfiiknt-w without IKT*
vons jeiiionft, hs obgervo^l in the fet'ble or uged.
KrinLouY. — Tht; niui<t common causes aro ijiphtlu'rin, nnd pimpio
muscular weakness from old age or ill lioallli. The ulToctinn \n ortm-
eionally caused by syphilis, tuberculosis, lead poisoning, aciito feviT, iind
hysteria. Inability to »wtillow is usually obf^erveil in u]tproa<'hinf( dit-
solution some time before failure of n^ptration and eiiruhition.
SYMPTOMATOUKtY." The P8»fntial symptom is dilliculty in dwnllow-
ing, which ni:iy develop ipiickly or plowly according to tlie nitiKO. It it
probable that complete aphiigia is never presont tinlcmi tlie pltnryni 1«
par;ily7.ed at the same time. When dno to bemorrluige into tin- neno
centres, it comes on eudflenly. and is at on*'e complet*'; but if remiliind
from ttimoi-8, it develops gradually. Following diphtheria, it usually
appears M-ithin three or four weeks after the beginning of the attai'k,
and may rencii its full intensity in three or four (Jnyi>. Ati the re#ull of
uervDUB disesBCs it is a raru afTection, nnd in any cnic seldum iipponri
until late in tlieir coarse. When of central origin, it \t SDmeLimet asso-
ciated with more or less panilviis of the sensory or motor nerves of I he
larynx. In local paralysis, the affection comes on grwhiuUy; Muckc-n*
zie states that he has seen sevenil instances in which the disoase lum
lasted from ten to twenty years, that it apparently Ii>hcJs ui'ter a tinif to
aomo stenosis of the gullet^ and that in long-standing c.ses the i»thn>us
faueium, and even the mouth, is often much contractad (UUMtteaof tho
Throat and Nose, \'uL Jij.
Plstienu are commonly Tory weak, bnt emaciation is not usually a
marked symptom exceptiog in cas«s of long (Juration. There is M>UI<>m
any regnrgitntion of food, though in mild caMem {taiients complain of its
lodging in the lesopbagaa. The aoBDd. which may be heard duriof
deglatition over the nonnal teeopbagns is greatly nMartd or may be tup-
presscd by permljna, m that, instoid of bvio; dUtii»ct as In health, only
a iriciding or dropping «9ui b« bctid. A boogie nuy be yanetl «j*ily
and ie len likely to caoee anMft thfto in health, bat wwrienelly, in
oaaes of long standing, conUaciion of the gullet ia aud Co oeenr, causing
maeh difficnltf in pHBBg the iaetniiDeal.
DuosoAUL— Pntslyna ie to be diitinguiahed ttpm apaani somI frmn
OMJigDuat diMaae*.
BhbIjm ie dMtinfaiehed Cm* eysw of the oMophetw m feUevw;
Fii ii,T— or nor aaonuoce.
mt
SrMMor
nj^
640
DJssAaEa OF TUE acaupusava.
PAKU.T8tB OP TSK ce8OPBA0V&
Spasm of tur OfBOVSAora.
Seldom any re;^ir]^Uition of food.
Boti^c juu»ed easily, excopc in rare
cuses of long: standinK.
No distinct soiiud pi-oduced by swol*
lowing.
Regurgitation of food rommon
At t1nK!S impossible 1o pius liOQRi&
Slmrp sound ti«art) over onophaswi
during dvirlutilion.
Wo find that malignant disease of the oesophagus causes difficulty in
deglutitiou, aiul, liko jiaralysis, geiiorally occurs iu advanced life, but it
is alteudecl by ]Kiiu, regurgitutiou of food, oud ooastant obetrnclioD to
the passage nf the bougio.
pKooNosis.— When depending upon muaciilsr weakness, diphtheria,
or lead poisoning, the jirognosis is very favomble, hut if due to lesions of
the nervous eystein it is gmve.
Treatment. — In the severe forms, little can be accomplished in Ibe
way of treatment. In any case where the canso can be found it
should be removed if jiossibje. Usually iron, quinine, and strrchniDc,
especially the latter, are important agents, together with a stimulating
diet. Mackenzie recommends farndiziition of the nesuphagns once or
twice daily, prefenibly before meals. The positivo poleshonld be placed
by means of the necklet in contact with the spinouR processes of lb«
upper cervical vertebrte, the negutive attached to the cesophngeal elec-
trode, which should l)e introduce*! three or four times at each sitting,
and retained for n few seconils. It in somotimes dosirablp to feed ll«
putieut liirough an wsophageal tube; espociallv is this necessary if the
pharynx uud larynx uro also paralyzed.
(
FORBIG.X BODIKB IN THE (ESOPHAGUS.
Foreign bodies, of great variety, may become impacted iu the an
ngus, where they interfere with respiration and deglutitiou. They gen*
erully lodge cither in the lower portion uf the pharynx or just bclov
it or at the upper portion of the wsopbagus directly beUiud tbe cricoid
cartilage, but sometimes they pans lower aud occlude the passage opposite
the bifurcation of the trachea or just above the utrdiuc orifice of tlie
stomach. The most common of these foreign bodies are large boluses of
food, coins, pius, fragments of bone, and plates with false teeth.
SvMPTOMATOLOuv. — When foreign bodies arc large and lodged in the
lower part of the pbar_mx, they may depress the epiglottis so as to cauw
immediate sufTocalioii. Ijirgo bodies may pruvoko retching or vomit-
ing, and prevent swHlIowlug either of solids or fluids. Smaller bodioi
usnally cause actual pain or jiricklng sotiiiutiousT sonictimes flight bleed-
ing, and frequently interfere with tbe swallowing of solids, but not with
swallowing of liqnid. 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 he impeded by involution
of the trachea or by spasm.
DiAGXOsis. — The presence of foreign bodies is to be distinguished
from globus hystericus and from paraesthesiu of the cesophagus. The
essential features in the diagnosis are the history, laryngoscopic exami-
nation, and exploration with the bougie. By inspection, afferfioiis of the
pharynx ami 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 linger will sometimes detect a foreign,
substance, and passage of the tesophagcal bougie will usually locate
the object unless small; but in some cases spasm of the (Esophagns
above or below the foreign substance seriously interferes with this
examination. Care must bo 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 hi/sfer-
icuJi 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 pariestheMn of the (esoph-
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.
Prognosis. — The lodgement of a foreign body often proves immedi-
ately fatal from suffocation. Sometimes comparatively smooth objects
have remained in the cesoiihagus 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 cesophagus, since it is
apt to set up inflammation which may be followed by abscess; or the
pressure may cause ulceration and opening into the mediastinum, the
trachea, or the aorta. Impacted bodies sometimes work their way to
%o
Fio. 239— FuXiBLB QlsopBAOEAL Fm.i .^s il-'i sizcL
the surface and may be discharged without i.nmediate danger, but in
this way they may give rise to a fistula, feon . uines they cause inflam-
mation and caries of the vertchne, or secui .y disease of the lungs,
pericardium, or other organs. Perforation liio o-sophagus usually
leads to emphysema of the neck, and iton, .y i)roves fatal. Great
injury ia sometimes unavoidably inflicted itlidniwiug these sub-
stances.
Repetition of the accident ia observed 1 ■ people in couBear"*"**
of spasm of the constrictor muscles of th' • ^us or of part'
41
«42 J)I8SA8Ea OF THE (E80PBAQUS.
ysis; but iu 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-
Btances. If not too large, it may be speedily removed by an emetic, for
which purpose apomorphine, gr. -^^ injected subcutaneously, may be
eliectually 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 {O'azffte
ties Bupitaux, 1870, No. 50).
SHHtr A.S*4nH
Fia, M>.— Bristlk Extractoh {% Bize).
B. Polikier, of AVarsaw {Rfnie menviieUe drs mahnlieff tie Fen fame,
Paris, 18!t'-i), reports twj) cases iu which lie succeedt'd in removing' foreign
bodies from the u'sojihiigus in cliildren, by a, sort of inas.sage ujiwiird and
backward with the iincrer prcRsed down between the trachea and stcruo-
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 di(:;estion, there is no objection to pushing the
foreign Ijudy into tlie wtouiiieli, care being used to avoid injuring the
o'sopliagiis; ami if tlie otfrtuliiig olijeet be lodged low in the jmssige,
this is Irequciitly the only ojieiation ilial eau tie iiractiued. Fortuiiatelv
many indigestible substances may pa.ss into ilie stouutoh without harm
to the patient. When substancei* arc iinnly lodged in the upper ]ior-
lion of the u'sophagn:?. ami cause distressing ur dangercmts symptom?,
laryngotomy or o-sojihagotoniy must be iieifortui'd. These operations,
which are fully described in textbooks on general surgery, not infre-
quently give good results.
par.t:sthksi.v of thk a:sopiiA(ius.
Paresthesia is a nervous atTeelioii in which the patient fancies some
foreign body lodged in tlie plKirynx or u'sojihagus. It usually occurs
iu women of enfeebled health, with nervous teniperanient, or in hvEteri-
parjesthesia of the aSSOPHAQUa. 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 vague fear of choking.
Etiology.— Some of the cases are neuralgic in character, others
hysterical; some depend upon derangements of the digestive system or
frenito-urinary tract; others upon a snuill 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 cesophagus, or, hiiving inflicted in-
jury, has subsequently passed on through the alimentary canal. Pins,
tacks, flshbones, and otlicr small, sharp objects are most likely to leave
this sensation.
SyiiPTOMATOLOGY. — There is usually a history of something swal-
lowed, which has apparently lodged iu some part of the throat or cesoph-
agus, giving rise to pricking sensations, or soreness, fulness, pressure,
or weight, whicli 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 senrfttion, but usually it only reveals to the physician a nor-
mal condition of the parts.
DiAON'Osis. — One of the most valuable points in the diagnosis is a
change:iblenes-5 of the f:in(ned position of the oliject. The patient is
often found to bo anfemic. debilitated, and nervous, frequently able to
swallow without niucli difficulty, but tlie dijignosis must finally be de-
cided by passage of the (i^soph.igcal bougie, or an extractor, by which
foreign bodies cap 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.
Tkeatmkst. — Cases depending upon ulceration or fissure are usu-
ally best relieved by tlie 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 nr)thing can be lodged in
the u?60phagus. Those of jjurely nervous origin are best relieved by
the same means, togetlier with the internal adTtiinistration of iron,
^juiuine, strychnine, arsenious acid, aud the bromides.
APPEKDIX.
Pleurisy.
Exciting Causes (page 62). — Among these are found infective diseases snch
as scarlet fever, typhoid fever, and syphilis.
Treatment (p&geli). — Antipyrine has been recommended in large doses for
reducing the quantity of fluid. It would seem to be specially indicated where
there is pain and fever with good action of the heart.
An exclusively milk diet for four or fite days is said to be even more efficient
than blisters, cathartic!^, and diuretics in promoting absorption of tiie effused
fluids.
Diagnosis and Prognosis (page 78). — Subacute pleurisy may be protracted for
months, resulting in permanent crippling of the lung from compression, or it
may result in emphysema of the opposite organ ; or the fluid may become puru-
lent, especially in children
Chrosic Plkdrisy, or Empyema.
Prognosis (page 77). — H. A. Hare (Practical Therapeutics, vol. ii., p. 660)
observes that the pneumococcus is a compiiratirely benign organism, con-
sequently the empyemas with wliiclt it is associated are the most amenable to
treatment.
The meta-pneuraonic pleurisies and empyemas of childhood are generally due
to pneumococci, and under proper treatment recovery is almost invariable.
Treatment (page 78). — Aspiration of the cavity repeated two or three times
will often prove sutficient in cases due to pneumococci.
(Under I^eurotomy, page 78. )— Moty, of Lille (Bulletin Judical du Hord,
June 14th, 1895) advocates incision as low and as far back as possible, generally
in the ninth interspace, carefully making an opening, layer by layer, to avoid
wouuding the diaphragm.
He believes that in this position not only the pus, hut the coagulated fibrin
and false membrane are much more promptly and thoroughly expelled. This
certainly seems reasonable so far as the products of inflammatory lymph are
concerned.
The operation is done by making a longitudinal incision three or four incites
in length down to the centre of the rib to l>e resected, and through the periosteum.
The periosteum is peeled off the outer and lateral parts of the rib with a spud,
and by means of some curved instrument — for example, an imcurism needle — it is
separated from the inner fiide of the hone. The rib is then cut at the ends of the
wound with lione forceps, a piece about two inches in length usually being re-
moved.
A pair of scissors or the bone forcepH is then forced through the periosteum
at the centre of the bed of the rib. and the blades are separated so as to tear as
large an opening aa desired inti> the pleural cavity.
646 APPENDIX.
If more than one rib must be removed, the wound may he enlarged by cnttlnif
at right angles from the middle of the original incision.
■ Drainage-tubee are inserted and the wound is dressed with iodoform gauee.
With two exceptions, I have never found resection necesfiary.
The radical operation which I have employed with much satisfaction for
many yean is well adapted to all cases where marked retraction of the chest has
not occurred. (Operation described on page 80.)
Bronchitis.
Symptomatology (page 90).— Broncliitis is ushered in sometimes with a chill,
usually with pain in the back and extremities, attended by a sensation of tight-
ness or constriction in the chest, soreness beneath the sternum, a harsh cough,
and frothy expectoration, sometimes streaked with blood. These symptoms are
followed by a daily increase in temperature of two or three degrees.
The temperature may continue one or two degrees above normal until con-
valescence. Even in subacute bronchitis there is frequently a temperature of
from one to one and one-half degrees above normal.
The temperature is usually higher in the afternoon, especially in children.
Chronic Bronchitis.
Symptotnaiology (page 91). — The puUe is usually increased in frequency
from ten Co thirty beats per minute, and an elevation of temperature of from
one to two degrees, with fret^uent variations, may persist for several weeks.
Capillary Bronchitis.
Definition (page 9.'j), — Capillary bronchitis cousista of an acute inflammation
of tlie mucous nienibrane lining the capillary hronchial tubes. It is a bilateral
atfectioD, usually resulting fnnii tlie e.\tenaion of iuHamniation from the larger
l)ronrlii, and in nearly all cases eventuating in lobular pneumonia.
It is usually treared of uniler lohular pneumonia, and the tlistioctions here
pointe<l out relate only to exceptional caseH.
li'dt/jwsiH (|iajie DH). — Onler (Principles and Practice of Metlicine. p. M2)
phueH the death rate, in children under live years of age, at from thirty to fifty
per cent.
When following whoopinji-cnuj^h or measles, or complicating any serious or-
ganic tri.ulile, <ir occuriing in delicate children, the pronnosin is unfavorable.
In these latter cases Osier Hlates that tliin. wiry children seem to' stand Uie disease
better than fat. tiabby childrcu.
LmtAK PNKI'MONIA.
SyinptomiituliKjy (\>-i^v l\<^i) . — In cliildnn there may also be initial convul-
sions, delirium, :iiid ^a^.tril' <li>tiirliani'i'r<. and the pain may he referred to the
abdomen instead of to the chest.
Proi/tii}nin ( [la^e \'i\) . — The occurrence of herpetic eruptionH is generally con-
sidered !i t,'iK>d -Miiptoni. and, ncciirdin;; to (i. See, the niortality is only about
one third as trreiit in tln'se patients a.s in olher i-ases nf pneumonia.
Tri'tttiiit-iit (pane i:?'^).— Witliin the first tenor lifteen hours from inception
of the -ittaek. dry cupping may be iidvantageously employed for the same purpose
as a blister.
PERTUSSIS OR WHOOPING-COUQH.
647
{Under Antipyrtlica. pnf^ 133.)— From ten to twenty minima of guaiacol
nibhed on thu surface viill tKjnietirutii itpi-vdily reduce Uiu tviupenture and t>XL-it«
free diRithoriwiB with ii]tpui¥nt benefit to the i>«tieut.
(Ctider Appiiciitiittof Coi'i. page 123. ) — Cold is moat likely to prove b«oeflcial
when the area of iuilnniniRtinii is Hiimll.
II. A. Iiarr> recnmnipndtt the cnUi Itath at a temperature of from 75* to Bfi* F.,
or even reduci-d to 6Q F , prece>le<l aod followed by stimulants. The duratioo of
tilt* bath is UKually from seven to forty-five minutve. depending ujiun the rapidity
with which the teriipt^-rutiiru itt reduced.
Tlie patient mwy W- placed in (lie buth wheo the temperature r^-ftoheB Kffl" F.,
■lid «imitld uhi-nyslie remi>v«HJ when tlier temperaturfi in the rectum han lieen
lowered to UK)" F. in (tthenic ca^es. or to 101° F in weak patientfl.
The tem[>eratiire should he frttiuently taken during the bath to a%'oid tbe
danger of too great depra-^nion. for it may be expected to continue downward a
couple of de^reea after tite patient ban l>een removed from the bath.
In whatever way cold is applied the foreKoiog caution about temperature
must always be observed,
Ex|.M'rimeuts have frequently been made with Bcmm tberapy, but tbe resiilte
are not encouragini; ; the mortality appearH to Ite liiglier tlian under ordinary
treatiiipnt. Lai*- in the dineaae counter-irritation ia beneflcial. Dry cupa are
eHjieciaLly indicated to relieve pain and congeHtiou, later to relieve the eugorge-
oieut aud dyi>puuii.
Ldbl'Lak Fnbukonia {PaKel2S).
ATtatomirat and f^thoioffifal Churacterigtics. —The surface of a Inng which
fft ti)e piHit of catarrhal pneutnonia. if tbe diitease is auperKcial. particularly at
the lower part, pre^ent^ bluish or brownish spots where tIte lung is rolIapRed.
Thet* are depr*'S8e(i tme or two niillimetres l>e]ow the surface, with ligbler-
colored lung tisme about them. Tliese spots may be of small oiKe. currenponding
to a single Inlmle ; they may include several lobules, or occasionally a liu:ge part
of the lung.
There are also i«een upon the surface rounded, imlated, redd isli- brown or gray
Rpntd nr nodulet* of oonHotidation. often rdigbtly raiaed, varying in idze from a
few millimetres to several eentimetrefl in diameter. At theqe noduleo crepita-
tion iH diminished ur abxent. the Iiitik io more friable and cannot Im inflated.
The iip|)er |>art and anteritir border of Bucb a lung are commonly more or len
euiphytiematouK. Aftt^r diphtheria and measles, not infrequently, the greater
part of a lot»_' m involved.
Etioiogg (imge 134) . —Lobular pneumonia may be the sequence of soarlalinn.
erysipelas, or typhoid fever, aud it may be caused by tuberculuitis.
Perttsris or Wboopiso Cocoh.
'/Wa/meiif (i«ge 15>'>). — Brorooform in dosoH of Tiii,-ri, three to five timoa
daily, for chitdreu from one to twelve years of uge, luis l>eeu very efficieDt fo
shorteDiiig the di>tea»e or at least relieving tlie distressing iiaroxyains during ila
continuance.
It may bi- adminiotered in wat<'r. or droppeil on a lump of sugar, or in nap.
■ule«. Wlieti given in capsules it it* bent to fill a ca|<«ul>^ just before it is swal-
lowed.
The medicine should be taken when tbe Btomach is partly Ailed, or with a
large draught of water.
-.-- 7n_r- iTi*
:r-iJ :■ -rz
:r .'ii^ w it
I - . J
PULMOSAHY PHTHISIS.
when two-thirds of one lung is iDTOIved with dt-oided ditM-OM* r>f tlu> ttppcmitA
Bpfx. the patient may lirealmut one-eighth as long ao the diaesaa Ims already
existed.
Abouttwenty-flve per ceut of recognized caseor ecover, although about twelve
per ceot. rif tNr liuiuiui fuiiiily die uf thie dtiiea>«.
TYetUmcjit (i«gi_'lT<»). — liyninaBlicfxen.'iisf to devfloptiw* rwipirat'>r>' niuscleB
and thf practice of taking dec*p iuiipirationH several timea a day nliould be in-
. aistcd upon.
Filling the lunge as completely as iHWdiblo. liolding the breath for a few
aecoiidH. and then fonMiig it nut iilnwiy tbrcitigli a hidhII H|ierture, is a very valu-
able exen'Ise for dilating the air cellt* ; it sliuuld i>(^ reiiieniber^d thtit the col-
Iaj»ed cfll in a tmiKt fa^'uralile nidus far the diaeaite.
From flvo to twenty miuiimi uf guaiaeol rubbnl upon the iturface when the
toniperalure rwu;he« 103' P. will oftou Bp«.*edily reduce it and give the [latient
much comfort. Care should be exercised nut to use enough to v&xise profuse
sweating.
For checking obstinate night sweatft, pilocarpine, gr. t'k to ^. may be
given. In addition to umtcd. good nourinhnient, and a fiuitahle climate, I am
convin^^ed thut IQ the present state of otir kmiwledge the antiseptic treatment
fiiriUHhert the (greatest chanco for curing cIiJh diseafie. The variuiiH prejiaratinns
of iodtue, creoKOT^, and the eMential oilfi have been found mont uneful for this
purjKMe. Benit-mbering always that nothing is to be given tliat diHturhit the
digMtiv« organs or diminishes the nutrition, our aim should be, by gradually
increasing d>)se^ to saturate iht- system as nearly as possible.
What^iver the modus o/jer«i(di of tlictw remedies, when they act well the
appetite and digescion are benefited, nittriticm iiiiprovee, [he cough diminishes,
and in couree of time many of the abnormal signs over the lungs gradually dis-
appear.
Of the preparationBof creosote, the carbuuatt? is preferable, as it has little tafite.
an<l if commenced in duttes uf "l v. after i^acli meal It may usually be increased
to forty or Tifty miuiuis three timea a 'lay withuut dtsluHiing Ibi.' hU'uibcIl
I have nut been able to give the carbonate of guaiacol in doiie« uf more tlian
one-tliird aa large as th'jiw of (he carltmiatc of creosote.
Tuberculocidiu and autiphtliisiu appear to stand in the same category as
tuberculin, excepting ihat thfy are letis likely to do harm.
Serum Therapy (page 178). — Numerous observers liave experimented quite
extensively witti tteruin obtaiued from the horiiW. mule, iiw, Koat. and dog that
were supposed to Iiave been rendered immune to vtry active tulwrculous matter
taken from the human subject.
A considerable numltcr of coses have boon re|>orted as greatly benefited or
oared.
Similnr nfaaerrations by other cqnatty reliable physicians have failed to cor-
rob(frnU> these results. AlUioughfiome patienti^ hare impruveil for a while under
this treatment, it ts to be recftllected t}iat perlodit of great improvement often
occur in the natural course of the iHsease. It will be obserred in nearly all the
reportK that a siitncionl time has not e1a)nted after the treatment to justify the
statement that the patient has been cured.
In a large |>erceutage of the caM>s favorably reported, death has occurred a
few monthH later,
William Oatto (British Stfittcal Journal, September 14th. 1895) exproMas
what appears to be a reasonable opinion, viz. : That we may expect a senim
remedy or pmphylactic for iliiei'pst i-i which one attack securea imumuity. such
650 APPENDIX.
as small-pox, measles, scarlet fever, diphtheria, etc., but that the essential facts
of tuberculosis do Dot atlurd a reasonable hope for a serum remedy.
Semmola of Naples holds that an organiem born nf tuberculous parents is
destined sooner or later to become a favorable culture medium, and that, on the
contrary, other individuals possess anatural imiumiity against invasion of Koch'i
bacillus. In what that immunity consists, we do not know. What is certain,
however, is that this reeistance has not for its basis an artificial an ti -tuberculous
toxine {AnnaU of Universal J^edical Science, vi., A. 85, 1890).
Inhalations (page 174). — Apparent benefit in sometimes obtained by inhala-
tions of oily solutions used with the nebulizer, — thymol, gr. ss.-i., with roeD-
thol, gr. X., to the ounce of liquid albolene. Terebene, irix.-zxx. ; or creosote,
Ti^v.-xv. ; or iodine, gr. ^-i. to a fimilar solution of irenthol in liquid,
albolenf, may l)e more beneHcial in other cases.
The young practitioner in cautioned not to expect much from inhalations, for
it must be remembered that only the minutest quantity of the medicament paoes
beyond the sr-cond division of the bronchi ; and even where freely applied, as in
the larynx, it lias no influence on the bacilli, whatever the inhalant used.
Climatic Treatment (page 174). — In many, death may be habtened by changes
that cause worry and necessitate giving up home comforts.
Chronic Endocarditis.
Treatment (page 230). — When tlie right side of the heart is engaged, as not
infrequently occurs in complicating bronchitis with emphysema or pulmonary
cedeinii and mitral disease, J. E. Atkinson {Maryland MedicalJoumal, Decembn
29th, 1894) urges the importance of blood-letting to save the life. (*. W. Balfour
{British Medical Journal, December 14th. 1895) states that digitalis in every
form isal)sorhcd witli difficulty and eliminated slowly. Tliia explains tl^e fre-
quent necessity for coinhining it with nux vomica or other reniedieK. The same
author iiswerta that when the swollen liinbH are brawny and tense this drug can
have little nr no effect until preceded by free purgation.
The infusion of the fresh leaves in the most efficient preparation, but usually
the tincture will answer tlie purpose, excepting when the diuretic effect is espe-
cially desired.
In many ])iitients the action of any (»f these heart tonicn i« greHtty facilitated
by mercurials, given either in small rejteated doses or in nitHierate doses until'
the bowels aft freely.
(Page 2:i0) . — lIo<ierKte exercise issiHuetinieaof great value in maintaining the
strength of the heart nmscle. Oerlel's methoii is sometimes useful in thm condi-
tion. The essentials of this nietlKxi arc the limitation of fluids ingested; the
diminution of fat prmluction by a diet of highly nitrogenouH solids and the
exclusion of fat; the [ininiotion of vigorous efforts of the csrdiac muscle by
severe cxeici^ie i>f the body muscles lu nu'tlio<iii'al and systematic liill-clinibing.
and the fi'siering of free diaphoresis from the skin.
Additional nieiuis for proiiucing diaphoresis such as Turkish baths may be
used. All lii|iiiils are to be reduced to about thirty-tive ounces of water per
diem. The solid TikkIs recommended as a daily ration are meat. fish, chicken,
or game, in all aUmt twelve ounces ; or one (.r two eggs, a little salad or cheese,
ami from four to hcvbh ounrt 9 of fresh or cooke<l fruit, and not more than five
ounces of tiread. The ascent of hills or mountains is to l>e made gradually,
takimr slioit st'-ps ami making frequent stops with deep inspirations if dvspnopa
comes on. (Tirmticth Century I*raciicp of Medicine, vol. iv., p. 485.) In
EKDOCARDTTIS—TACnyCARDIA. 6fil
tbe same conaectioo the treatment a(lv<K-ated by Dr. Schott, of Neuheim n^ar
Frankfort, ts recuDiuiend^d. This coQ»i«tfl eA8«<utiaUy lo the iiiw< of baths and
methudica) exorciau of tbe voluutury tuiiiKltw. TIil-iw balhii are iimid at a tem-
pt^rature of 88" F. to Wi" F, : the water contaitu fre« carbonic acid giw, ubo alka-
line chlorides and saltK of iron, tlie elTccta of whifh on tlie idciii runj' be Btituu-
tatiug b> ttie heart. The pfTect of tlie bath ia usually to reduce the rate of the
heart's conlractiuU and to increase tlie force of the reniricular iiystol*^. The
mtucular exerrineB whicli arf> a part of th»* treatnieot cuDsiHt of Hexion and ex-
tension of the up|>er nrtd lower extreiiiitifn witli rotation and Mexion of Die
trunk to an orderly HUL*ce<Mion, each inovenieut beinK reHisted liy ao altviidUDt, BO
that the effort thu« calk-d forth in j^rnduuted by the degree uf resiiitauee offered.
Either of theHC methods rnu^t Im:- employed very eautioiuily wlien tlie inyo-
cardiiini is degenerated or the walls of tbe heart are dilated; otlierwiBe the
result may be diMuttrouit.
In proper rasen either method trill aometimea ac(H7mplii«h muchgoo<].
A much pleaBantffl- and e<(ually satinfactory coume of treatntent for patients
who are not contined to bed cotmiatA of judtciouH bieyrle-riding, which securea
gentle exerelae of the muacleM, free diaphore«i(t. atimulatlcm of the heart miwcle,
and which Ik. at the same time, an aKrw'Hblo re<rreattoD. Indeeil, 1 know of no
form of exercine ao conducive to Btrenj^theniDg thu heart ba cycling under proper
reetrictionft.
HTFEBTBOPHY and DU.ATATloy OF THK HEART.
TfHtiment (|MiKe 239).— W}ien rewiiItiuR from over-exertion, rent hi bed Iflmnet
finportaui. In rapid dilatation, indir.kttil hy jj^allopinK rhythm, iirKcntdyBpucBa,
and «]ig)tt lividity, 0»ler rei'onimeiida ihat twenty or thirty ounces of blood be
drawn at once aa the only iiieaoa in many I'a&es of Having life.
DU^VTATION OF Ttie HEaHT.
Etiology {page 240)— Bollinger call^ attention to the great frequency of heart
disafww in Munii-h. whero it rank.i tliini ainting the caiiMOH of deatli, and tttatea
that great lieer-drinkem nearly alt aufTer in the coun>e of a few yean from dila-
tation of tlie heart (Medical I'reitA and Circular, Loudon. August 3-Sth. lSti5).
FATTV 1 1 BART.
Sffinptomut'flttgjf (page 24S)."Che;u»-Su>ku!!i respiration iaalto ijocaHioually
met with in unomia. moniugitiH. and affoctiooii cauitiiig pre»fturc on the hraio.
Sypbiutic Piskasb of tiib Heabt <Page24&}.
H. P. Loorain (American JmtrtMl of the Mexlicat Scitncen. October. 1895) sug-
geata that when the symptoms of cHniiac failure occur in the prime of life for
which tio c-itiste Huch ai rheumatism, valvular <liHeaae. arterial rhangen, or renal
dineaftecan l>e di^ovored. oflperiHlly in a piitient having a ayphiUtic hiiitory,
ayphilis should i>e suspected as the caiitie of heart trouble.
TaciiycariiIa (Page 249).
In the so-called irritubie htviri of Moldiers. excoasive use of coffee and tobacco
U proliably the maia catixe of tht« affection.
663 APPENDIX.
Bbadtcabdia (Page 260) .
Usually the pulse runs from about forty to fifty-five beats per minute.
According to Balfour (Ttie Senile Heart, 1894), it is occasionally physiologi-
cal, but in other instances it is probably due to some action on the spinal accessory
nerve either at its origin in the cervical canal, during its passage through the
skull from the foramen magnum to the jugular foramen, in its course through
the neck, or in the chest after it joins the vagus. Bradycardia is nearly always
associated with hypertrophy and dilatation of the heart, the latter predominat-
ing, and it usually occurs only in epileptics.
Anqika Pectoris (Page 250) .
Q. W. Balfour classes as true angina those painless paroxysms of cardiac
dyspnoea, so often fatal, and states that in his experience the greater number of
fatal cases of angina pectoris have been of this character.
Diagnosis (page 253). — According to G. W. Balfour, constipation due to
torpor of the colon is frequently attended by neuralgic pains radiating from the
neighborhood of the scrobiculus cordis over the edge of the false ribn, and some-
tiiiic's shooting into the cardiac area. Such pains are constant, and are at^
tended with exacerbations; they are not increased by exercise, and they never
shoot into the arms.
Burning, stinging, or cutting pains, probably of rheumatic or gouty origin, are
sometimes felt in the heart itself ; and also pain in the heart n>ay result frota
pressure on the cardiac nerves by an enlarged gland or by an aneurism.
In these cases there is apt to be an absence of pliysical signs of atheroma of
the arteries or dilatation of the heart, autl of thatawful sense of impending death
that is almost diagnostic of angina pectoris.
Prognosis (page 252). — The less there seems to be the matter with the heart
the more grave is the prognosis if the attacks of angina are at all severe.
In some cases the pain is removed under appropriate treatment, hut the dis-
ease progresses for a few weeks, montlis, or years to a fatal termination.
Treatment (page 252). — For the paroxysmal dyspnoia with or without pain,
the hypodermic injection of a small dose of morphine and atropia will tsome-
tiraes give great relief. Nitroglycerine, on account of its property of dilating
the arterioles and thus relieving the intercardiac pressure, has been recommended
for the cure of angina i>ectoris.
AciTE Sore Throat.
Treatment (page 313). — When the inflammation is severe, great relief may
be obtained from one or two doses of the nitrate of pilocarpine, gr. | each. This
remedy sliould caune profuse swenting, and, in about one-half of the patients,
profuse salivation, within half an hour. If it does not act in this time the second
dose should be taken.
Diphtheria.
Etiology (page 329). — W. T. Councilman {Boston Medical and Surgical
Journal. 8epteni))er Utii. 1895) expresses the I>elief that the primary lesion is due
to the Klehs Lotfler bacillus, but that lesions of internal organs are caused by the
toxines which it produces. F. G. Novy (Medical Sews, Philadelphia, July IStb,
DIPHTHERIA.
693
1805) aUUM that the bacillus is preeeot In serenty-three per cent of the cases of
real cliuicul iliplitlieria.
The u^eiwity for uasuniio^ tbut there are two varieties of diphtheria, and the
dc'Uii>iiutrnti«i lliat io many cases th^ro is a mixed infectiou, whilui iu a large
DUtiittvr lit healthy indiriduali the Klfbo-l^ftter Ltacilli Nn-ariii iu t)ie throat.
shows that our knowlcwl^e nf the |iat)iii1f»gy i>f thU diwade is still incomplete,
J. W, Wright {Bi}$tvn JUeilical and Suri/ical Juunuil. vol. cxxzi. . p. 320. 18(M>
contends that there is prai-tically no difl^rence in the virulence to be obserTml
between the bacilli iu mild ami thuee in aa^v^re cases of di|>htheriu.
Recent iuTeHtigaCJons havu shown virulent bacilli in a large ptTcentaKe of
pereono who have been expoeed to diphtheria and who do not wmtracl the di»-
eftM : tliereforH the ludividtial pon-er of rtwi^tance is a mout ini]R>rtanl faiMor in
the pathogenesis of this disease. It is probable that eorironnient lias much to
do with itM bfginniDj!;.
Diagnosis (pa^^e 3S2). — nactf>rioloRi<^al examination in madp, acrordinf; to
George 11. Weaver, by inoculatiuf? a culture-tube containinK LutBer's blood-
serum mixture with the bacilli obtained from the fulite membrane. To make
the culture, a stout platiaum wire, sterilized iu the tiame of an alcohol lamp, is
puslied into the menibraut' or is drawn along its edge, and then drawn over the
surface of the srjidifled blood serum in the culture-tube. This inoi-ulated aenim
is kept at a temperature of fi-om W F. to 984" F. for twenty hours, by which
time there shuuld be a diiitiucL growth <jf tlie diphtheria barilli. Other bacilli
from the tlu'uat will uoi hav^ multiplied much iu w; tihurt a time and at so high
a tenipurature. A coveralip preparation in made in the usual way, and stained
for fruui three to Ave minutes with I/iIIIit's ulbaline uiethylene blue ; it ID then
waahed with water uud examined under ti une twelfth immersion U-nis.
L0fi1er'abloo<l-serum mixture is prepikred with three parl«iof beef- blood serum
(obtftined by allowing the blo'Mt to coagulate and stand until the nerum rises to
the top) and one part of beef broth with onn per c(>nt of peptones, one per rent
of glucose, and one-half of one per cent of fwidium chloride. ThU preparatjun Is
plare<l in a tube in a slanting p<Mition and coagnlareil with dry heat ju«t below
the lx>iling-[K)iQt. It should subti<>quetitly be Hterilized on three HuccesHivedaya
for half an hour in live Bteam.
The beef broth is prepitred as follows : one pound of beef is nuicerated tn one
quart of u.'pid wnter for twelve hours, or for only one hour in water a litih' be-
low the hniling-iKiint. It is then etralneil. and Hutwec)uently Ixdled and tiltereil.
ProfjnoKU ( page 3)12). — The death-rate varies greatly Inaporaiiicand epldemlo
diphtheria alw> at different |>eriods of an epidemic.
SometlmeH tlie death-rati- iu as low as teu ))er cent, hut in more maliicnant out-
breaks it may reach sixty per cent. Tlie uatumi history of tlie dineam* -''ows a
regular cyclic vaiiatiou Ui ita gravity. Starting at a minimum death-rate, the
fatality grailually increases with only slibtlit ri-mi*tionH for several y»ar8, until It
be<viiiies fine oT the mcwt dreaflwl dinea.-<es: for a f«w yean* tliis mnii rnancy COD-
tinues, and then tliA death-rnte grndually. or at times rapltlly. il*- ^'*t^ for four
or Ave years, until we begin to think that the disease may finally di-iappear alto-
gether.
(Page 333.) It is stated by W. H. Welsh (Transaotions of lU-. ^ -t^noiatioa of
AmericaD Physicians, vol. x.. 1695) tlwt, as a result of iheanlit-v i i treatment,
tiiere is an apparent reduction in the mortality arot>ng surgi'';il •)•■/<« of 34.1
pnroent after tracheotomy, anrl of -10 5 per centafter intuliation \ i" Hitorial
article {" lievue (Hn^ralf rfe Clinique ft df Therajtntiique,*' J: ■!•■ 'Ifn pmc-
tioen*^ l*ari8, August 3Ut, 1&95) it is stated that, with the anr''> ■ tmatmeat
654 APPENDIX.
in hospitals, the mortality after intubatioD ia <mly 23.8 per cent, although it n
62.5 percent after tracheotomy.
These results, especially after intubation, are certainly very much better tbiD
were obtained before the serum treatment came into use.
Treatment — Topical (page 386). — Strong aolutiuns are very objecti<uiable be
cause of the pain which they cause. It has been claimed that by painting the
throat every hour or two with crude petroleum, which causes no pain, the mem-
brane is speedily removed, the danger of infection greatly diminished, and coo-
valescence hastened.
Carbolic acid may be used in the strength of from one to two per cent ; five
per cent is especially recommended by Oertel, but it is much too strong.
Two and one-half grains of sodium bicarbonate added to each ounce of the
peroxide of hydrogen neutralizes the free acid that is necessary to preserve it,
and renders it non-irritatiog, but does not diminish its eflficiency if added only
an hour or two before the solution is used (E. R. Squibb, Annual of the Uni-
versal Medical Sciences, vol i., 1804, P. B. 29).
General Treatment (Page S37}.
Antitoxin. — It is now believed that many disea-ses, especially those which
seldom affect an individual more than once, are self-limited by the formatioo
within the blood of a product capable of destroying the toxic material that ex-
cites the disease, hence called antitoxin.
In Buch diseaeen, if life be prolonged until a sufficient quantity of the anti-
toxin has been developed, the toxic agent is destroyed and recovery follows, if
no serious complications have arisen. In diseases which can be communicated
from animals to roan, and vice versa — such, for example, as rabies and diph-
theria— animals have been inoculated with the attenuated toxic principle, in
small but steadily increasing quantities, until an antitoxin is developed in
sufficient quantities to render the animal immune to further pernicious effects
from the cmtagium.
It has l>een found that the blood serum in tliis condition when introduced
into other animals or into man tends to render them also immune to the same
viruK. The home in ]iarticular has heen inoculated with diphtheritic poison
until iiiimimity to its further effecta has been obtained. The animal is then
bleii and th(> blood allowed to separate, and the serum is preserved as anti-
toxin.
Crucial exi>eriment8 have not been made to determine the value of diph-
theritic antitoxin, but experience indicates that it is capable of greatly diminish-
ing the mortality of this disease.
If in large liospitala or xvarda for diphtheria every alternate case were treated
by antitoxin Jilime, and the other cases by other well-known and valued methods,
it woulil Hoon l>e pusaible t<i determine the exact value of this new agent.
The statistics nsyet obtainable are very unreliable. Thus far, favorable cases
attract disproportionat? attention and are more frequently reported than the
failures. Fi^urt's from mortuary reports of city health officers or of hosptals
that compare the mortality of a certain period with that of a previous period are
lialtlf to he misleading, for it is well known that in different epidemics of diph-
theria or in different periods of tlte same epidemic the death-rate varies fr«n
ten to sixtv or even seventy-five per cent, regardless of the method of treatment
NotwithHtandine the want of accuracy in our present information, it is clear
*bat very few untoward results have followed the antitoxin treatment, and thit
poeitlt-e benefit U ap)>arent ; Btill we are Dot yet ju^ifled in relying upon ii to
the ezcltuioD of other remedies.
It is claimed that whert; antitoxin ■■ adtntnlslered on tlie Brat day of Ui« di»-
oaa« all of the ca»e» recav(<r. but that it in li>«i and leiw eflei>tiv«< with thu iirojrreBs
of the diHeaiw, and thut it HeeniM uf iittk- valu'-' after tlii; fourth ur tiflh duy.
It should tIit>rvrMre htt f^iveu us humu us the diuffuosiii bun Lk.i'U made : and
when ih«t di»eane in known to be present iu tlie vicinity, the phyisitriBn ithould
not wait for barter lological coDftrmation. The antitoxin aeruni ih adiilinjittered
hy hypodermic injection, preferably into ttonie part of the body where Iht-'re la
ati abiiiiilaDce of iooao cellular tissue, ta order that it may be easilydiHuaed, and
thU5 HA far an possible avoid the pain (%'hich necessarily attvnda and follows the
injection of two or three drachiiiB of tliiid.
With the more coDrentrated solutioitH lately nworninended by Beliriug and
otliera, the jnjevtiuott are more L>a^ily mii<le aud cauHi* l«iw juiiu. vVii itfdiuury
bypoderriiic syringe, or. bi-tttT still, a larger syrinKe made for tlit* purpom-, may bt<
used. It JH cuiiiinouly recniniiieinletl that the injection b<' iiimif intx^i the loose
tissue heueatli the ^Icin on the anterior portion of the c hej^t or the oiit*-r aKpect of
the thighH. The point of selection should depend partly upon the pr«ition in
which the patient prefers to lie, liecaiise there is itsually a gttod deal of soreness
for from twenty-four to thirty*stx hotim afterward at the niu- of injetrtion. T
hare often verified E, L. Slmrly'sstateinent that hy|HHlermioiujert.ionscaiii^ less
puiii when made just within tlie lower anf^le of the scapula or in the Rluteul
region than in other parts of the body -. therefore I would advise the wlection of
one of these places, provided Ih*^ |>aiient's decubitus permito. Die skin should
be made surfiically clean l>efore the injection ih given, and it is npedlesn to nay
the instrtinieut munt tte a««plic. AHmit one-fourth of the curative dtwe appears
to act as an efUcient prophylactic, secunng immunity for a period of from three
to eight weeks ; but some dauber attends it^ administration. It is j^enerally
considered that one thousand antitoxin unit« inuHt be given as a curative do«e,
and iu yoonif children fn»n live hundred to eiKht hundre«l units hav*- been
recotimieudi-d; hut Behring and Ehrlit-h {lietitnchf imftliciittgche Worlietiactiri/t,
LeipxtK. November 13th, 1894) concludeii that six hundred tmits were more ettl-
cient than a larger (juuntity. Behring also believes that several small doses at
intervals are Uatvr tlian a single large d(jse.
In ttdulta the diwe should be fifty per cent larffor ; the whole aniount may be
given at once nr iu two or three snialler doses, two to four hours apart. It is the
usual custom lo HilininUtcr it all at one injection.
In »evero citses the full dose iiisy W i't>[ieated two or three times at intervals
of from twelve to iwenty-fnur houm.
The principal ill etTects that havo hcen attributed to antitoxiu are the oceur-
rence of a rash upon the skin, and in Mjme cas** tedious convaIesi-*'nce; but «
few deatli!4 are known to have resulted, even from tjie small doses used as a
prophylactic.
In favorable cases the temperature diminishes within twelve to twenly-foiir
hours, tlie membrane noon begins to exfoliate, and there is a general bettermeui
of the constitutional symptoms.
Antitoxin may now be obtained at mosC well>equipped drug-stores and from
vatious boards of health.
It i^ put up in vials containing from a quarter of a drarhro Cn two drachma,
in varying strength.
One of the stronger preparatinni^ ront^ini) as many ns 2, 000 units in a quarter
of ft drachm of fluid. £ach vial in talwled to show the strength of the dose It
^ppEXD^-^'
. alter iatubf^tion i-
*".,«'■> tr:"-"^ ■-'''';■"''
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vVruw. *
bl.-.» >»^'^
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inn tl"
U ■
by "'■■ ,^ - -^
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fto"
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■ ^M'^=^-'^-'^t-r^benu>rrUa.^**
lVDfrjO'3 AyOINA.
657
TQbinff^u, 189K : AnnaU of Surgery. Philadelphia, 1806), th« disease occurs most
frerjiientJy among workera in grmio who are in the liabit uf chewiag bits of hay
and graio. lie believes tltat the diaeaae is Dot directly comiuunicabte from ani-
mals to man. but that both are infected from a common ttoune. It attacks either
MX : it ia rare in childhood, {>rol>ably owing to a better couditiou of the teeth
than in the adult.
SymptomatiU(}{jy. — Tlie aymptonu, when pyogBnio infection iit not present, are
those of a neoplasm.
The development is slow, and there is no pain (•xc<'pt from etTecta of nerve
pressure and stretching. There is no (erer, and a granulation tumor may be the
only eviftenct* of tho disease.
Pyti^t-nio iufection is very likely to occur, and then the progress of the disease
beeniries more acute aiid rapid, the symptoms being those of a chronic septic in-
fection. T>ie swelliug produ<-ed feels nearly as bard as a hony growth, and may
bo taken for n rapidly growing sarcoma ; but sooner or later ninuses are formed,
and the actinomycotic detritus may finally l>e discharged from the softened mass.
Diaffnoitia. — Actinomycosis ts to he distinguished from tub(*rculoHis, oyphilis,
osteo-sarcoma, and pyemia. When we Bnd a Arm. hard swelling having the
appearance of an abscess, which when opened shows scanty contenta as compared
with the amount of diseased ilasiie, it Hhould lead us to suspet^t the disease ; hut
the essential point in the diagnosis is the presence of the ray -fungus in the de*
tritus. Normally, the disease is limited by a clear line of demarcation.
Prognoiiig. — The prognosis is very unfavorable unless the disease can be com-
pletely eradicated by surgiral means.
The course is alow when uncomplicated, but when pyogenic infection oocun,
as is usually thu case, the course is rapid. One case is reported to have extended
over twelve years ; but in many, a fatal termination occurs in less than a year.
Death resultti from exhausllun and marasmus, unless Uiere is some special cause
dui-* to the orgaus involved.
Treattnent. — Tlie tr>>atment is surgical. UnleM «U of the involved tissue is
removed, the disease will recur. Other treatment in still largely experimental,
In cases where the knife cannot be employed, caustics have been used. Nitrate
of silver has given the l»e»t results.
Thomassen of Utrecht tir^t strongly advocated the use of iodide of polnaeium,
given in doses of gr. xl. to gr. Ix. [>er day. He claimed that, by charging the
blood with inditie, further development of the fungus was prevented and Iho dis-
ease cured : hut there appears to be evidence that although good results are re-
ported from its use, it does not stop the progri»«8 of the disease, Oxygen is said
to destroy thefungos ; and such diAinfectanUtas carbolic acid, tincture of iodine^
peroxide of hydrogen, and methyl-violet are useful.
LtTDwio's ANOINA. (Page 863).
Ludwig's angina consists of an acute suppurative inflammation of the con-
nective tissue surrounding the submaxillar)' gland. It causes a hard, sublingual
swelling, with elevation of the tongue and a swollen deep-red or bluish-red ridge
extending along the ttiterior of the lower jaw, and a more or less brawny swt'lling
below die angle of the jaw exlendiug dowu the lateral and (rout part of (he neck.
ft iaa grave affention. whioh tends to extend downward bpn**ath the cervical
faacia. cauxiug great )jniu. dyspbriiiia. dysphonia. and Anally dyspncea. Death
results in about forty per cent of the cases. Supporting treatment with early,
free incisions offers the most promising means of relief.
42
APPENDIX.
AlWffBff^ OP TBS TONOUE (P»ge 908) .
Absceu of the base of the tonffue rvHembteM Ludwig'H angina and Buppuratln
tomiliti?). Itcauaeaextuusivuttn-vlIiDK iu tliobw* of the toDgue, oftetiins-olvtug
the rvgtoD of lh« toDsil, aod eitendiuK dowti the side of the pharynx aad to (he
Urj'ux.
It in attended by f^reat pain, dysphaf^ia, and, in some caara, dytiplionia and
dj-gpnwa. It is a k^^^ iifft^tion, but fortUDat«ly Uie abec«H« will often open
spoutaueoUBly. If it doee not bo open hu incision into it must be made <bo«ever
difHcult) . and in aome instances tracheotomy will be necetwary to asTe tbe
patient's life.
HyPBRTBOPHY of the TOKBIl*.
Prognosis (pa^e S7I). — It in believed by many, and aeems to have been dem-
onstrated by Knickmanii (see Phthisis), that diseased tonsils lead to ptUraonary
tuberculosis and lerviral ad^uttJM.
Trcatviimt (page 371}.—! have not been in favor of removing tonsils that
were not large enough to interfere witli phonation or reepiralion. unless the;
wer^Huhject to frequent intiaiiimatioD ; but if Kruoknmnu and Dieulafoy *« (Ixn-
dou i^rncHHoner. July. 180-')) olwervations should be eontlrraed. tonsiUi:
should generally l>e recoiimvended whenever hypertrophy is pmnounoed.
EvRRtaoN OF TnR Ventricle of Moboauni (Page 488).
Everfion of the ventricle df Morgngni is very rnre. and only a few ca^ee are n-
ported in medical literature. Of tht«e. the first that was diagnodticated befan
death was reportwj bytieorgeM. Lefrert»{New ^ork Medical Hecvrtl. June, IB'8).
At that time only oue or two other c-aiteti had been difcurere<l [x.iHt-mortpra. Tbe
cases thus far ub«K>rvet) are so few that the etiology has not beva ascertained.
Oue oaw that I have treated was uiidimbtedly caused by a large cyst that in-
volved tbe side of the baite of th** tongue, pn-ssed in the right side of the larynx,
and extended down beneath the Jaw into tim neck.
The affer*tioa consists of a prolaptte of the ventricle which has the appearanco
of a Diiic>oth. rounded sessile tumor of a pinkieh color which overlaps the rocaJ
cords. The iii.-is-i isnoft. as can beeasily dpnionstrated by pjiliJiition with a pmbe;
and ID this respect it differs greatly frvmi tibroid gruwUisand frcmi iuduniUoa
of chroniccntarrliul laryngitis, tulwrcu lewis, and Byphilis. Tbe condition ckusm
dj-splHinia or ct^mtplete 1<m<8 of voice, and may oecusiuu more or lew dyapDoaa.
Thi* treatment will vary with the extent of tlie prolapsus. Astringent applica*
tJooH may be of some value, but surctf^ful roplaoement cannot Ite ho)»ed fur
In certain CAsee the ma«t rould he redui-ed hy the careful application of the
gal vano- cautery ; and where the ventricle lit ftuniciently prolapsed il in pmbable
tluit after thnroui^jb auiUHthetiTation of the larynx with cocaine the prtitruding
mass could lie retuoVMl with a snare or guillotine. In Lefferls' case, ihyrobimy
was performed and the everted wcculus cut off with scissors. Tlie voice was
restored and all of the otlter symptoms were relieved.
Id my oa»e. I anptrated tlie ey^t. drawing off two otinces of thick, mucilagi-
nous fluid, wlitcli caused sutMidence of the Hwctling of lite Iar>-nx eo thai the
everted ventricle came Into vii^w II wmh about flve-eighthft '^f an mcli long by
Uiree-eighths of an inch in its other diatiieters. I 6rat nip|>e<l it mih a cuttiaf
EMPYEMA OF THE AXTRUM
6S9
forcepa. but was uakble to cot it. I then caught it and cut it off cltnrouftltlj
with R Bnare amied with No. B piano-wire, uaing the long bent tube dHdwd in
Pig. 208.
FiUCTVBK OF THK LARYNX.
PrtyQtuiaijt (jMig^ 481>).— F, 3l[ltry {Archive* de MAUcine ft de T^inriimfiif Milt'
taim. PariB. November and Dei-eniber. iSflfij mi vr thai thf average nmrtality is
from 81.33 tu 60 per cent, but that in caanH ari^iug frum guasliut n-nunda it is
much lew cm aconunt ut the nature of the wound, which in many catwe per-
mits the free paenage of iiir.
FoHUG» Bodies in tub Labtnx.
Treatment (page 492).— It would appear from tho experif'noe of J. W. Olelta-
mann and olhent (Tranttactions of American t<aryngi>)ot(ical AsaooiatioD, 1896,.
page 200) tlmtKirfttein'Bautrwcope would prove Tery nerviceable insomo of theeej
oaaes. particularly in children.
RHHims.
Anatonteal and Pathological CharaeterisiicM (pafi:« B32). — In «xceptIoiiftl
oaaea an excens of fibrin collecta in irr>-t:iilar tn:i8Ae8 or as a membranous lay«r.
Tliis i» Bometiniet) termed vievibraninis rhinitiit. and is believe<l by some to l*e of
diphtheritic <iriK<n ; hut the fact thnt no casett have proven contagious, and that
Uiey di> not terniiiiate fiitnlly, lead.i us to believe that they are the reeult of ordi*
naiy ioflamtnation.
Nasal Mucocs Polypi,
Anattjmical and Pathoiogical Ckaracterittic* (page 003). — Nei^'es have
dernoDatrutt'd iu thewKruwthshy niettuBnf methylene blue slain, by O. KaHscher,^
of Berlin {Archil^ /ur Lnrytiffoloffie, vol. ii., Nn, 2, IftSK'i). This confutes
generally received opinion that theae growths have no nerve fllanieuta.
Empyema of thb ANTntTi.
Treatment (page 5B'i). — Tlie main olijectiun to puncture of the antrum above
the alveolus ifl the difficulty nf keeping the opening {latent ; but this may h<t ob-
vinle'l by niakiDg a large opening a centinti^tre or nion- in diameter. 8iifh an
opening •>ir*:TM an opportunity of curetting the antrum as may be Deeesaary in
some conditions.
Nirhnlaa Seun han obtained moat aatiftfactory reeultn by temporary neteo-
plastic resection of the anterior antral wall, for the purfiose of detectinR and
removing the cause of chronic suppuration. In the I\tciftc Mnlical Journal for
D«<:eml>er, 1H07, he rays : " After p<Tforniing what ia entille<t to be called a radl*
cal operation, a free communication is eatablislied betwe«n the antrum and
the nasal passage, either by dilating the normal opening, or by making a new
on*> from the antrum into the inferior meatus by perforating the thin bony sep-i
tuMi nith a curved force|>s. Disinfection of the carity and thorough tubular
drainage complete the operation.
"The operation is performed under partial general anwwthesia. The cheeh
and lip« muM be well retrarted : a L'-tihaped iiicisiou i» tbcu made through
the mucous membrane and the perinnteum down to the iKioe in wirh a way
that the anterior vertical incision fnllo just behind the eitituence of tlie root of
APPENDIJC.
the caniDi* tooth ; the second vertical ipcision about thrt^t^uarters of an loch
bfhind the fln^t. and the coDnectiag tnuufvernc inciBion at a point above the
alveolus, on a levt-l with the floor uf thv antrum.
" With a thin car^'cr's cbisct. Lhrec-quarters of an inch in width, the nntriior
autrul whII in cut in the tMtiie directioiiK, and the t)ODf at tht has** of ih^ M^uim
quHdrniiK^ilar flap is fmi.-iurt^ by inserting au elevator iiilo tlie atitrum Ihtounh
the tniiiBverse cut and uminK it as a I^'ver. The flap. con)po««d of'nmcou'i m* ni-
brane. jipriosteuni, and bone, ia ikjtv turned upnanl, and throD^jh the* up«>ning
the antrum ih explored carefully by iusfrtiug the little Hnger.
" ProjectiuK roota vt carioitB t(K>th. caries of the inn* r mirfacf* of the antral
walU. nequ^tra, fungous KrnnulatioQH. and the presence of foreign ttidiea ar^ the
condilious most frecjiieiitly found an ptriiiauent caiuwit of vuppu ration.
"Tlie Use of the sharp npnon is indiRpenitahle in effecting mechanical removal
of iiifect4Hl tiseuM or h>nM> enhetanree.
** With a iiharp curved forceps an adequate opening is made from the nniruin
intothenoseat one of the pointH iudicatfKl ubt)r«, and with the tame instnini^ot,
or a probe aniiecl with a loop of strong silk ilirt-ad, a fenextraled tube the size at
a lead pencil ia drawn through tlie antrum into the mouth and cut ahort Dear
the opening in the antrum. With a rongeur forceps a small semicircular defect
is made in the lower margin of the deflected quadrangular bone>f)np to furnish
spare for the drainage-tube, when the Hap ia brought into position and gutur«d in
pla<x: with two catgut iiutures which include coily Ui« mucous membrane and
the periodteum.
"The twoi^udsof the rubber tube are connected with a silk thread. The cavity
is flushed daily with a saturated sohitiou of b<:iric acid or Thiersch's solution j
and if the discharge ia fetid or profuse, the irrigution is precedeil by an injec-
tiou of peroxide of hydrogen. An soon an suppuration ceases, the silk thread is
cut and the rubber drain drawn back into the antnini, the same local treatment
being ixiutinued. The opening in theanu-inn on the side of the mouth closes io
a Hhort time, with little ur no defect of the Umy wall of the antrum. The oawl
drainage ohnnld be rontiuuea for several weekn — long enough for Uie opening lo
become perniauent and liueU with mucous niembrane."
i
I.\FL.AMXATiO!r OF TUu Fbontal SiNCS (Page RtM).
It is not eiasy lo reach the frontal sinus in the healthy state, bnt it Is usually
much less diftlcuU in pathological conditioDs after removing part of the turW*
oated biHly.
FoKVEUTEU 8k.\hk ot Shell— Pakobmu (Page 991).
Treatment.— Vo rules fur treatment can be formulated, though solutions of
strychnine hsveocvfLStonnllT proven curatire. and theeymptoms not infrequently
disnppear under pro)>er treatment of the various inllauiinatory affections of tlw
naree that may be present.
AlfOSHU.
TVeafmmf (page 592). — Joal of Moot Dor^ succeMfed In curing tno o:
that had for several months resisted treatment by irrigation, electricity, and
strychnine, by the employment of douches of rarlMinic acid. This was applied
by meantt of an ordinary seltzer niphon. which wh» turned npside down and th*
OrmcK) held cloM to tlie nostril (Londtm Lattcnt. May 18th. 1996).
'as«^^^
RBTROTfASAL FIBROUS TUMORS.
t
DKPLECmON OP THE NaSAL SePTUM.
Treatnient ipnge r»l>6> — Thickpning of the lower nart of the septum in nearly
always |ir<«<>iit in ihysi* eaAPit, aiid the rrault^ are better if a trephine is run
throu({h the lon-^r ]>art and the (lejitum ia thfu broken loose at its lower edge by
the foroepe, I have found ihe operation foi deilectioo of the canilaginous
s^plum greatJy fncililati*i] by the tme uf a himked rartila^e knif^ designed to
nmke KiibniucottB inciKions. The knife is entered through a tunnll opening in
the mtioouft membrane and forced back between tlx* mucosa and Ih** cartilage,
when it ift turned with the cutting point tuword the cartilage, more or leM
oblicjuely aa desired, and then drawn forward. It doe« not out through the
mucous membmne of tlie opponite nide.
ECCHONDRDMA AKD EXOSTOSIS OP THE KASAL SKPTTTM.
■
TreatTHent (]iag<A 5fiS and fJOO) — Giiiucul lias been reconinn^nded aa B local
ana?Mthetic and it sumettnn^u acts very satisfactorily in iDcreasing aud pro*
longing anawtliMia if applied after the cocaine. I use for tbiN a tweuly-five- to
fifty 'per-cent. solution in almond oil. After the operation the caroe ta packed
aa re<xiiiimpnded in treatment ff epi«taxi&, either with a strip of hfenioetatic
gauz«, or a Btrip of antieieptic Hiirt;eim's lint ; thin strip ih about three feet long
■tid half au inch wide.
It is prepared beforehand by soaking and then drying, first in a saturated so-
lution of boric airid in alcohol, and then in a saturated Bolution of iodoform in
etber. It is kept until wanted in a g!aB»-><toppered bottle.
Tliis has proven, fnr nie, the most satisfactory of any of the naaal tampons.
Tlte i>atient id directed to wear it from two to tire days if it does not cause
pain nr become offensive ; then either to return tu the operator or to remore it
bimaelf.
Usually on the second day, and each day thereafter, I have as much of th«
packing witbdrawn as can be taken out easily; the piece iscutoS. and time
allowed for tlie BecretJons to soften the remainder.
n^TKRTROPHV OP THE PIIARYXGKaL To«81L.
Ajuttomieal and Pathoiogical CharaeterinticH (page 013). — ^Tbo changea In
the glandular tiasne sometiiuett cl- sely reaeiuble those frequently wimeeeed in
the fauciaJ tonsil, though in the majority of cases the new growth mon> closely
resembles an exuberant {lapilloma. ItH surface ix not tTaveraed by blood-vesaeli,
but here and there small arterial loops may Iw seen.
liETRoNASAL FiBROCB TVMORS.
TVeatrntnt (page 024) —Should recurrence of tlie tumor take place, it should
be treated while it ia yet nmall liy thi' gatiauo-oautery, by electrolysis, or by iu-
iJeottons into the growth, by meima nf a long hypodermic needle, of a m>luliou of
'liirse to Are per cent of carbolic acid with iwenty-flve to forty per cent of lactic
acid, in water.
The weaker aolution Is uaed at first, and the slrengfh gradually increaaed
with Bubse<]nent injectiontt.
To prevent pain. th<* injection should be preceded by afewdropeof afotir-per*
eent. solution of cocaine (Form 140).
662 APPENDIX.
Goitre.
Treatment (page 681). — AdrainiBtration of tliyroid extract or of desiccated
tfayroidB haa been followed by most satisfactory rCKults in many casee. In a
serieeof over fifty cases investigated by H. O. Ohla and myself, we found marked
improvement in about seventy-five per cent.
In all of my own cases, when the remedy had any effect it acted promptly.
In one case of moderate enlat^ement of many months' duration that had
withstood the ordinary treatment for Ave weeks without perceptible diminution
in the circumference of the neck, the measurement was reduced half an inch by
one week's use of the desiccated thyroid.
The doee of this remedy for an adult is from one to five grains three or four
times a day of a preparation of which one grain represents eight grains of the
fresh gland, or about one-eighth of a sheep's thyroid. The smaller dose should
begiven at first, andthequantitygradually increased to the larger if no untoward
symptoms occur.
The unpleasant symptoms I have observed from large doses were severe head-
ache, rapid and irregular pulse, great nervousness, and in one instence symptoms
very closely simulating exoptbalmic goitre.
Desiccated thymus glands prepared in the same way, and given in the same
manner, I have used with benefit in some cases.
Surgical Treatment. — Experimental total thyroidectomy almost invariably
causes death in animals, whatever thpir habits or the nature of their food.
Foreign Bodies in the CEsophaous.
Treatment {page fl42).— Frank Van Allen {Medical World, October, 1894)
suggests an ingenious aid to tlip removal "f small bodies. Four to six ounces of
milk are to be swallowed by the patient, and in about forty minutes, by whirh
time it will have coagulated, a prompt emetic like sulphate of sine is adminis-
tered.
FORMULA.
PRESCRIPTIONS.
Sbteral of the formulffi relating to diseases of the throat and nasal pas-
sages are taken from the Pharmacopceia of the Hospital for Diseases of the
Throat, London. The various miatures, 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 sulBcient for one pill.
1. 9 Morphinffi sulphatls gr. i.
Antimonii et potass, tart gr. 1.
Ammonii chloridi 3 i.
Ext. grindeliffi robusts fluidi fl. 3 iv.
Sympi pmni viiginionn et
Misturfe glycyrrhlzs comp aa fl. 3 ij.
M. S. Teaspoonful, for cough. Especially useful in acute bronchitis.
2. 9 Morphinffi sulphatis gr. 1.
Chloralis 3i-
Syrupi zingiberis 3 iv.
Misturte glycyrrhizffi ad fl. J i.
M. S. Teaspoonful every half-hoar until relieved. For spasmodic
asthma.
8. Emulsion of Cod-Liver Oil.
B Olei morrhuffi S ij.
Sacchari 3vi.
Acaciffi 3 iv.
Olei gauttheris tti iv.
Aqu» q.s. ad fl. ^ iv.
Tritniate 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. 9 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 medir
dne for protracted bronchitis in children.
664
FORMULA.
6, 9 Morphinffi Bulphatls . . . ,
Ammonii carbonatls . . . .
Syrupi pruni Virginians
MiBtnrie glycyrrhiza comp. .
M. 8. Teaspoonfiil in water, for cough.
tohen opiates are not contra-indicated.
i.
aa fl. 3 iv.
A most useful cough syrup
6; Pil. Can. Ind., Hyoscyam.^ et Quinina Comp. (Xo. 1).
9 Ext. can. Ind. (Allen's)
Ext. niifis vom.
Ext. hvoscyam. (alcoholic)
Caiiiphorio
Quininn muriate
M. 8. Before mealjs and at bed-time.
gr. i.
gr. isa
7. Pil. Can. Ind,, Hyoscyam., et Quinina Comp. (No. 2).
B Ext. can. Ind. (Allen's) .
Ext. nueis toiu.
Ext. hyoBcyain. (alcoholic)
Creasoti
Deitro-quininiB
M. S. Before meals and at bed-time.
gr. i
gr. t
gr. i.
mi.
gr. ij.
8, Pil. Capsicum, Hydrastine, Papain Comp.
3 Oleoresinie caiwicl m ^
Ext. nucia vom. gr- i
Hydrastine nmrinte gr. J
Papain (Carica papaya) gr. iij.
Acidi salieylici gr. i.
M. S. After meals.
9. lodol Ointment.
IJ Acidi cjirbolici m vi.
Olei rostti m V.
loditl gr. XIV.
Jjimolini i sn.
M. S. A ruhiabh' ointment for hetiUny abratfions of the nostril and
upper lip (mil fir htiiliiitj ero.sio}is of the septurn.
10. B Antiiiionii et potassii tartratis
Caiitharidis et
Olei tifilii
('aiii]ihone et
Ext. stniinonii (aqueous) .
Adipis
CiTiiti simj)liri.s
M. S. Counter-irritant ointment.
. KT. XX.
aa gr. xl.
aa gr. Ixxx.
. 3 iiss.
, ad 3 i.
11. 9 TinctiiriP iodi 3 8S.-3i.
Pota.'isii iodi<li gr. i.-ii.
Aqua; ad fl. 3 i.
M. S. Use as an injection, which should be withdrawn in about five
minute!>. For vhroni<- phnritiy.
0AROLES-TROCHISCI OR LOZENQEa.
665
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. B Potassii bromidi ....
IS. 9 Potassii nitratis ....
Potassii chloratis ....
Aquffi ferventis
M. 8. Use as hot as it can be borne.
ASTBIXGKXTS.
14. B Acidi tannic! '.
15. 9 Aluminis ....
16. Q Ferri et ammonii sulphatis
17. 3 Sodii boratis
Glyeerinffi ....
Tincturffl myrrh»
Aquw ....
gr. ixx. ad fl. S i
gr. IX.
gr. XX.
ad fl. I i.
gr.iij.-3ij. ad fl. ji.
gr. viij. ad fl. 3 i.
gr. viij. ad fl. 3 i.
gr. XXV.
TIV XXV.
TTl XXV.
ad fl. 3 i.
M.
18. B
M.
10. B
20. B
21. B
22. B
23. Q
24. B
STIMULANTS.
Acidi acetici dil "l xv.
Glycerins "l xviij.
AquK '. ad fl. 3 i.
Acidi carbolic!
Potassii chloratis
AXTI3EPTICS.
Acidi carbolici vel.
Potassii chloratis (see Stimulants 10 and 20).
Potassii penuanganatis
Hydrargyri chloridi corrosivi
Aqnee cinnaniomi
gr. ij.-x. ad fl. 3 i.
gr. x.-xxv. ad fl. 3 i.
gr. ij.-iv. ad fl. | i.
gr. i-gr. 8S. ad fl. 3 i.
q.is.
TROGHISCI OR LOZENGES.
Each lozenge eontainsseventyto eighty i>erfent of red-ourrant fruit paste,
one to two per cent of powdered tragaciintii, four per cent of sugar, and a
varying quantity of the medicament according to the following formula;:
SEDATIVES.
25. Troch. morphinee sulphatis
36. Troch. est. opii
27. Troch. sodii boratis
28. Troch. ammonii chloridi ....
29. Troch. lactucarii (Aubergier'»)
S. One ever>' half-hour or hour as needed.
take and efficient in mild vases.
. gr. ;,'„ ad troch.
. gr. Vs '■
■ gr- ii.i"
. gr. ij. ■■
These are eery pleasant to
666
FORMULA.
UO. Troch. chlorodyne
HI V. ad troch.
31. Troch. Lobelice Compound
Q Ammonii chloridi .
Ext. lobelite .
Ext. glycyrrhizffi .
CodeiQffi .
gr.i.-
gr.i.
gr. Vq ad troch.
83. Troch. Morphia, Antimony et Ipecac Compound.
9 Morphinffi hydrochloratis ....
Antimonii sulph
Pulv. ipecac
Olei sassafras
Balsam tolu
Ext. glycyr., acacis et sacch. alb. .
88. Troch. Terpin Hydrate and Cannabis Compound.
0 Terpin hydrate
Ext. can. Ind. .
CodeiDffi .
Ol. iiienth. pip. .
Sacch.
34. 0 Troch. Mist. Qlycyrrhizce Compound.
Same as migt. glycyrrhizte comp., U. S. P.
35. Troch. Opii et Anisi Compound.
Q Pulv. opii . gr. ^
Olei anisi, ext. glycyrrhl.ffi, acacia, et sacch, alb. q.s. ad troch.
gr.A
gr- A
gr. A
&a q.s. ad troch.
gr.ij.
gr. A
gr.i
"I A
gr. iij.
DEMULCENTS.
!t6. Troc/i. Althea.
? Altheie, acaeite, et sacch. alb.
37. Trorh. Ulmi.
\i Mucil. ulmi cort., albumen ovi, acaciee
Sacch. alb a& q.s. ad troch.
ASTRINaBNTS.
38. Q KramerijB ' . . . gr. iij. ad troch.
39. e Kino gr. ij. " "
40. I^ Acidi tannic! gr. iss. "
41. Troch. Krnmerice Compound.
V, Pulv. cubebffi gr. i
Ext. kraiiierite gr. i.
Potassii chloratis gr. ij. ad troch.
STIMUIiANTS.
42. I{ Acidi benzoici gr. Uj- ad troch.
43. 'B, Cubebffi gr. ss. " ■•
44. B Guaiaci gr. ij.-iij. "
45. B Pyrethri gr. i. •• «
VAPOB INHALATIONa. 667
4fi. Troch. Acid Benzoic Compound.
Q Pnlv. cubebie gr. i
Acldi benzoici gr. ^
Potassii chloratis gr. ij. ad troch,
47. Troch. Cubeb and Potassium Chlorate.
^ Cabebn gr. \
Potassii ohloratis gr. iij. ad troch.
48. Troch. Ammonium Compound,
9 Ext. glycyrrbizffl
Cubebs
Pulv. ulini cort.
Ammonii chloridi
Acacise et saoch. alb.
gr-i
gr.i.
gr. iij.
q.B. ad troch.
49. Guaiac and Ammonium Compound.
9 Ammonii chloridi gr. i.
Guaiaci resins gr. i.
Potassii chloratis fiT- ij- ^- troch.
Potassinm chlorate is more pleasant and more e£Bcaciouii in compressed
pills than in troches.
ANTISBPTICS.
60. 9 Acidi carbolici gr. i. ad troch.
51. 9 Potassii cUloratis (see Stimulants 19, 30).
VAPOR INHALATIONS.
Mackenzie's eclectic inhaler is the most couiplete, but some or the cheaper
instruments will answer the same purpose. An inhaler which is in common
nse consists of a gla^s 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° P. or as indicated by the formula. They should be used morn-
ing and evening for about five minut«s 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 luaintain their tsusj^nsion in the water, as
shown in the following fonnula:
63. i( Olei cajuputi til viij.
Mag. carb. lev. gr. v.
Aquffi ad fl. 3 i.
M. 8. A teaspoonful in a pint of water at l-W F.. for each inhalation.
The vapors may be sedative, antispasmodic, antiseptic, or gently or
strongly stimulant.
668
FORMULA.
SEDATIVES.
68. Q ^theris et alcohoUs,
54. If Ghloroformi et alcoholis
55. If Lupulinse .
56. ^ Ext. belladonnee vel
Ext. stramonii .
57. If Ext. opii
58. If Tinct. benzoin! coiup.
59. If Tinct. opii camph. .
ANTISPASUODICS
60. :R Athens vel chloroformi (as in 53, 54).
61. If Amyl nitritia
Afi
aa
. gr. XXX.
gr. V. ad fl. 5 i.
gr. T. ad fl. 3 i.
fl. 3i.
fl.3i.
ta viij. ad fl. 3 i.
MILD STIMULANTS.
63. If Olei pini sylvestris
63. If OleicubebsB
64. ^ Olei cassisB
Olei limouis
M.
65. If Olei anisi .
66. If Olei niyrti .
Cauiphorffi
M.
67. ^ Terebene
Alcoliolis
M.
68. More stimulatwg than the above, and antisepti
If Acidi carbolici .
CO. ^ Creasoti
70. If Oleicari .
71. If Olei juniperi
72. If Acidi carliolici .
Animonii chloridi
Olycerinie .
Aquue dest .
M.
73. If Tinct. iodi comp.
(Tlyct'rinH! .
Aquro dest.
M.
74. B Creasoti
Glyceriiije .
A<]utL' dest.
M.
n xl. ad fl. S i.
3 ss. ad fl. S i.
nivi.
■n, X. ad fl. 3 i.
^. vi. ad fl. 3 i.
m vi.
gr. V. ad fl. 3 i.
31.
3 1-
gr. XX. ad fl. 3 i.
TH xl. ad fl. 3 i.
Tij, vi. ad fl. 5 i-
Til XX. ad fl. I i.
gr. XIX.
gr. xiT.
3i.
^ V.
3 i.
3 vij.
. 3 88.
. 3ij.
q.B. ad S i.
SPRAT INHALATIONS. 669
75. ^ Hydrargyri chloridi corroaiv rrfra
Glycerinw 3 ij.
Aquffi dest 3 ^•
M.
STRONG STIMULANTS.
76. ^ Olei calami arom m v. ad fl. 5 i.
77. ^ Olei oaryophylli m x. ad fl. S i.
78. ^ Tinet. iodi comp m x.
S. Repeat two or three times at each inhalation.
79. 9 Aquffi ammoaiffi et aqus aa fl. 3 iv.
SPRAT INHALATIONS.
Spray inhalations are to be used by the physician or patient in full
strength, vith the compressed-air atomizer; the aqueous solutions maybe
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 may be classified as sedatives, astringents and stim-
ulants, htemostatics, and antiseptics.
SEDATITES.
80. 5 Potassii bromidi gr. xx. ad fl. 3 i.
81. ^ Cocainn hvdrochloratis . . . gr. xl. to Ix. ad fl. 3 1.
M.
83. H Ext. pinus canadensis dest : ss.
Olei geranii ni iv.
Olei petrolinffi vel liquid albolene . . q.s. ad fl. 3 i.
M.
88. I^ Antipyrini gr. Xi
Zinci sulph gr. Ij.
Ext. hamamelidis 3 i.
Aqute dest. q.s. ad I i.
M.
84. If Acidi carboliei gr. iiss.
Mentholia gr. v.
Liquid albolene 3 i.
M.
85. H Acidi hydrocyanici dil 3 ss. ad fl. 3 i.
To be used only im a cold apray.
86. If Acidi carboliei gr. i.
Sodii borntis
Sodii bicarb iia gr. ij.
Glycerinaj Z\.
Aquu] dest. q.s. ad 3 i.
M.
87. If Olei petroliDte vel liquid albolene.
670 FORMULA.
ASTBIireBNTS AND STIUOtiAKTS.
88. It Acidi tanniei gr, iij. ad fl. | i.
89. I^ Zinci sulphatis gr. ij.-i. ad fl. J L
90. I^ Zinci chloridi gr. ij.-i. ad fl. 3 L
91. ^ Aluminis gr. z. ad fl. ^ i.
98. H Ferri perchloridi ST- "J- ad fl. 5 »-
98. ^ Morph. Bulph gr. ir.
Acidi tanniei
Acidi carboUci aa gr. xxz.
Glycerinffi
Aqnn dest a& fl. ^ es.
M.
04. If Acidi tartaric! . gr. i.
Acidi carbolici
Zinci sulph aA gr. ij.
Aquffi dest. fl. ^ i.
M.
95. I( Acidi tartarici gr- ij.
Ziuci sulph gr. zv.
Aqute dest. A. ^ i.
M.
96. ^ Acidi tartaric! gr. iij.
Zinci sulph gr. zxx.
Aquffi dest. fl. S !•
M.
97. 5 Acidi tartarici ffi". ij.
Zinci chloridi gr. xv.
Aquie dest. fl. 3 i.
M.
98. H Acidi tartarici gr. iij.
Zinci chloridi gr. zxx.
Glycerinffi Z iij.
Aquee dest. fl. S i.
M.
99. It Rxt. hamainelidis dest.
100. R Acidi carbohci gr. ll.
Glycerin* 3i-
AquiB deBt. fl. I i.
M.
101. I( Cupri Bulpliatis gr. x.
Aqute dest. fl. 3 i.
M.
102. Vf Cupri sulphatis gr. XX.
A<nia' dest. fl. I i.
M.
103. R Aeitli carbolici gr. zxx.
Ext. iiiuus canadensis dest ni xx.
Liquid albolene . . . . q. 8. ad fl. | i.
M.
bPRA T mHALA TIONS.
104. Q Acidi carbolic! gr. ijss.
Mentholie frr. v.
Liquid albolene fl. S i.
Acidi carbolici ta i.
Mentholis (cr. i.
Olei KaultheriiB Tiij.
Liquid albolene fl. 3 i.
671
M
105. ^
M.
106. «
M.
107, «
Olei caryophyl.
Liquid albolene
Olei caryophyl.
Terebene
Liquid albolene
M.
108. IS Fl. est. thuja occidentalis.
100. Q
M.
110. 9
111. 9
113. ^
M.
AtuminiB pulr.
Glycerini
Aquffi dest. .
HEMOSTATICS.
Perri chloridi
Acidi tanuici
Liquor, feiri chloridi
Aqu» dest.
ANTISEPTICS.
lis. ^ Sodii benzoatis .
114. 9 Aqute calcis
115. It Bromini
116. If Acidi lactici
117. ^ Potas&ii pemianganatis
118. It Potassii chloratis
119. ^ Acidi borici
120. ^ Listerine
TIlV.
fl. Si-
tu viij.
Ta XX.
q.B. ad fl. I i.
gr. XXX.
3 iv.
q.8. ad fl. I i.
gr. V. ad fl. S i.
gr. X. ad fl. 5 i.
Hi
q.s. ad fl. S i-
3 i. ad fl. 3 i.
fl.3i.
gr. ss. ad fl. I i.
ni. XX. ad fl. I i.
gr. V. ad fl. I i.
gr. XX. ad fl. 3 i.
gr. X. lid fl. = i.
3 i.-ij. ad fl. 3 i.
131. If Hydrogen perioxidum.
ThisiB usedinfullBtreugthaspurchasedat the drug store, or diluted with
one or two parts of water, according to the amount of smarting produced.
133. Q Acidi tartarici gr. iss.
Hydrarg. chlorid. corrosiv gr. SB.
Aqune dest. fl. 3 i.
H.
673 FORMULAS.
DRY INHALATIOJiS.
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 withont
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.
SBDATIVKS.
133. R Acidi hydrocyanici diluti fl. 3 i- ad fl. J i.
S. A teaspoonful at each inhalation.
124. R iEtheris. 8. A half- teaspoonful at each inhalation.
125. ^ Aiiiyl nitriti m i-
Alcoholis Tl XXX.
M. S. Use at each inhalation. This is useful, especially in spasmodic
affectiou.fl.
12C. R Olei santali aibi "l i.
Aleoholis tti xxx.
M. S. To be used at each inhalation in divided doses.
127. B Chloroformi fl. 3 ss.
S. To be used at each inhalation ; to be breathed slowly.
STIMCLANTS.
128. I? Tinct. iodi m i.-xil.
In thi.s siiuie category may be included the carbonate of anmionium and
camphor, used as smelling-siiltn; and nascent chloride of ammonium, used by
any of the inhalers constructed esi>ecially for that purpose.
FUMING I^'HALATIO^'S.
Funiinpr inhalations are prepared by saturating bibulous paper with a
solution of the remedy of a given strength, drying the paper, and then cut-
tinjf it into twenty equal parts, each of which will contain one twentieth of
the amouiit of iiu'dicine used. These strips may be rolled into cigarettes, or
they uiay be burned under a funnel which will conduct the smoke to the
mouth. They are eiiii)loyed in asthma and spasm of the laryni. The prin-
ci])ai uietliciiies employed in this manner are :
12!l. It Potassii arst'uiatis gr. xv.
ISO. K Sodii iirseiiiatis gr. xx.~il.
lai. I{ Pdtasf^ii nitratis gr. xii.-lx.
Aquw ad fl. |i.
PIGMENTS.
673
The three latter may be modified, as recommended in the Throat Hospital
PhannacopGeia. 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 pa{>er to the air a few luinutes 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. benzoiui comp.
188. Nitrated papers with tinct. hyoscyami vel stramouii.
134. Nitrated papers with oleum santali.
135. Nitrated papers with oleum sumbuli.
STIMULANTS.
136. Nitrated papers with spts. camphorse.
137. Nitrated papers with oleum cinnamoml.
138. Nitrated papers with oleum cassin.
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
I'.he 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 anesthetic, astringent, stimulant, or
antiseptic in their effects.
LOCAL ANESTHETICS.
189. 9 Morphinie snlphatis gr. iv.
Acidi carbolic! gr. xxx.
Glycerini fl. 5 i.
M.
Thirty grains of tannin may be added, when a slightly astringent
effect is desired.
140. R Atropine
Strophanthin.
Olei caryophylli .
Acidi earbolici
Cocainju hydrochloratis
Aquie dest. .
M.
141. I* Chloral ....
Aquae ....
M.
143. If Morphine sulphntis .
Chloroforuii .
M.
143. ^ Sol. cocaina)
This solution iw rarely used for an
gr.i
"l iij.
gr. X.
gr. XI.
n. = i.
lu] fl. I i.
gr. XX.
ad fl. = i.
lO.'f to 25;?
y other purpose than that of produc-
ing anffipthesia of the faucial surfaces— where the throat is hyper-sensitive —
to facilitate an examination of the pharyiigo-larynx.
43
674
FORMULA
ASTRINQKNTS.
144. It Zlnci chloridi
gr. I. ad a. 5 i.
gr. x.-xxz. ad fl. | i.
146. ^ Fernet amiuoDiisulphatis
gr. XIX. ad fl. 3 i.
Ta xl. ad fl. 3 i.
148. ^ Acidi tannic!
3ij.
M.
ad fl. S i.
STIMULANTS AND CAUSTICS
149. H Zinci chloridi
gr. XXX. ad fl. % i.
gr. XX. ad fl. 3 i.
151. ^ Liquor ferri chloridi
fl. 3 ij. ad fl. ! i.
3 ss. to 3 i> ad fl. ? i.
153. ^ Liquor hydrargyri nitratis
ni xl. to 3 ij- ad fl. 3 L
154. 5 Tinct. iodi
5i.
gr. I XX.
M.
adfl. 3 J.
156. Q Argenti nitratis
gr. Ix. ad fl. I i.
157. It Argenti nitratis .
gr. xl. ad fl. % i.
158. ^ Argpinti nitratis
gr. z. ad fl. 3 i.
159. R Tinct. iodi.
160. ^ Liquor iodi coinp.
ANTISEPTICS.
161. IJ Acidi carbolici
gr. zxx. ad fl. 3 i.
INSUFFLATIONS.
Powders have been extensively used in the treatment of nasal and lar\'n-
geal affections. 1 am accustomed to dilute most of the drugs which I em-
ploy in powdered fonn with from one to four parts of sugar of uiilk, acacia.
or starch. Of the following powders, two or three grains are used at each
insufllation.
SEDATIVES.
162. H Bismuthi carbonutis.
163. H Morphinse sulphatie gr. ^gr. i
Bismuthi carboijRtis gr. ij-
M.
Tannin or iodoform may be added.
164. R j\l(»r|»i]. sulpli gr. iv.
Bisiiiuthi enbnit 3iv.
Amvli 3 i.
M.
105. B Miirphiiiii' gr. v.
loilol
liisiiiutlii siibiiit.
Sacch. lact. fia gr. XIX.
M.
INaUFFLATIONa.
675
166. 9 Sodii bicarbonatis
Sodii boratis
Amyli ....
Cocainn hydrochloratis
Sacch. lact.
M.
167. ^ CocaiDS hydrochloratis
Atropinffi
Mag. carb. levis .
Sacch. lact.
M.
168. Q Cocainffi hydrochloratis
Atropinae
Morph, eiilph.
Mo^, Carb. levis .
Sacch. lact. .
M.
ANTISBPTICS A2fO STIMUIiASTS.
169. Q Acidi borici
170. 9 lodol
171. 5 lodoformi
Acidi borici
M.
172. B lodoformi
Binmuthi subnit.
Benzoini res
M.
178. 9 lodoformi.
ASTBINGESTS AND STIMULANTS.
174. B Hydrastum muriatis
Acaciffi
175. 5 Pulv. res. myrrh».
176. 9 Morph. sulph
Acidi tannici
Pulv. Andersouli
M.
177. R Benzoini res.
Bisniuthi subnit. . ; . .
M.
178. Q Bisinuthi subnit.
179. fl Hyd. chlor. mitis.
180. ^ Aluininis
Sacch. aibi
M.
161. It Antipyrin.
Codiiiiip hydrochloratis
Mag. carb. levis
Sacch. lact. ' .
M.
aa gr. iss.
gr.l
gr. iv.
q. 8. ad gr. C.
gr. I.
tfr. i
gr. IV.
q. B. ad gr. D.
gr. X.
srr. i
aa gr. xv.
q. 8. ad gr. D.
fia gr- 1-
gr.l.
aa gr. xxv.
gr. XIV.
q. s. ad gr. C.
gr. V.
gr. xxv.
31-
aii gr. I.
lia gr. 1. '
ua f;r. x.
gr. XV.
q. s. ad gr. D.
676
FORMULA.
NASAL DOUCHES.
The following preparations may be used as insufflationsor by the anterior
or posterior nasal douche or syringe, for detergent or antiseptic puriioses.
They should always be used warm, and may be followed by more jKitent
remedies. The amount given below should be added to a pint of water at
blood heat, and part or h11 of it used at each application.
182. ^ Sodii ehloridi
188. If Sodii bicarbonatis
184. ^ Potassii pennanganatis
185. ^ Acidi carbolic!
186. If Zinci sulpho-carbolatis
187. SaW-ylate Wash.
^ Sodii salicylatis
Sodii biboratis
Sodii bicarbonatis
Sodii ehloridi
M. S. 3 i. ad aqu» tepidte O i.
er.
ni.
ffr.
xsv.
gr.
XXV.
ga
3 vi.
- a&
31.
INDEX.
/( luu been deemed bett to give a aifnopaU of the articlea on each diaeate and iU differentiations,
luins abbreviatitma that vnll need no explanation to the profeaaion.
Abdominal brefttblDK, 11
AtMcesf iafra^lottiu. due to sypfailiB, 430
of tbe larytuc. lUus., 439. 430
■ymp., 439; dlag.. prog., treat., 480;
dlff. (r. croup; fr. retro-pbatTngeal
ahsceAS, fr. acute catarrhal ioflamma-
tion, fr. oedema, 480
of tbe luDK- 129-lSl
symp., 129;diaR.. ISO; prog., treat, 181;
dltt. fr. bronchitis, fr. pDeumoula,
fr. pleurisy. 180
of the nasal septum, 608
dttr. fr. cancer, 573; fr. heematoma. OOS
of the tonsils, syn. of pblegmououa ton-
sillitis. 866
retropharyngt«al, 383-386
Abscission of tbe uvula, 359
Accentuation of the heart-sounds, 192
Acute and subacute brouchltis, 89, 90
anat.. path., etioL, symp., 89
catarrhal laryngitis, syn. of acute laryn-
gitis, 3M
cold In the bead. syn. of acute rhinitis. 522
coryza. syn. of simple acute rhinitis, GS£
endocarditis. 319-323
syn.. anat., path., 319; etiol.. symp.,
diag.. 330; prog., treat.. 331
dlff. fr. pericarditis. 320
follicular glossitis, symp., diag., prog.
treat.. 34T
follicular pharyngitis, 3S9. 840
anat.. path., etiol.. symp.. diag., 889;
prog., treat., 840
dift. fr. simple acute sore throat. 339
follicular tonsillitis, dlff. fr. mycoels, 376,
377
InflammBtlOD and cedeoia of the uvula,
treat., S5«
laryngitis. 394-397
syn., anat., path., etiol.. symp., SIM;
diag., ^"S; prog., treat., 806
dllT. fr. Hpasm of the glottis, fr. croup,
fr. paralysis of the vocal cords, fr.
foreign bodies. 39S. 396: fr. croup,
414; fr. retropharyngeal abscess. 430
nilll»t7 tuberculosis. 185-167 [166
Kcat., path., etiol., 16S: symp.. diag.,
dift fr. other forms. 166. 167
myocarditis. 331
nasal catarrh, syn. of simple acute rhini-
tis, ess
Acute ossophagitis. 633, 683
etiol., symp., 633; diag., prog., treat,
633
pericarditis, 313
pleurisy, 61-73
etiol., symp.. 63; dlog., 86; prog.,
71; treat., 73
dlff. fr. pleurodynia, fr. pericarditis,
fr. pneumonia, fr. phthisis, fr. coU
lapse of the lung, fr. cancer, fr. hy-
pertrophy of the liver and spleen, OS-
71; fr. abscess of tbe lung, 180; fr,
angina pectoris, S51
pneumonia, syn. of lobar pneumonia, 113
rheumatic sore throat, 316, 317
anat., path., etiol., symp., 816; diag.,
prog., treat., 817
diff. fr. acute sore throat, 312, SS3
rhlnorrhea, syn. of simple rbiuiti.^, 532
sore throat. 311-314
syn.. anat., path., etiol., symp., 311;
diag., 313; prog., treat.. 813
dlff. fr. Bcarlatiua, fr. acute tonsil-
litis, 313; fr. acute rheumatic sore
throat. 313, 334; fr. sore throat of
scarlet fever, 334 ; f r. acute follicular
pharyngitis. 339
Sthenic poeuuionla, syn. of lobar pneu-
monia, 113
tODSillitis, 363-367
syn.. 302; anat.. path., etiol., symp.,
883: diag., SW; prog, treat., 366
diff. f r. acute sore throat. 313 ; f r,
scarlatina, fr. diphtheria, fr. sup-
purative tonsillitis, fr. syphilitic sore
throat, 3M-366
tubercular phthisis, dlff. fr. lobular pneu-
monia, 137
tubercular sore throat. 3B0-853
anat.. patli.. etiol.. symp,, 850; diag.,
a'll: prog., trpat.. 853
dlff. fr. rheumatic sor» throat. 330;
fr. chronic follicular pharyngitis, 844;
fr. syphilitic sore throat, 851, 862.355;
f r. scrofulous sore throat. 350, 351, 353
tuberculosis dlff. fr. emphysema. III
Adams' clamp. 596
Adenoid growths in the vault of the pharynx,
syn. of hypertrophy of tbe phuTD-
geal tonsil, 618
Adenomata, 467
678
INDEX.
Adhesion Id srphllitlc sore throat, SOS
of the inoer surfacea of the arytenoid
cartllaitea, did. fr. bilateral paraly-
sis, 618
Adlroudacks for phthisis, the. 17B
AdTentltloug sounds, 46-M
JSgopbony, SS, S7
Aerial froltre, syn. of tracheocele. 480
Afte modifles percussion sounds, ST
Altken, me mbranous croup, 411
Albolfloe in Inhalations or sprays for throat and
DOSd, US, 441, 580, fiSS. 5S8. 667, 666, C67
Alcoholic stimulation in bronchitis, 98; In pul-
monary phthisis, 171 ; in acute endo-
carditis, S21; in chronic endocar-
ditis. 224: in angina pectoris, 253;
in erysipelatous sore throat, 816; In
diphtheria. 886; In syphilitic laryn-
ffitlB. 448
Algleri tor phthisis, 179
Allen, Harrison. iDequallty of the choane,
309: gal V a no-cautery, 544
Altlngham, mouth gag, lUus., 419, 617
Allison, Scott, stethogooiometer, lllus., 18;
differential stethoscope, lllus., S7
Alps, goitre in the. OM
Ambidexterity In examination of the larynx,
S8S
American Journal of Medical Sciences, con-
tagious pneumonia, Wagner, 116;
diphtheria, Prudden, 839; congenital
syphilis. John N. Mackenzie, 44»:
lupus, G. M. Ijefferts, 4.11; laryngec-
tomy, Qeorge B. Fowler, 48S
LaryuKO logical Assoclatinn. Transactions.
Registers of male and foinale voict's.
TlioiiiHS R. French, -M^: choaiise un-
equal. Allen, SiXl; nciiie tnliemiJar
sorethroii[. Delavan. I'li; leucnplakia
huccalis. Ingnls. .ItU; cliroinlc acid
in trachfiina. C'liarlew E. Sajous, 4IIM;
tul>eR'iil;ir luryngitis. Jarvjs, 441 ;
feeding in liiryiii;iil«. Beverly Roll-
inain, 44:): smire fotvepn. Jnrvis,
473: tliyrotfuiiy, .Tosepli I^idy. 475:
laryngntoiiiy. Colicn. iHi; uhorcft
laryntis. George M. I^'ITeriB. E.
Ilol.leii. ,V)l: Num.'. F, I. Knight. .W1.
SO-.*: fnlselln voii-e. J. C. Mnlliall.
603: larynjjeal vertigo. E. I. Kuiglit,
mU; relation of hay fever anil condi-
tions in the iiaMsl pa.sHageR. Wltllani
H. Paly,.'i.Vl: nnsnl cnncerons tumors.
R. 1'. Lincoln. :i7A: detle<.'tion of the
nasal st'plnui. D. Rrysou Delavan, ,194:
same. P. N. Rankin. 0O5; rhino-
InryngitU, Beverly Robinson, 6O0;
eTtiriiatiou of nasal tumors. Lincoln.
ttr.'
Amphoric cough. 50: resonance defined, 80:
redi'iration. 41, 46. 47; sound, 41;
voife, .IS. 57: whisjier, 58
Amygdalitis, syn. of aciile tonsillitis. 36i
Amyl nllrile in chronic enilocarditis, £29
Ancemia, dilT fr enilocaniiiis, !K6; fr. tuber-
cular laryngitis, 4^
Anflemic, hnmic or org«nlc murmiin, IBB,
804; diir. fr. atheroma, 80«
Anaesthesia of the larynx, 499. 600; otlol.,
symp., diag., prog., treat., 480; of
the pharynx, ettol.. prc^., treat, M
produced generally, 4SS, Stfi, OOO
produced in tubercular laryngitis, 448
produced locally, 74, 80, M6, 407. 400. 4SS,
467, 484, 496, 644, 608, S97, OSS. 486, 448
Annstbetlcs, pigment, 666
Anatomy and physiology of the h«art, 177-180
Anchylosis of the arytenoid cartilajcea, 514,
616; diag., traaL, 616
Anemone pratensis. unsatisfactory in per>
tOSBlB, 165
Aneurism, aortic or thoracic, 10, 888 866
of the aorta, dlff. fr. acute pleurisy, 70;
fr. solid tumors, 868; fr. aortic pul-
sation, fr. pulsating empyema, 888;
fr. dilated auricle, tr. consolidatloD
of The lung, 8H; fr. aneurism of ths
pulmonary artery, 8CB
of the arch of the aorta. 867
of the arteria Inoominata, 866, 806
of the ascending aorta, lllus., 809
of the descending aorta, 887
of the heart, etiol., diag., prog., troat.. 945
of the pulmonary artery, 864, 866
diff. fr. aneurism of the aorta, 866
of the slnusea of Valsalva, 867
Aneurismal murmur, dift. fr. mitral, 196
Aneurlsmatificope, the, 801
Angina diphtheritica, syn. of diphtheria, 8S8
epigloltldea, syn. of acute laryngitis. 8H
laryngea, syn. of acute laryngitis. SM
membranosa, syn. of diphtheria, 828
pt^torls, 850-268
etlol.. asO; symp., diag.. prog., SI:
treat., 25?
diff. fr. pseudo-angina, fr. Intercostal
neuralgia, fr. acute pleurisy, fr
myalgia, 351. SS3
Anglomata, or vaacular tumors, iltus. . -107.
4e8
of the nose. syn. of vascular naaal tumors.
570
Annales de Oynfcologte et d'Obslftriqiie.
diphtheria. Roux nnd Yersin, 336
des Mnlndles de I'Oreille, fractures of the
larynx, Panas, 4«tt
Annual of the Universal Medical Sciences,
(tjRioma pulmonale, 151 : p.wuilo-
iliphtheria, Smith and Warner. *»;
diphtheria Infectious thmiigh cloth-
ing or furniture. Oranoher, XM:
spasm of the glottis. I.bt<et-Barbon,
406: rhinitis. Raulin. 5S2: nasal o«-
seoux cysts, Macdonald quoted br
ChaHe« E. Sajons. 670: adenoid
growths in deaf-mutes, Wr6blewshi,
014
Anomalous h>-art snnn<l:i. S05
Anorexia in iiil>ei-CLilnr lar^'ngltls, 4S7
Anosmia. .W1. 50-;
etlol.. .Vl ; •'vnip.. ding., prog., treat.. 60t
Anstie, F. K, value of sphygmocrspb. 811
IXDEX.
679
Antlpneumotoxin In pneumoDia, blood semm
or. 183
Antlpyrlne la whooping couRh, 155; In rheu-
matic sore throat, S17
Antiseptic xarKles, formulEe for. U7
loienges, formulae for, 048
▼apor Bprays. formulee for, ttSS
and stimulant insufflations, fonnuln for,
plftments, formulee for, S5S
Antispasmodic vapor inhalations, formuls
tor. oeo
Antrum, empyema of the. BTB-fi8S
of Hlghmore, illus., 808, BTQ
AorU, the, ITS
aneurism of the <8ee aortic or thoracic
aneurism)
aneurism of the ascending. 90B
aneurism of the descending, 8S7
atheroma of the, 354-2U
coarctation of the, MO, 367
rupture of the, SBfi
&ortlc aneurism, dUT. fr. pulmonary cancer,
144
area, illus., 198, IW
endarteritis, syn. of atheroma of the aorta,
-JM
murmura, 1Q8-300
obstruction, Illus., 809, SSB, 290
or thoracic aneurism, 14, SS6-S66
anat., path., etlol.. SS6; symp., 298;
diafi;.. 002; proK., treat., S65
diff. fr. chronic endocarditis, 290,
SXt; fr. eccentric cardiac hfpertn>
pby, SSB; fr. solid tumors, fr. aortic
pulsation, fr. pulsating empyema, f r.
dilatation of the auricle, fr. aneurism
of the pulmonary artery, fr. consoll*
datlon of the lung, 262-369
pulsation, diff. fr. aneurism. 268
regurgitant murmurs, 200
regurgitation, illus., 200, 2SS, 928, 890
semilunar valves, 178
valves, 7; disease of, 296
Aortitis, 254
Apex-beat of the heart, 10, 182, 184-I8B
Apex, pleurisy of the, 82
Aphonia, functional, hysterical, or nervous,
syn. of bilateral paralysis of the
lateral crico-arytenold muscles, 608
Aphonic pectorilocjuy, 58
Aphthous sore throat, syn. of simple mem-
branous sure throat, 324
ApoeumatosiB, syn. of pulmonary collapse,
130
Apoplexy, pulmonary, 19, 1.*C, 188
Applicator, chromic acid, 40D: for intubation
tubes, illus., 430; cotton, 9C8; post-
nasal snare, C23
Arch of the aorta, aneurism of the. 257
Arching of the tongue ao obstacle to laryn-
goscopy. 290
Archives O^n^rale de M^decine. erysipelatous
sore throat. C'ornll, 314: eryslyela-
tourt laryneilis. Comil. 428
Archives of Laryngology, trachoma of the
vocal cords. Carlo Labus. 408: lupua
of the larynx, F. I. Knight. 491
Arcblvea of Pediatrics, Influeasa, Gbarlea W.
Earle, 920
Area of cardiac impulse, 189; of cardiac dul-
ness, flatness, 189; of cardiac sounds,
191; valvular, 197; of endocardial
murmurs, illus , 196
Argand lamp for laryngoscopy, ST9, 261
Arizona for phtblsis, 175
Arteiia Innomlnata, aneurism of the, 265
Arterial diseases, cardiac and, 212-266
Artificial light to illuminate the larynx,
direct. Indirect, 275
Ary-eplgloteic folds, 296
muscles, paralysis of the ttayro-epiglottio
and, Goe
Aryteno-eplglottldean folds, 296
Arytenoid cartilages, illus., 296
cartilages, anchylosis of the, 914, 516
muscle, paralysis of the. 611
Asch, Morris, lupus of the larynx, 461
Aspiration In acute pleurisy, 72; in subacute
pleurisy, 78-79; in chronic pleurisy,
78; in abscess of the lung, 131; In
pericarditis, 217
Aspirator, mode of using the. Ti-TS
Asthenia in diphtheria, S3S; In acute tuberou*
lar sore throat, SS2
Asthma, 10S-10B
anal., path., 102; etlol., 108; symp., IM;
dlog., prog., 109; treat., 106
diff. fr. bronchitis, 92; fr. capillary
bronchitis, fr. spasmodic laryngeal
affections, fr. emphysema, fr. cardlao
dyspncea, 105; fr. stenosis of tbe
larynx, 467; fr. hay fever, 551
Asthmatic hay fever, 554
Astringent and stimulant Insufflations, form-
ultQ for. G57
and stimulant spray Inhalations, formulae
for, 65S
gargles, formula for. 649
loienges, fonuulfie for. MS
pigments, formula.- for, 666
Asystolism, 241
Atelectasis, syn. of pulmonary collapse, 139
Atheroma of the aorta. 254-2Sti
syn., anat., patli., etiol., 294; symp.,
diag., 255: treat., a5B
ditT. fr. diseoMo of the valves, fr.
ana'mlc mnrmura. 25G
Atheromatous dcBeneration of the aorta, syiL
of athfroma of the aorta, 251
Atomizer. 401. jn-i; for oil, 5.3(1
Atrophic folllmilar plmryngilis, 843
rhinitis. 5W. M7-5.t2
antLC, path.. 647: etlol., symp., 648;
tilaK,, prop.. 649: tn'at.,550
dltr. fr. lupus, fr. syphilis, fr. sup-
puration, fr. rhlnoliths, fr foreign
holies. WO I fr. chronic suppurative
flhiuoiilitis. 6W
Atrophy of the heart, oyn. itiag., 842
of tlif vocui cords. ,M5
Auricles of the heart. 178
680
INDEX.
Auricular systole, 189; illus., Sin
Auscultation, 0, 34-47; mediate, immediate,
84; rules for, 38; in bealtb, 8»-41: In
disease, 41-47; over the heart, 18B; lo
aneurism of the aorta, 801
AuBOuttatory percussion, 32-33
Austria, rhinosclerma In, 688
Austrian mountains for phthisis, 175
Autumnal catarrh, syn. of hay fever, 8S8
AvenbruKKer, percuHsioa, 31
Avery, laryngoscopy, 872
Axillary region, 4, 8
Babbinqton, laryugoscopy, 273
Bacilli, tubercle, 1S7; transmitted to fcBttu,
1S8; staining, 164, 169; in endocardl-
tlB, 2ffi; In lupus of the larynx, 4S1
Bacillus, Klebs-Lomer, dipb., S29
mallei, glanders, 589
tuberculosis, S78
Bacteria in pericarditis purosa, 312; in ulcer-
ative pericarditis, 288; in hypertro-
phy of the tonsils, STXI
Balfour, Q. W., quality of murmurs of the
heart, 200; heart disease, 247; brady-
cardia, 290; mode of adminifltering
chloroform in angina pectoris, 8S8
Barker, Fordyce. turpeth mineral In croup, 417
Barrel-shaped chest, 12
Base of heart, to find, 168
Basedow's disease, syn. of exophthalmic
goitre, 633
Battery, gal van o -cautery, 84S
Baumes. laryngoscopy, 272
Bazln, leucoplakia buccalis, 360
Belfleld, W. T., Kuslnco) in phthisis, 173;
iodine trichloride in surgery, 441
Bell sound In percussion; 31
Bellocq, laryngoscopy, 272; cnnula, 306
Benign growths in the larynx, Illus., 466-476
sj-nip.,466; diag.,467: prog., treat., 469
diff. fr. syphilis, fr. tubercular laryn-
gitis, fr. lepra, lupus, outgrowths, fr.
urerHJon of the ventricles, fr. raalig-
nant tumors, ■ie7-469; fr. malignant
tumors, 47U, .Wl
Benuattl, laryngosfojo-, 272
Berberiue, identlcnl tvlth hyilrastine, 95
muriate in chronic iarj-ngitig, 407; In
rhino-pharyngitis, 610
Berliner klinisohe Wocbenschrift, tubercles
in lung, Virchow, 107; sound in em-
physeina, Oerhardt, H>9: pneumonia
contagious. Kuhn, 116; blood serum
or atitipni-umotoxin In pneumonia,
KlriMpenT, 123; dislocation of the
larynx, 11, Braun, 490; operations on
thi> anlriini. Krause, 582
Best. J. K. . fiiriincitlosis of the nose, 55ft
Bi^snuski. pleurisy, 06
Bilateral paralysis of the lateral crico-ary-
tenoiil muscles, ilhis.. aW-filO
syn.. etiul,, symp., SCS; (iing,. treat.,
510
paralysi.s if Die p(>sterinr crico-nrytenoid
muscle, illus,, 511-513
Bilateral paralysis of the posterior crlco-«i7-
tenoid muscle, anat, paUi., etloL,
symp., B13; dlag., prog., treat., 518
diff. fr. adhealoQ of the Inner surfaces
of the arytenoid cartilages, fr.
spasm, 513
Bilious pneumonia, 128, 1S9
Bllocular pleurisy, dlft. fr. other fonns, 83
BIrch-Hlnchfeld, P. V , bacilli transmitted to
foetus. 158
Bird, hydatid cysts of the lungs, 149
Blzot, aortitis, 254
Black. O. v., clnnamoa water antiseptic, SSO
Blake, Clarence, snare for polypi, 667
Blanden, deflection of the na-al septum, 505
Blood serum or antlpoeumotoxln in pneu-
monia, 128
Blue disease, the, syn. of morbus csenileas. 246
BocelU, Ouido, distinction between serum and
pus, 77
Bolleau, aortic regurgitation, Illus., 30S
Bokal, retropharyngeal afaecesa, 884
Bollinger, case of glanders eleven years, 500
Bone drill. 582
Bony tumors, nasal, 671, 67S
Borgiotti, case of cesophageal spasm Ave hun-
dred and thirty-one days, 638
Boric acid In cinnamon water highly effective
In diphtheria, 886
BoBworth, tongue-depressor, Illus., STl; tuber-
cular laryngitis, 486; cancer In the
larynx, 476; chronic rhinitis. 687, 545;
mucous polypi in asthma, 505;
saws, 601
Bougie, oesophageal, 890; olivary, 035
Boundaries of the heart, 188
Bouveret, L., pleurisy, 76; tachycardia. 24S
Bowditch, danger In washing pleural cavity, 78
Boyle, Immediate auscultation, 34
Bozzini, l.trj-ngoscopy, 278
Bradycardia, treat., 260
Brainard, bone drill, illus., 583
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 Buffer, 329
Broad condylomata, 8S3
Brodie, mode of applying mercury to Infants,
577
Bronchial cough, 69
fremitus, 16
glands enlarged, 152, 153
respiration, 4], 45
tubes, fremitus in dilatation of the, 15
whisper, normal, exaggerated, cavernous,
58
Bronchiectasis or bronchi catasis, gyn. of dlla<
tatlon of the bronchial tubes, 100;
syn. of fibroid phthisis, 150
Bronchitis. 89-100; acute and subacute. W.
90 ; chronic, 80. 90-96; capillary, ft5-W:
plastic, 99, 100
diff. fr. abscess of the lung. 180: fr.
pulmonary gangrene, 145; Cr. trach'
eitis, 401
IXDEX.
681
Broncho-cATerDous reaplntlon, 46
BroDcbocele. syn. of goitre. 629
Bronchophour. 36; nonnal, K; wblaperingr, S8
BroDcho-pneumoiila, syn. of lobular poeu-
monfa, 183
Bronchorrhi^a. W
Broncborrbcea, 02
BroDchotomy, 496
BroDcbo-vMlcular or barab respiration, 41, 44
BrooiclfD Medical Journal, pneumonia con*
tafcious. Matbeson. 116
Brower, Daniel R., mode of ventilation In
dlpbtberia, 834: exopbtbatmlc goitre,
Brown Induration, Bymp.. diag., treat., 184
Browne, Lennox, dlpbtberia. 328, S34. 886;
acute tubercular sore tbroat, 350.351;
faypertropbjr of tbe tonsils, StZ;
Spasm of the pharrnx, SDO; definition
of croup. 411: syphilitic laryngitis,
443. 448. 440: lupus of the larynx, 45S;
lepra of the larynx, 454: endo-laryn-
geal cauterization In cancer, opera-
tion of resection of the larynx, 481
Walton, epistaxls, 563
W. N., large rhinolith, 604
Bnilt de diable, syn. of venous murmur, 207
de pot fOi^, ayo. of cracked-pot resonance,
31
BrUDS, Paul, pincette, illus., 291 ; Infra-tbyrold
laryngotomy, 476
Bulbar paralysis. proKn^ssire, 391
Bulletin de la 6ocl^t6 de Chirurgie. deflection
of the nasal septum. Cbassalgnac, 595
niMicale des Vosges. cause of angina pec>
torls. Li4geois. 250
Bums of the pharynx, scalds and, 3112
Burrs, nasal. 546, 598
Bursa pbaryngea, illus., 809
Cabot, A. T.. pteurotomy. 76; drainage tubes,
illus.. 79
Calculus of the toDsfl. sj'n. of concretions of
the tonsils. 8T5
California for bronchitis. 95; for phthisis, 175
Calomel in lobular pneumonia. 1£2; in acute
sore throat. 31D: in diphtheria. 83D
Camman, stethoscope, illus.. S^. 36
and Clark instituted auscultatory percus-
sion. 32
Camphel), see Harries and Campbell
Canadian Practitioner, siphon drainage In
pleurisy. Powell. 79
Cancer (see alsomalignaut>
Cancer, did. fr. leukoplakia buccalls. 363
of the larynx, dlff. fr. chronic larynRitls.
403, 404; fr. syphilitic laryuKltis. 447:
fr. lupux. 453
of the pharynx, annt,. path., symp,. .386:
diag.. treat., an7: iliff. fr. chronic
rheuiiiutlc son- thnrnt. fta>: fr. syph-
ilis, fr. fibrous tumors, 387
Of the tonsil. 380. 3X1
diag.. 380; prog., treat.. 81
dlff. fr. tubercular ulceration of the
tonsils, 878; fr. hypertrophy, fr,
syphilitic ulceration, 880, 881; fr.
rhlDolIths, 606
Cancer, pulmonary, TO, 146, 148
Cancerous growths, dllT. fr. nasal mucous
polypi. 566 ; f r. nasal bony tumors, SH
Capillary bronchitis, 95-98
anat.. path., 93*. etiol., symp., disg.,
96; prog., treat., 06
dlff. fr. phthisis, 96; fr. asthma, 97,
106; fr. lobar pneumonia, fr. lobular
pneumonia, fr. pulmonary cedema,
97, 98
Carbon dioxide in asthma, 106
Cardiac and arterial diseases, 11, IBB, S12-268
aneurism, 246
dilatation syn. of dilatation of the heart.
28B
displacement, dlff. fr. hypertrophy and
dilatation of the heart, 238
dulness. 188-100
hypertrophy, 14
hypertrophy, eccentric. 386
hypertrophy, simple, 234-236
impulse, 185
murmars. 195-211
origin of dropsy, indicated, 11
pulsation, 185, 187
region, form of the. l&l
resonance, 25
sound, modified by disease. 185
Cardialgla. 247
Cardiectasis. syn. of dilatation of the heart,
239
Cardio- pleuritic friction murmurs. 196
Carious teeth, a soil for leptothrix buccalis,
376
Carroll, stetbometer, Illus.. 17
Cartllagi's, arytenoid. 300. 614: of Sanlorini. of
the larynx, of Wrisberg, 296; cricoid,
tracheal, 290
Cartilaginous tumors, illus., 467
dlff, fr. nasnl mucous polypi. 506: fr.
ha>umtoina of the nasal wptiiui. CKk.'
Cary, Frank, mode of feeding after intulia-
11(111. 421
Caseous pneumonia, 156
Casselberry, Wm. E.. mode of feeding after
iniulmtion. 431
Catarrh, epidemic. GIIi; acute nasal, 5£!;
clirimic. 527; autumnal. 559
Catarrtial diailn'sis. firr
fever, epidemic, 510
hay fi'vcr, KVl
larj-ngitis. Illus.. 300
dilT. fr. diphtheria. 331: fr. croup, 4 lb
pneumonia, syn, of lobular pneumonia. 123
sore throat, syn. of u^-ute sore throat. -311
stage of croup. 412
CntarrhuK it^tivus. syn. of hay f^ver, ,Wi
Caustics— piirriicntN: stimuhinls and, 656
Cautery fli-cirodt-B, 416
In disenses of tlie throat, imitsim. 240-485;
in diseo.'ics of the nose. jKUjritn,
.%'iO-ft.17
Cavernous souml. J1 : respiration. 40; whisper,
58; cough, 59
682
INDEX.
CeotnlbUtt far kllnlBCbe Medlcln, spasm of
the oesophaKus, Borf;lottl, Sfi
Cerebral croup, syn. of spasm of the glottla,
406
Chancre In the throat. 853
Chanalgnac, relation of Kenerative organa
and tonBils, 876; deflection of the
nasal septum, 996; retro-naaal flbrouB
turn ore, 631
Cheesj' Infiltration of the lunK, 166
Chest, dimensions of the. 3-8; form of beal-
tby, 9-13: pigeon breast, 10; harrcl-
shaped, 12; size of the, 17
Cheyne-Stokes respiration, S48
Chlari and Riehl, lupus of the larynx, 461
Chicago Medical Journal and Examiner, tyra-
paoitic resonance in pleurisy, Ingals,
6S
Uedlcal Record, resection of the ribs in
pleurisy, A. B. Stronir. T8
China, dlstoma pulmonale in, 160
Chloride of Iron In erysipelatous sore throat,
316
Chlorine inhalation In phthisis, 172
Chloroform for angina pectoris, mode of ad-
ministering, 86:2; a preferred ansra-
tbetic for children, 878. 496. 618: for
chronic laryngitis, 407; for general
anaesthesia. 432, OSS; preferred to
ether In tracheotomy, 48S; for
couF:h. 501 : for myasls norium, 606
ChoauEe. the. illus.. 809
Chondritis and perichondritis of the laryngeal
cartilages. 488. 434
etiol., symp., 483; dlag. , prog. , treat. ,
an
Chorditis tiiberosa. syn. of trachoma of the
vocal cords, 406 .
Chorea laryugls. SOI, 503
anat,, path., etloI., symp., 601; dlag.,
pro^;., treat.. 603
(lifr, fr. hysteria, SOS
Chromic acid applicator, 409
acid iu tracboiim of the vocal cords, 409;
elTect Iu rhinitis compared with that
of galvauo-cautery, Si37. 541; In hy-
pertrophy of the pharyngeal tonsil,
616
Chronic abscess of the nasal septum, diff. fr.
mucoiia polypi, 5*16
bronchitis. 14. «». 00-95
anat., path,, 'JO; etiol.. symp., 01 ; dlag.,
ftt; protf.. 98: treat.. 04
catarrli. syn. of chronic rhinitis. 537; syn.
of inCimii'scPTit rliinltia. 531
catarrh of tlu' larynx, syn. of chronic
Inrynfiitis, 3iH
coryzfi. wyti. nf i-hronic rhinitis, 52T
eudociinlitis, ^*J:1 ;.'30
et i"l-. Mjniii.. '-^i-i; diaR. . S.'fl: proK. ,
L'->: I rem.. i.1i
ditr, fr. fiinot lonnl iliseiisfstif tlic hi'nrt.
fr, piTicarditls. fr. nim-uiin. fr. thn-
rucii: an>-urism. fr. fntly heart, fr
i-rmfreriitjil ili'f.iiiniry. ■.>-.>IJ, :.-J7
follicular glossitis. ;MT, 348
Chronic follicular glonitts, symp., dUg.,
prog., treat., 848
ditr, fr. rheumatic sore throat, 819
tollicalar pharyngltiB, Ulna., IMMIS
syn., 340; anat, path., etlol., 841;
symp., 848; dlag., prog., tre*t , 844
difl. fr. chronic rheumatic sore throat,
819; fr. sypblllB, fr. tubercular aore
throat, 844
follicular tonsillitis, syn. of hypertrophy
of the tonsils, 370
Inflammation and elongation of the utoU,
8S&-809
diag., treat., 850
laryngitis, illus., 306-406
■yo., anat., path., 8B6; etlol., i^mp.,
899; dlag.. 408: prog.. tT«at.. 404
diff. fr. paralysis of the rocal cxtrds. fr.
(edema of the larynx, fr. tubercular
or syphilitic laryngitis, fr. canon',
402-104
myocarditis, 281
oesophagitis, 688. 684
etlol., symp., dlag., prog., treat, BO
pericarditis. 213
pharyngitis, syn. of chronic follicular
pharyngitis, 84(i
pleurisy. 18. 76-88, 180
anat., path,, etiol., symp., TO; diag.,
prog.. 77; treat, 78
diff. fr. pneumothorax, fr. hydro-pnen-
mothorax, 88: fr. pulmonaiy cancer,
147
pneumonia, syn. of lobular pneummla,
123. 128: syn. of flhrold phthisis, 167
rheumatic laryngitis, syn. of chronic rt>eo-
matlc sore throat 818
rheumatic sore throat. 31H-88I
syn.. anat, path., etiol.. symp., 818;
dlag.. 319; prog,, 320; treat, 821
diff. fr, chronic follicular tonsillitis,
glossitis or pharyngitis, fr, tubercu-
losis, fr. cancer, fr. neuralgia, fr.
tobacco sore throat, 319, 880
rhinitis, 527-653
syn,, 527
stenosis of the larynx, illus.. 4S6-'iaO
anat, path., etlol,. symp.. dlag.. 4SG;
prog., treat., 457
diff. fr, asthma, fr. foreign bodies, fr.
compression, fr. tumors, fr. paraly>
V sis of the abductors. 4.'?
suppurative ethmoidltis, 685-687
etiol,, symp., diag.,S85; prog., treat,
5He
diff. fr, raucous polypi, fr. atrophic
rhinitis with cpdema.fr. suppuratloa
of the antrum, fr. emphysema of the
sphenoidal and frontal sinusea. 6fB
touHilllMH. syn. of hypertrophy of the too-
Kils. 8T0
tuberculoids. 158
difT fr. other forms of phthisis, IflB
Ciiiisi'lli. c'llvniiic puncture in thoracic aneo-
\ visni. 'Sm
( CirfTuiisi^ribed pleurisy, 83
INDEX.
Clrcomscribod pleurUj. diff. fr. hydatid c^Bts
of the lung8, 190
Olrrhosli or sclrrhus of the lungs, bju. of
dilatation of the bronchial tubes,
100; syn. of flbrofd phthisis, IfiS, 167
Claric. see CamniAQ and Clark
J. B.. ImmuoitT to tubercular Tims se-
cured, ITS; solution of iodine for
goitre, 681
ClaTlcular region, 4
Clergyman's sore throat, sya. of chronic fol-
licular pbaTyngltis, 840
Climatic treatment, subacute pleurisy, 75;
bronchitis, 96, 100; asthma. 100; em-
physema, US; lobular pneumonia,
128: pulmonary phthisis, 174-178; In-
fluenza. SB; hay fever, GGS, SC8
Clinical Diagnosis, Jasch, bacilli Id phthisis,
164
Closure of the poet-palatine space obstructing
rhinoscopy remedied, 805
Cloves in larynKitiB, HOlutlon of, 448
CoarcUtloD of the aorta, 206. S67
syn.. see; dlag.. treat., iST
Cocaine as an anaasthetic. 74. 60, 366. 2D0, 370. 874,
S7T. 407. 40«. «». 4%, 457, 484, 491, 4I«,
9S7. 544, 968. 597. 508. 61)8. 010. 617, 660
as a sedntlre. 380, 901, ses. 937, 080, 988, 901,
906. 584, SHr. 651, 657
caution in the use of. 898. 580. 560, 068
not to be used m a sedative in acute sore
throat. 814
Oog-wbeel respiration, 41. 43
Cohan, J. Soils, laryngeal Illumination, 3S9;
laryngeal examiuation, illua.. SR6;
larynx of woman, illus.. SOO; simple
membranous sore throat, 3S7; chronic
rolllcular pharyngitis. Illua., 34S;
scrofulous sore throat. 348 : scalds
and bums of the pharynx. 3tti; hy-
pertropby of the larynx, 455; benign
laryngeal tuiiiorn, 463: malignant
tumors on the larynx. 176; laryngec-
tomy, 4R2: nervous cough. 400; laryn-
geal paralyflis, 509; spasm of the
(Ksophagiis. 637
Cohnhelm. pulmonary thrombosis, 138
Coll of tubing to apply cohl waif r in pneumo-
nia, diphtheria, croup, 122.835.3^,416
(see Leiter coil)
Cold applications in pneumonia. VH; in cer-
tain diseases of the thront. *17. S30,
335, 361. 363. 369. 370, 3WJ. Sffi. 408, 410.
416. tm: in nose bleeding. 553, 053
(see also Ice)
Collapse of the JukuIaf veins. 307
pulmonary, 131^14^
Colorado for aBthma. 106; for phthisis. 175;
rhinitis In, .liT
Compendium deChinirKie Pratique, deflection
of the nauil aectiim. Binnden. 500
•Jomplete extirpation of the larynx described,
482
vlompression of the rpsophagtis. 'i37
Concretions in the tonKil. nyn.. eliol., symp.,
prog., treat., 375
Condylomata, syphilitic. 198, 4G8. 97S
Congenital deformities of the heart dtff. fr,
chronic endocarditis. 330, 287
deformity of the nose, treat., 508
murmurs, 304. »16
syphilis of the nose, etiol.. symp.. diag.,
prog., treat., 077
Consolidation of the lung, difT. fr. h]^peKro-
pby and dilatation of the heart, 287;
fr. aortic aneurism. 864
Convulsive disorders dlff. fr. retropharyngeal
abscess. 384. SHB
Corea, distoma pulmonale In. 150
Coraiculiun laryngls. syn. of cartilage of San-
tor ini. 896
Comll, erysipelatous sore throat, 814; erysi-
pelatous laryngitis, 488
Corvisart, syphilitic disease of the heart, 845
Coryza, acute, 533, BOl ; chronic, 687; sypbU-
lltlc. 567; In measles, 901
Cotton applicator, illtis., 068
Cough, amphoric, bronchia), cavernous. 59:
laryngeal. 59. 400; In hypertrophy of
the tonsils, 371; Irritative, nervous,
408
Craclced-pot resonance. 28. 31
Cramp of the cesophagiin, syn. of spasm of tho
nesophafnis, 637 •
Creaking or cnimpling sounds, 58
Creasote for pulmonary phthisis. 173
Crepitant r&les. 48. 51
rAle redux, 118
Crequy, removal of foreign bodies In the
cesophagus, B48
Crico-ar)-teuoid muscles, paralysis of the,
50»-514
Cricoid cartilage, illus., 299
Crico-tliyroid muscles, paralysis of the, 906
Croup, membranous, 14, 411'486
tent. 416
Croupous bronchitis, syn. of plastic bronchi-
tlH, 09
pneumonia, syn. of lobar pneumonia, US
Crumpling sounds, creaking or. 63
Crushing tumors with forceps. 474, 578
Csokor, transmltutlon of bacilli to fu-tus, 198
Cuneiform cartilages, syu. of cartilages of
Wrlnberg, 2!W
Curable mitral regurgitant murmurs, StB
Ourschmnnn, cause of asthma, 103
Curtis, H. Holhrook, chronic rhinitis, 637;
wash-l-ottle. ilhis., 5>4iinaaal trephln-
inK. 001 ; vaporirer, illus., 618
Curveil line of rtntnHis in pleurisy, Illus., 64. 6ft
Cutting fon-fiw. riRht iinple, 597
oiH-mtiims <in laryiigeal tumors, 474
Cyanosis, syn. of inorlms cirruleus. 240
Cyclojiedla of the bineaites of Children, pleu-
rotijiiiy. A. T. CalxX, 78; asthma
nnifng Hebrews, Haltmann, 103;
iliiulilcpt"^"""^"'"- 115
Cycloi)e(liii of Prnclical Metlicine, rhinitis, C.
.1. I). Wiiliiuns. 525
Cynanchi'larynRfn, syn. of acute Iaryngiti8,894
pharyn^ea. syn. of acute Rorc throat, 311
tunsillari!), syn. of acute tonsillitis, 80S
684
INDEX.
Crrtometera, IT, 18 .
Cfstfc growths, llluB., 466; retro-nasal. 6S6
Cysts or the lungrs, hydatid, 148-lSO
Czermak, laryDgoscopy, 373
Da Costa, J. H. , divlaf ons of the chest, 3 ; tym-
panitic resoDonce, 39, 80,66; pneumo-
pericardium, 818; irritable heart of
soldiers, 249
Dakota for phthisis, 176
Daly, William H., hay fever related to condi-
tions In nasal pasiiafces, &S3
Damoiseau, pleuritic sympton.s. 64
Danforth, J. N., mixeil sarcoma. 478
Davidson, atomizer, lllus., 40S, 406; oil atom-
izer, illus., 5S6
Deafness, throat. 610^13
De n^renvllle, epilepsy following initatioD
of pleural surfaces, 78
Deferred expiration. 43
Deflection of the nasal septum, 5M-597
auat., path., etiol.,5lH; symp., diag.,
prog., treat.. 6%
Delafleld. pneumonia infective, 115
Delavan, D. Brjson, acute tubercular sore
throat, 353; hemorrhage after ton-
sillotomy. 375; leptothrix buccalis,
876; electricity in rhinitis, 553; em-
pyema of the antrum, 57S: deflection
of the nasal septum, 694, S06
Demulcents, trochisoi or lozenges, formnlie.
Dennison, Charles, binaural stethoscope, 87
Dental Reviow. cinnamon -water antiseptic, O.
V. Black. 336
Derbyshire neck, syn. of goitre, ftSO
DrtwendiiiR aorta, aneurism of the. 257. 3.W
Des Maladies dn Sinus Maxillaire. luultiple
secretion of pus in the antnim, Oi-
rnldes. 570
Deutsche ChimrKie, tracheotomy. Max Schdl-
l.-r. 4Hfi
Klinik. iM-nign growths in the larynx,
U'witi. 4(B
mediciiiiscliu Zoitung, heredity in ostluiia,
I^zariis. 100
meiliclnisi'he Wochenschrift, pneumonia
con t agio UK, MoKler. 110; transmiiUtJon
of liacilli to ffptus, F. v. Birch-
Ilirsflifcld, 158; nasal tuberculosis,
F. Ilnliii, 57M: difTfrt'iitiiitionof nanal
affi'ctidii'*, Max Schneffer. ."iWi
Mediziiiul-Zi'itung. trauRiiiissioTi of bacilli
lo fii'lus. t'siikor. IW
Deutscht-s Arehiv fiir Idhiiwhe Meflicln. don-
giT from hi-art in pli-iirlsy. Leichton-
Btorn. 71
Deviation of llic septum, diff. fr. polypi, 565
Diairnosis. pliysicnl. 3-5!i
DiaphragTiifitic hernia, dilT. fr. pneitmotho-
nix. K8
pleurisy. 71. f*2
Dla.'iloli' of Ihi- hi'iirt. IPO
Diastolic niurniiirs. ^"lO
Dicrotism. HHt
Dictlonnaire EncyclopMle des Scleuoes mMI-
calee. luflammatloD In removal of na-
sal tumors, outer, 638
Diffuse abscess of the larynx, syn. of pblefc-
monous laryngitis. 427
aneurism, 2S6
pulmonary hemorrhage, syn. of pulmonary
apoplexy, 187
Dilatation in laryngeal diseases, 449, 457. 45S,
47S, 488, SIS; in stricture of the ceso-
ptaagUB, 035. 696
of the aorta, dlff. fr. aortic aneurism, SM
of the bronchl&l tubes, 15. 100-lOS
syn., anat., path., etiol., 100; ^ymp..
diag., 101; prog., treat., 102
dlft. fr. phthisis. 101 ; fr. gangrene. 145
of the heart, 288-842
syn.. anat.. path., etiol., 299: symp,.
240: dlaf., prog., 841; treat.. «2
dlff. fr. pericarditis. 241 ; fr. myocar-
ditis, S38; fr. eccentric cardiac hy-
pertrophy, asT
hypertrophy and, 296-230
of the larynx, 457, 4S8
Dilated auricle, dlff. fr. aneurism of the aona,
264
Dilator, cutting, laryngeal, 458; for RricUiR
of the oEvophsgus, 696
Diminished resonance, 56
Diphtheria. 828-388
syn.. anat., path.. 8S8: etiol.. 39S:
symp., 390; diag., SSI; prog., 3£;
treat.. 333
diff. f r. sore throat of scarlet fever. 381 :
fr. simple catarrhal or rheumatic
phar^-ngilis, fr. tonsillitis, fr. ery-
sipelas, fr. scarlatina, fr. simple
membranous sore throat, fr. phli-ir-
monouK or erysipelatous sore throat,
fr. phlegiuonousor erysipelatous wrr
throat, 331, 333; fr. hypertrophy "f
the tonsils. 3%: fr. acute tonsilllllK.
365; fr. croup, 415: fr. phlegmonous
larj'ngitis. 437
Diphtheritic larj-ngitis, 455
diflf. fr. phlegnionous laryngitis, ti7
Dtphtheritis, syn. of diphtheria. SW
Dii)h>ci>ccus j)Uenmoniip of Fraenkel. 115
Disease of the aortic valves, diff. fr. atheroma.
256
PislnfectJon in diphtheria, extreme. S94
Dislocnlion of the larj'nx. 4'JU
of the nasal bones, treat . SM
nis.'tecting aneurism. 2SB
Disseminated pneumonia, syn. of lobular pneu-
monia. 183
Distoma pulmonale. 150, 151
symp.. diag., treat.. 151
Divisions of the chest, lllus., 8-8
supra-clavicular, 4; clavicular. 4: infra-
clavicular, 4. 6; mammary, 4. 5; in-
fra-mammary, 4, 6; Bupra-f^emal. 4.
6; sternal, 4, 6: superior sternal. 4.
10; Inferior sternal, 4. T; supra-scap-
ular, scapular. Inter-scapular, 7; In-
fra-scapular, 8; axlllar7, 4, B; lafra>
axillary, 4, 8
INDEX.
685
Donsldfloo, F., treatment of nasal polypi, 666
Douches, nasal, lUHtrumvots, S91
nasal, formuin, 636
Dover's powder in acute larynftUis, 806
DralDoge tubes for chronic pleurisy, n-81 ; In
abscess of the lung, 131 ; for empy-
ema of the antrum, 668
Drill, bone. S8S: for cutting cartilage, S06
Dropsy, diseases indicated by, 11
Dry Inhalations, formulie, 6M
pleurisy, 61
rUes. 48
Drzewlecki, J., pleurisy, T3
Dulneas, 35, %. ^ 29; triangle of, 64; cardiac,
188-J90
Dupuytren. retro-nasal fibrous tumors, 621
Duration of sound, 88, 39
ELutu, Cbablss Warrimoton, Influenza, S20
Eccentric cardiac hypertrophy, syn. of hyper-
trophy and dilautlon of the heart,
Eocbondroma and exostosis of the nasal sep-
tum, llluB., 597-601
diag. , prog. , treat. , 506
Ecchondroses. diff. fr. nasal cartilaginous tu-
mors, 571
Eclectic inhaler, 049
£cnuiement in hypertrophy of the tonsils,
mode of, 873, 874
ficraseur, galvano -cautery , SffT, 969, 571, GT3,
028; guarded wheel, 474
Edinburgh Medical Journal, bradycardia, Bal-
four. 250; antesthesla of the larynx,
HcBride, 499; empyema of the an-
trum. McBrlde. 580; large rhlnoUth,
W. N. Browne, 804
Egypt for phthisis. ITO; nasal nyphltls in. S74
Electric lamp for trauslllumlnatton, 581
light for larj'nffeal Illumination, 281
Electricity In rblnltlB. 552
Electrodes, cautery. 340: laryngeal. 500, 511
Electrolysis, 372, 601 ; method of. In retronasal
tumors and goitre. 622, 631 ; for stric-
ture of the fFSophagus. nS7
Ellis, curveil line of tIatDetia In pleurisy, Illiu.,
64. 65
Elongation of the uvula, chronic inflamma-
tion and. a58
Elongali.ll uvula, on obstniction to laryn-
goscopy, 289; remedial. 306
Em ball o meter, .33
Embolism, pulmonary thrombosis and, 138,
18!l
EmphyseTiiB, subcutaneous. II; pulmonary,
107-112: atrophous. 109
Empyema, chronic pleurisy or. 61, 76-82
of the antnmi, Ulus.. 579-584
etlol.. SHi: synip.. dlag., 580; prog.,
trcftt.. .VtJ
dlff. fr. empyema nf the frontal slmis,
fr. Ruppuratinn of the anterior eth-
moid I't'lls. fr. polypus, fr. nzifna, fr.
foreign hollies, fr. nyphiilR, fr, cftrles,
fr. (li^u-iiKe of the sphenoidal sinus,
580, 581
Empyema of the frontal sinus, dlff. fr. empy-
ema of the antrum, 681
of the sphenoidal siniiees, 683
symp., treat., 683
dlff. fr. empyema of the antrum, 6S1
Encephaloid cancer of the larynx, 476
Endocardial murmurs, 196, 196, Iflis
Endocarditis, acute, 219-aet
ulcerative. SSS, 223
chronic, 2ffi-280
Endocardium, the, 178
England, goitre in, 039
Engorgement, in lobular pneumonia, 118
Enlarged bronchial glands, 152, 168
aoat., path., etiol., symp , IBS; dlag,,
prog., treat., 158
dlff. fr. phthisis, 153
glands at the basK of the tongue, dlff. fr.
chivsnlc rheumatic sore throat, 319
tonsils, an obstacle to laryngoscopy, 900
Enlargement of the heart, syn. of simple car-
diac hypertrophy, 384
or bulging of the pnecordiai region. 1S4
Epidemic catarrh, syn. of Influenza, 619
catarrhal fever, syn. of influenza, B19
Epigastric pulsation, 187
Epiglottis, large or pendent, obstructs laryn-
goscopy, 201: illus., 204, 206
ulceration of the, 896
Eplstaxis. 569-503
syn., anat., path., etlol., symp., BOB;
dlag., prog., treat., 560
dlff. fr. pulmonary hemorrhage, 186
Epithelioma. 801, 480; dlff. fr. lupus of the
nares, 588: fr. rblnoecleroma, 589
Erichsen, nasal syphilis, 5T7
Erysipelatous larjrngitiR, 428, 429
etlol., symp., dlag,, prog., 438; treat.,
420
sore throat, 314-316
etiol., symp., dlag., prog., treat, 815
dlff. fr. diphtheria, 832
Erythematous sore throat, syn. of acute sore
throat. 811
Ether for general aneesthesla, 583, 618
Ethmoid it itt, chronic suppurative, 585-587
Eustachian orifice, 808
Emersion of tile ventricle of Morgagnl, dlag.,
treat. , 483
of the vt-ntricle of the larynx, dlff. fr.
benign tumors, 409
Evulsion of nasal mucous polypi, 666
of tumors. In the larj-ni, 473
Exaggerateil bronchial nhlsper, 68
pulmonary rpsimance, H
respiratliiii, 42
Examination of the chest, physical, 3-60; of
the fauces. 271-310
of the heart, physical, 1S3-1&1
of the trachea, illns., 300
Exocanllal friction soumls or murmurs, 195
Exophthalmic goitre. 082
sjTi.. Ka
ExostoslK of the nasal septun:. ecchondroma
am!, .wr-fiiil
Exoetoses. dlff. fr. nasal cartilaginous tumors,
^^^^—086 iNDSX. ^^R
^^^^^^r liTI; rr bimy ttiiiuint,ffni: fr. foreign
Flint, AiMtln. cyrtofnetar. lllua . IT, U9: hw><
I^^V bodlf^ otn
Bier ROd plnciBirier. lllua, 91; p«^
^^B Explmtory power Rrnalxr Uuui iiwiilratorr, 90
cuiHlon. », M. W: tfinpanlilc raM-
^^B EniriMitkiD of Uk iMrjXiX. |>ani*l. oomplece.
nuicr. K; pulmonary icangRna, HI;
^^1 481. 488
pulmnnnrj' pbtbltlt. 10t
^^H Cxtnctor, for luUihuLlnu. tiO: brUtIv, ftU
Florida for pfatblHls, iTn
^^H £rud«tlvff ttronchltls, ■td- of plastic broc*
FlnctuatloQ of fluid Id the pl«aral carltgr.
^^ft oUtto. ■■
•fffMOf. M
^^H luyoKlUk, qrn. of mniibratunu croup, 411
Follicular dlwma of ttw tia«o phMTua, qh.
^^H Rac« of croup. 413
of rhlDo-pluuTii?1tt«. our
RloMltln, nciitc, chnmlr. 847. MS
^^H Faook. lIiLTox, nirceiT In croup. 416
pborrnitltU. acut«, 8». S4D; idu-onle. Hfr-
^^H FithniwUK-h. (niiHilllUfmr. lilus.. m
SM
^^H FsIm- croup. ayiL of BtWBOi of th« glottis. 496
Foatalne, citrtc add la dipblberla. 8»
^^m ' FalwMto volcv, BOS. MH
Force of the bean. Inrraaaed. dluluialNdtflM^^I
^^H Vuvdiam or ranulUAtlao. fill. Cia. SI4. MO
^^B
^^H Vtecfculated MLroonala. 407
Fompa. lonsll, 879; larytiEoal. 471: ofl^*
^^m Fkllr bmrt, »0^«4
43X: puudi. CB; luwal d>— liiK. KB;
^^^^^ etiol.. »rinp.. MS: dloK. proK. treat.. $14
Mptum, IM; rii^i aoif |0 cuttlnf . H?;
^^^^^^H aUt. fr. <JiniDlc nnilomnlittH. SM, !BT;
mnoTlDir pharjimwil fTlaad witk.
^^^^^^P fr. cbroulc rnxocApilltift, 2<tt
«i9-«»: flexible <Ew>pha««al. Ml
^ Faumi. dlKrnwKiir Ihi?. !I11-381
Forvlirn IhhIIr* in Uiv larjrtix. 4aCMIH
^^H «xaiuliMtion of ihr, ?ri-3l0
ermp-. 400: dla«.. prDg., trwkL. 4fl
^^^1 Faiivi^l, niK]ltrn«nt tmnnni In Ihw Urrns, 409
dlff fr. abacMo. 9M. aM; fr. ibi:u[« lar^
^^^1 Fii>bl^ rwiptrntlOD. 1^
yngltla, auO; fr. phb^cmnnoox larya-
^^H F«tld (onu of tracbeitli. 461. 48t
itltta. 4iH: fr. ataooaU of tlM lairaz.
^^^1 Flhrlnuui broncliUlB, ajrn. of plosllc broo*
4.17
^H chltK W
bodiee Id tbe noM, 608, 004
^^^1 Fil>ro-(!«l hilar tumoTR, Id 1Ii« Iuj&x, IIIu«.,
ajrrop . dioc.. BR; proc , (rrat.4IH
^H
dilT. rr atrophic rbtnltlft. 54»; fr. eta*
^^H yibroM ileiEvaeritloa of the Itinss, tyo. of
PXi-niA, Ml : fr naiuil inin.-nua polrpL
^^B niiroid phthitii, un. 107
5dA; fr. nasal nuilliniaDt lunionLm:
^^H dlMue of the bMrt. aytt. of cbruaic tnro*
fr. «xoAi<:iaU. fr. rhlnollttut, fr. alai-
^^H cantltlN. m
ple ratarrli. fr |hiI»iI, flia
^^^B tfllOlM of tbti luuKi. ills. fr. (^iupbjrsetu&.
bodl«« In the o-aopbo^t. MHW
^^B
Hymp.. 640: dias., pri)|c.,U1: trML.
^^^^^ phUitoit. IM. lor-iw
frli
^^^^^B sjrn., lU, 107; oniiL, p«th.. tS7; etiol..
dlir. fr etrlcturv nf th« n«nphainn. !■
^^^^^f KjrtDp.. lOili: pru«,, ltt>: Uv«t.. 170
fr fk>biiB hyaterliMu, fr parwUiaal^
^^^^^ dirr. fr. olhrr forms, IH. XtT!
^■H!
^^^H pblbliln. nyii of dllnUtloiiuf tlii.' branch Ikl
bodloa In thr pharynx, Stt, V» ^^^M,
^^H lubeit. lUO
ermp.. dlaf.. proir.. iTNit.. KS ^^^B
^^^H tninoni. <Utt. fr. nd^nold irrowtlw. 614
bodlea In tbe trai^itra. 4H-49& B
^^^H PibmniA nf larj-itKti-pbAT^iis. Illtni.. MS
BrDap.4ltt: dlaK..4n; pms., tirat- . W B
^^^P of tile rocal cord*. Illuijt., 4'Kt. 407
Fcmiiila for rm-al dlelanoH of nBaBbor. STC B
^^H Flbtvmitta of Um^ nArm, ^n. of nuoj fibrous
FoRMutK r>ir iir«acrlptifa« ttb-tK ^^^B
^^^B polrpi. 801
FotdUc pharrDcli. ^n)- of vanlt at Om ll^^^|
^^^1 Fibro-mucxMis tumors. retro-nBial, 6M. Mft
jDx, an ^^^^Bi
^^^H diff. fr. nnoAl flbroniatA. ^
Fort. A.. olMtrolyala tor itrlctiirB of At
^^H PtbnwlH. ayn of flbmia |ibihtsl§. 107
u^enphacus. flST
^^H Flbroiu Krowtba. dtff. fr. tuual muooua
Fosia iDDomlnata, 9tC
^^1 p«trr>i. fiM
of KosonitiMrUfv, llltts., flOB
^^^B polrpi, ihumI. 060
Fo«t«r. llluatrulaiHor tlM Mttoo of the bMTt,
^^^1 tunora of tbe Daao-pbarrnx. flKMU
9as,«io
^^^H diff fr, cKHosrof tbe pbaryux, 387; fr.
Fowler. 0«orK« B.. larroieeebnij. ffl
^^H rrtro-tuUHil nbro-mucouii tumors, AH
Fox. lll£non. acutu tonsUIItla. W
^^H Pflvr'K phUiiMis, «]rfi. of dllnUtlgn of thai
Frmctun^ of tbe laryns, 4n, 4M
^^H bn^nrbl*! tulN«. tOO
aoat.. path., «Uol., Kjinp., tflac. . pn^
^^^1 Flrat •tAKV nf lobar pneumnnli. 117; of porl*
treat. 4»
^^B oftftlllls, <18: of plitfaulk, 1«I-IM
Fnetiuvfi of iIm Doaa, 608, IM
^^H Timarm, pultBooanr. 9
srinp.. dla«t.. pfx>s.,O0S: treat.. IM
^^B rUtdiMl, lllua. K
P^aaokel, dipliviiccits [inenmnttl*'. IIB: l^^l^
^^H naM) probe, tllua., 687
luffbiwllll. IfV.: llliiiiiinMiV.Sn.^^^B
^^^B PbUiwn, hepatic, imrdlac, Sn, M
rhlnrvtifijir. UIhk,, •TR: catHV <)f'^^^^|
^^M diet. fr. doloeu. »
fantlle coryia. Stt ^^^B
^^H Plrxtble iianphntial loroept, lllua., Ul
Ftaentacl, reaunaace In pteurlajr, M ^^^^|
INDEX.
(JS7
Fnenum obstructs luyiiftoscopy, a short, 890
France for phthisis, 175; Ro'tre la, tSS
Fnok, aortitis, SM
Fremitus, Dormat vocal, 15: friction, bron-
cbial or rhoocliial, 16
French, Thomas R., reKlsters of male and
female Tolce, 896
Friction fremitus, 16
SOimdfi or murmurs, 4A, 61, 59. 68; ex-
ofcardial, pericardial, cardiac, 106;
endocardial pleuritic, cardlo-pleu-
ritlc. 106
treatment in laryufteal tumors, 473
FrledlKader, diplo<K>ccus pneumoniae, micro-
coccus, IIB
Frog face. 690
FronUl sinus, Intlammatlon of the. BM, 689
Fuming inhalations, formulee, AM, 665
Functional aphonia, syn. of bilateral paralysis
of the lateral crlco- arytenoid mus*
cles, SOB
disease of the heart, neurotic or,
»I7-S49
Furunculoslfl of the none. 568, 550; treat.. 658
FDtterer, L. O., treatment of chronic pleurisy,
78
Oaos. 419, 618
Oalrdner, diagram of pbyslolofcical action of
the neart, 181
OalTono-cautery in various diseases of the
throat and the nose. S6«. 840, 846, 348,
867, 878. 878. 374. 880. 886. 410, 458. 470,
601. 537, 538. 589. 644, 568. 566, 660, 670,
Sn, 676, 578, Sm, 688. 617, 092
compared with chromic acid, 537
teraseur, 578
handle with dcraseur. lllus., 667
snare, lltus., 628, 634
Gangrene, amphoric resonance In, SI ; In lobar
pneumonia. IlB; pulmonary, 144, 146
Oarcia, Hanuel, laryngoscopy. 8TS
Oargles, formulse, 647
Qarlond, Q. M., curved line of flatness in
pleurisy, illue., M
Ooiette des HApitauz. sterilized air in pneumo-
thorax, Potain, 68: potassium iodide
for angina pectoris, Huchard, 958;
removal of foreign bodies with skein
of thread, Crequy, 649
Oasette Hebdomadaire. fracture of the larynx,
Henoque, 489
Gee, cyrtometer, 17; tympanitic remnance, 80
Generative organs to tonMiU, relation of, 8^
Georgia mountalos for phthiRis. 175
Gerhardt, pulmonary emphysema, 100
Germain SAe. lactose diuretic. 930
German mountains for phthisis. 175
student's lamp for larj-ngeal illumlDation,
ST9, 281
Germany for pbthisla, 175; rhlnosck'roinn In,
688
Gibb, erysipelatous laryngitis, 400
Glbbes, Henpage. bacilli, illus. ("colored
plate), 165; sisiured immunity to tu-
bercular virus, ITi
Glraldes, multiple secretions of pus in the
antrum, 579
Glanders, 689, 590
anat. path., etiol., symp., 689; diog.,
prog., treat,, S90
dlff. fr. rheumatism, fr. pyaemia, fr.
typhoid fever, fr. syphillB, fr. scrof-
ulous eruptions. 600
Glands, enlarged bronchial, 158. 158
enlarged at base of tongue, 81B, 889
Oteltsmaun, tubercular sore throat. 85:2
Olobe nebulizer, lllus., 174
Globus hystericus, 600
ditl. fr. foreign bodies in the oaso-
phagus. 641
aiossltis. acute follicular, 847
chronic follicular, 847, 848
Glottis, 898
spasm of the, 406, 407
Goitre, 689-681
syn., anat., path., etiol., 680; symp.,
dlog., prog., treat., 680
dlff. fr. exophthalmic goitre, fr. ma-
lignant tumors, 680
aerial, 486
exophthalmic, 68S
Gold and sodium chloride for immunity to
tubercular virus, 178; for syphilitic
larjmgitlB, 448
Gottstein. malignant tumors In the larynx,
476; wool tampons, BS8
Oouty affections ditf. fr. chronic rheumatic
sore throat, 819
Orsncher, diphtheria propagated by Infected
clothing or furniture, 884
Granular sore throat, syn. of chronic follicu-
lar pharTDgitis, 840
QraTes' disease, syn. of exophthalmic goitre,
683
Gray hepatization. 118. 114; lllus., 117
Great Lakes, rhinitis near the, 687
Orlppe. syn. of InflueoEa. 610
Gross, 8. D., foreign bodies, 499. 404: instru-
ments for removing foreign bodies
from cavities of nose and ears, lllus.,
601
Gualocol. for phthisis, 173
Guaiacum for acute tonsillitis. 806; unsatisfac-
tory in phlegmonous tonsillitis. 869
Gueneau. Noel, diaphragmatic pleurisy, 88
Guido BooelU. pus dlff. fr. serum, 77
Guillotines for throat, 473
Oumnia. XA, SM
OurgW. 48. 59
Gussfnbauer, ortiflcial larynx, 4PS, 483
Outtmann, tympanitic resonance, 30
Hack, hay fever, relateil to conditions In
nasal passages, 553
Hnemadynamoiiii'ter. 19
riipuiatt'nifsls ililT. fr, hasmoptysls, 135
HfFmatonia of thf dosbI neptuiti. etiol., symp.,
tlinjr., iirog., treat.. (MM
lUff. fr. mucous polypi, fr. cartilagl-
nnus tumors, fr. hj-pertrophy of the
turbinated body, fr. ecchondroma, 609
688
INDEX.
Hfemlc murmuTB, 804
HsemoptyBlB. 1S4, ISG, 3S0
diff. fr. hfematemeflis. 135; fr. epta-
taxls, fr. faemorrhage of the gums or
the pbaryoz, 186
HfemoBtaticfl, sprajr Inhalations, formulse, 6fi8
Hahn, F,, nasal tuberculosis. 578
Haines, W. S.. iodine trichloride In tubercular
larj-ngitis, 441
Hairy heart. 81S
Hamilton, milk spots, 213; pueumo-peri-
canlium. 218; acute endocarditis, 319,
230: myocarditis. 231
Hammer for percussion, 21
Hammond, hcemadynamonieter. Utus., 19; ex-
piratory force greater than inspira-
tory, 20
Hark in. epistaxis. SS]
Harries and Campbell, etiology of lupus of
the larynx, 452
Harsh respiration, syn. of broncho- vesicular
or rude respiration, 44
Hay asthma, nyn. of bay fever. 553
fever, 558-558
ayn., anat., path., etiol., SfiS; symp.,
diag., 554; prog., treat,, S66
dlff. 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, 210
Head, sections of. 902. 541, S7D, 5M
for laryngoscopy, good and poor positions
of. 2W. 285
lower than the bmiy In taklnx fo<Ml iu cer-
tain throat diseases, 442, 50G
Heart, the. 177-211
aneurism of the, 245
apex beat of ihe, 10, 180. 182. IW
atrophy of the, 2*!
coii>;enital dffomiity of the, 227
dinslole of the, IftO ,
dilatation of the, 239-242
failure in atheroma of the aorta. 2S5
fatty, 242-24-1: degeneration. iDflltration.243
font- ..f the. uio<lified, IM. )t«, 187
hairy. 212
neoplasms of the. 240
neurotic or fuuetlonal disease of the,
21T-240
physical cxanilnatiou of the. 188-194
physioLigical action of the, I80-1K3
rupMirc 'if the. 245
Riiimis, Imw caused, 190, 191: modified by
liisi-ase, 101-194; anomalous. 205
sypliiliN (if the. 245
fiystnl.' "f the. m)
to liti.l the limits of the. 188
tiiTiiorB of till'. 2 It!
valnijiir ilisens.- of the. "iJi-H^O
Heath. t'hri^InplnT. enipyeiim of the antrum,
Hi'tcosis larynijis. syii. <if lul)t;rciil;ir luryii.
ciii-;. Vil
Hemiplegia causes cxaggcratt.il respiration. 42
Hemming, Hugh, syrup of chloral la diph-
theria, 836
Hemorrhage, pulmoiutry, 134-136: after ab-
scissloD of the uvula, 350; after too-
slUotomy, 374
Remorrhogla narlum, syo. of eplstaxia, 559
Hemorrhagic infarct us. syn. of pulmonary
apoplexy, 187
pleurisy, 61
Henoque, fracturfi of the larynx. ISO
HenrotlQ. gag. lUus., 419, 018
Hepatic dulness, flatness, 8S, K
pulsation. 1S7
Hepatization, red, yellow, gray, 118, 114
Heredity of phthisis, 156
Hernia, diaphragmatic. 88
Herpetic sore throat, syn. of simple membra-
nous sore throat, 8M
ulceration, 806
Herynge (see Krause and Herynge)
Hilton, sacculus lanmglB. 297
Himalayas, goitre in the. 68D
Hlppocratea acquainted with iuccusbIod. 90;
percussion. 21
Hotden, E., chorea laryngls, BOl
Home and its comforts best for odroaced
caaea of phthisis, 176
Hooper. F. H.. operating on beolgn tumors In
the larynx, 473
Hopmonn, nasal papillary tumors, 509
Hospital sore throat, syn. of chroalc follicular
pharyngitis, 840
Hot applications in pneumonia, 122; la dlph-
theria,SSS ; in phlegmonous loDsillltls,
309: In croup. 416; in tracheitis, 401
Hots, F. C, throat deafness, 611
Huber, myocarditis. 231
Huchard, free protracted use of potamlum
iodide to cure angina pectoris. 298
Hungary, rhinoscleroma in. 583
Hunter. John, empyema of the antrum, B!9,
582
Hutch in BOS, spirometer, 18
Hydatid cysts of the lungs, 148-lBO
anat., path., etiol., 148; symp., diag.,
149: treat,. ISO
diff. fr. phthisis, 149; fr. circumscribed
pleurisy. 150
Hyde, J. Nevlns, treatment of lepra of larynx,
4.55
Hydraaiine Identical with berberlne, 95
for chronic follicular pharyngitis, HU
Hydro- pericardium or pericanlfal effusion. 15,
21fi. 219
anat.. path., etiol.. symp., diag., SIS;
prog., treat., Sl9
diif. fr. hypertrophy and dilatation of
the heart. 238
Hydrothorai. 13, 15. 64
etiol., symp.. diag., prog., trettt., S4
difr. fr. pueumonia. 120; fr. pulmo-
nary collapse, 143
IlypeT-geiniH. pulmonary, 132-184
HyiierteKtlienia of the larynx. 82. GOO. 301
anal., path., etiol.. symp., diag.. SM;
prog., treat., BOl
INDEX.
689
HTperaeBthesfa of tbe pbarrnz. 888, 889
Bypersarcosls cordis, aju. of simple cardiac
hypertrophy, 884
Hrpertrophfc rhinitis, lllus., 6S8. 540-647
anat., path., etiol., symp., MO; dlag..
542; prog., treat., MS
difr. fr. Intumescent rhinitis, 084. 049;
fr. syphilis, tr. nasal mucous polypi,
542, 548
Hypertrophy, simple cardiac. 14. 884-386
ODd dilatation of the heart, lllus.. 311, 886-
8S9
syn., symp.. S30: dlag., prog,, treat.,
239
diff. fr, retraction or consolidation of
the lung, fr. cardiac dilatation, fr.
pericardial efTuston. fr. cardiac dis-
placement, fr. thoracic aneurism,
237-!»9
of the larynx, 46S
of the lirer diff. fr. pleurisy, TO
of Luscbka's tonsil, syn. of hypertrophy
of tbe pharyngeal tonsil. 618
of the pharyngeal tonsil, lllus., 618-G90
ayn.,anat.. path.,613: etiol.. symp., 614;
diag. , prog., treat.. 616
diff. fr. nasal mucous polypi, fr. flbrold
tumors, 616: fr. fibromata, 631
of the spleen or of the liver, diff. fr. pleu-
risy, 70
of the tonsils. 370-^6
syn.. etiol.. symp., 370: diag., prog.,
treat.. -371
diff. fr. diphtheria. 882; fr. cancer, 380,
381
of the turbinated body, diff. fr. hsematoma
of the nasal septum. 603
Hypodermic syringe, lllus., 508
Hypostatic congestion, 138
Hysteria, diff. fr. chorea laryngls, 608
Hysterical aphonia, syn. of bilateral paralysis
of the lateral crico- arytenoid mus-
cles. 608
Hysterical or peeudo angina pectoris, diff. fr.
angina pectoris, 3S1
Ice Id diphtheria and other diseases of the
throat, 3»4. 367. 860. 416. 438. 638
Ichthyosis lingua?, syn. of leucoplakla bucca-
lis, 360
Illumination of the throat. 375-884
Immediate auscultation. 34
percussion. 31
Immunity to tubercular vims, how secured, 173
Incipient hypertrophy due to Bright's disease,
lllus.. 310
Incompetency of heart ralvea produced, 334
Increased vocal renonance. 56
India, myasis nnrium in. 605
Induration of the lungs, syn. of fibroid phthl-
elB. 167
Infanta, syphilitic sore throat in. 316; syphili-
tic larynRitis in. 449: acute rhinitis
in. .sad; syphilis of the no«e in. 577
Infectious endocarditis, syn. of acute endocar-
ditis, 310
44
Inferior costal breathing, 11
meatus, lllus., 809
sternal region, 4, 6
turbinated bodies, lllu8.,80e
Inflammation of the antrum or frontal slniues
diff. fr. acute rhinitis, 534
of the frontal sinuses, lllus., 684. 56S
symp., treat., 684
of the larynx, syn. of acut« laryngitis, SM
of the lungs, popular name for pneumonia,
118
of the uvula, acute, chronic, 866-800
Influenza, 510-523
syn., anat.. path., etiol., symp., 510;
dlog.. OSO; prog., treat., 581
diff. fr. rhinitis, fr. Inflammation of
the lamyx. 631
Infra-azlllary region. 4, 8
Infra-clavicular region, 4, 5
infra-glottic dropsy, syn, of cedema of tbe
larynx. 430
laryngoscopy, lllus.. 293
Infra-mammary region. 4, B
Infra-scapular region, 4, 8
Infra-thyroid laryngotomy, 476
Ingala. emballometer, lllus., 8S; flat trocar,
lllus., 79; drainage tubes for empy-
ema. lllus. . 81 ; nasal speculum, lllus.,
801 : modlflcation of Shurly's battery,
illus., 846; cautery electrodes, lllus.,
846; tonsil forceps, lllus., 878; laiyn-
geal applicator, illua., 405; cbromio
acid applicator, galvano-oautery
handle, lllus., 409; punch forceps,
lllus., 4SS; nasal BclSBora, lllus., 546;
nasal syringe, illus. ,050; snare, lllus.,
067; nasal dressing forceps, illus., S76;
electric tamp for transillumination,
661; drainage tube for the antrum,
lllus., 683; septum forceps, lllus.,
septum knife, illus., 596; right-
angle cutting forceps. 697; nasal
saws, illus.. 5BQ; nasal spatula, illus.,
heavy -bone scissors, lllus., nasal
bone forceps, lllus.. 600; post-nasal
snare applicator, illus,. 633
inhalations, formulte, vapor, 640-661 ; spray,
651-668; dry, 6M: fuming, 6M, 656
iuhaler, 619, 6M
Injections for pleurisy, stimulating. 81
Inspection, 9-14, 86, 88. 183, 1S4, 273, 803
Insufflations, formutee, 666, 657
Insufflator, illus.. 586
Intensity of sound, 33. 80. 41
of heart sounds, niodlfled by disease. 191
of vocal resonance, modified by disease, 55
Inter-arytenoid fold, lllus., 300
Intercostal neuralgia or pleurodynia, diff. fr.
pleurisy, 68; fr. pneumonia, 119; fr.
angina pectoris. &\
Interlobular emphysema. 107
pneumonia, often Included in lobular pneu-
monia. 133
Intermittent dilatation preferred in stenoats
of the larynx. 460
rhythm of the heart, 108
690
INDEX.
Intermittent venous murmura, 907
Internal treatment, diphtheria, S87
International clinlca, operating on benign tu-
mon* in the larynx, F. H. Hooper, 47S
Congreas Larjngology and Otology. Trans-
actions, myzomata transformed into
sarcomata, ScbifTera, S66
Journal of Surgery and Antlaeptlcs, nasal
vascular tumors, J. O. Roe, STO
Medical Annual, tachycardia, L. Bouveret,
349
Medical Congress, Transactions, eplstaxis.
Harkin, S6I ; Walton Brown, 56U
Internationale klinfsche Rundschau, pericar-
ditis, von StofTela. SU : nasal tuber-
culosis, Michelson, S78: adenoid
growths in deaf-mutes, Wrdblewski.
614
Interrupted or cOR-wheel rrapiration, 4S
Interscapular region, 4. 7
Interstitial pneumonia, often included in lobu-
lar pneumonia. I'm
pneumonia, syn. of fibroid phthisis. 128,
167
Intubation In diphtheria, croup, and Other
throat diseases. SSS. S97. 415. 41»-iSl.
428. 420, 4S2. l.W. 458. 456. 459. 472.
4S4, 400. K13. 615
described. 418-421. 458, 459
instruments. 418
IntumeRcent rhinitis. 698. 531-540
anat., path., etiol.. symp.. 531; diag.,
prog., treat.. 5S4
difT. fr. sluiple chronic rhinitis; fr.
iinsal nuu'oiis polypi. 534; fr. hyptT-
tro|ihic rhinitis. .'h}J. M'i
Inversion of a patient to remove foreign bodies
from the trachea. 491
Involution of the trachea. 4H5, 4S6
etiol., Bymp.. ding., prog., treat,, 486
Iodine for Ininiunity to tubercular virus, 172;
for iul»erciil'>sis. Sil
trichloricie in surgery. 441
Inspiratory powi.T Icsh than expiratory, SO
Irrilahility of the tongue reuietiied for rhino-
scopy. .104
Irritable faiiwa an olistacle to laryngoscopy.
28!*; rem.'died. 305
lienrt of soldiers. 249
Irritniive cough, treat.. 49^
Italy. rliinos«^'lerottin in, 668: goitre in, 029
JaccoTd. jili'iirisy. 83
Jackson, Ilugliliiigs. nose-bleeding preceding
api'i'lfxy. ."ifiO
Japan, di.sioina [luliiionale. 150
Jarvig, small nasal sjieculuin. illun. . 301; tu-
IxTcnlur laryngitis. 441 ; snare for-
ceps. 47:); rhinitis. 545; snnrc. 567;
nasal vascular tnninrs. .')70; drill. 5!t8
Jaworski. pneiimiinia enntagions. 110
Johnson. 11. A., inspection in ptitliisis. Uti
Journal Aiiicricnn Mt'diciil Association, pneu-
nifinia contagious. Jnnorski. IHi
de Mi'decine de Paris, epllejitic aslhma,
Poulet, IW
Journal of Laryngology, lepra of the laryi^
Morell Mackenzie, 464
Jugular veins, collapse of the, 307
June cold, syn. of bay fever, BBS
Kkloid did. fr. rhinoBcleroma, &BB
Kennedy, fatty heart. 242
Klehs-Uffler bacillus a cause of diphtheria,
389
Klemperer, Q. and F. . experiments with blood
serum or anti-pneumatoxln in pneo-
monla, 123
Knife, laryngeal, 474; septum. 596. 590
Knife-grinder's rot, ayn. of dilatation of the
bronchial tubes, 100
Knight, stethoscope, illus.. 36
Charles H., galvano-cautery in chronic
follicular tomtillitis. 372; nasal osas-
ous cysts, 570
F. I,, lupus of the larynx. 451: cb<ffc«
laryngls, 601. 608; laryngeal vertigo,
6M
Koch, bacilli in lupus of the larynx. 451
tubercle bacillus. 156
tuberculin, disastrous use of. 464; in tu-
berculosis of nares. 57S.; curative la
lupus of the nares. StH; Inactive ta
rhinoscleroma. 589
Kfinig. canula, 486. 4X8
Kramer, head-band for reflector in larrngo-
scopy, 277
Krause and Herynge. treatment of acute tubn^
cular sore throat. 353
operations on the antrum. 6H2
Krishaber. illuminator, lilus.. 27H: thyroto-
my. 475
Kuho. pneumonia contagious. 116
r.uiDt's, Carlo, trachoma of the vocal cords, 408
Lactic acid in diseases of the throat and dom<
.%■*. 336. .WO, 3S1. 417. 578
Lactose diuretic. "■SO
Laennec. theory of the cause of pulmonary
emphyHema.20: mediate auscultation.
34; bronchial resjiiratlon. 45; rHles.M
La France Mf^dlcale. carbon dioxide in asthma.
Weill. lOG
Lamp for laryngoscopy, German student's. SI9:
for trauatlhimination of the noKal cavities,
electric. 58]
I,ancet. laryngeal. 397
Larry, aerial goitre, 486
Larj'ngejil and tracheal respiration. 41
applicator. 406
cough. 59
electrodes. 509
forceps, illus., 471
knives. 474
lancet. 397
phthiKis. syn. of tubercular laryngitis. 43*
tuberculosis, syn. of tubercular laryngitis,
4.'M
tubes. 418. 459 (see intubation)
tumors, illus.. 4Q3-4H5
difT. fr. syphilis. 447
vertigo, treat., SM
ir^DEX.
691
Larrngectomy. modes described. 483, 488
Laryngisnius fttridulus, 8>-n. of apftam of the
KloCtis. 4US
LaryOKltlB. acute. 398-397
chronic. 3D8-408
chronica, wyo. or chronic laryDgitls, 396
due to small-pox, 4&5
eryalpetatous. 4SS, 4A
exudative, sjn, of meinbraDOus croup. 411
of loeoslcs. 49S
of scarlet fever, of Bmall-pox, 4U
phleKtiinnosa. sjd. of phlegmoDOua laryn-
gltiB. 427
sero-punilenta. syn. of phlegmonous laryn -
Kit is. 4?7
Buhaciite. 397, 398
Bubmucosa piirulenta, syn. of phlegmon-
ous laryngitis. 437
Byphilltic, 443-450; in infants, 449, 490
traumatic. 396
tubercular. 4IM-443
LaryngO' pharyngeal sinuses. S96
Laryngophony, 54
Laryngoscojie, a. 274; preferred form. S83;
manipulation of. *J)^2K0
Laryngoscopic mirror in position. illuB., 386
Laryngoscopic rctliftor, IIIiib., a<3
Laryngoscopy, illus., 373-^'93
infraglottic, S!W
obstacles to. 2>«i--Xi2
Laryngotomy, supra-thyroid, infra -thyroid,
475. 47C. *fi-i
Larynx, a normal, illus., S93. 305: of n-omen.
In fnrmhiK head tones, illus., 396
abscess of the, 4a!i. 430
aniDBthesIa of the, 499, 500
artiflclBl, 4^
benign tunmrK of the. 4G5-~17G
cancvr of the. 47r.-4H3
chronic stenosis of the, -l.'iti-459
cystic growths of the. 400
diseases of the, SiH-Tilf,
dislocation of the. 4'.IU
extirpation, partial, complete, 481-483
fon-ign bodies In the. 41ti)-493
fracture of the, 4H0, 4no
hyperu-sthesia of the. 500, 501
hyi>ertropliy of the, 45.')
illumination of the. l*75-2«3
lepra "f the. 451
lupus of the. 4.M-4M
malinnaut tumors of the, 476-483
morbid KrowthK of the. 463-483
neurak'a of the. 5Uti, 501
a-deina of the. 430-4.3.^
parfesthesln of the. 500, 501
resection of the, 481
spasm of the. in adults. 497, 496
ventricles of the. 3W7
La Semaine M/>illcale, causes of angina pec-
toris. 251
Lateral region. 3
La Tribune MMicale, lactose diuretic, Oermain
s*e. aso
Laugenbeck, retro-nasal flhrouB tumora. 631
Lawrence, retro-nasal flbrouB tumors, 631
Lazarus, heredity in asthma, 108
Leared, binaural stethoscope. SB
Lefferts, George M., history of lupus la the
larj'nz, 451 ; everslon of the ventri-
cles of Morgagnl, 4N3; chorea larya-
gis. 601 ; retro-nasal cystic tumors,
630
Lelchtenstern, pleurisy, 71 ; empyema in chil-
dren, 77
liCldy, Joseph, thyrotomy, 475
Lelter coil for applying cold through a circu-
lation of water. In tonsillitis, 369; Id
croup, 416
Lepra of the larynx, illus., 454, 455
path.,etiol., Rymp.,dlag., prog., treat, 454
dlff. fr. tjenlgn tumors, 469
Leptothrlx buccal Is, S76
Leucoplakia buccalis. 300-363
Byn., anat., path., etlol., 900; Bjmp.,
dlag., 301; prog., treat.. 303
dlff. fr. professional patches, SfiT;
fr. smoker's patches, fr. mercurial
patches, fr. syphilitic patches, fr.
cancer, fr. jtsoriasis lloguie, 861, 364
buccalis et llntnialls. syn. of leucoplakia
buccalis. 300
Levret, laryngoscopy, 1T3
Lewln, Ifenign growths In the larynx, 469
Lewis, foreign bodies in the trachea, 493
Ix>yden, cause of asthma. 103
Lit^geois, cause of angina pectoris. 250
Ligation for extirpation of tumors, SS
Lime-water vapors in diphtheria. 410
Lincoln, It. P.. nawil cancerous tumors, 578;
extirpation of nasal tumors, <>31
Llnsley*s translation Fr^nkel's Bacteriology,
staining bacilli. IKS
Lipotnata. 407
Liston, laryngoscopy. 272
Litten. pulmonary throml>ofils and embolism,
i:J8
Liver, enlargement or hypertrophy of, 68, TO
Lobar pneumonia. n-'i-1£l
syn., anat.. path.. 113: etlol., 136;
synip.. 116; dlag. 311*; prog.. 131;
treat., 123
dlff. fr. capillary bronchitis, 97; fr. lo-
liular pneumonia. 127
Lobular pneuinonja. 323-I2K
syn.. anat.. path., 123; etlol., symp.,
i:M: diag..l25; prog.. IVT; treat., 128
diff. fr. capillary bronchitix. 1p7: fr.
capillary hroncliitlB, fr. pulmonary
collapse, fr. lobar pneumonia, fr.
aeute tubercular phthisis. ]2ri-l2N
Local ana'NtheKla produced by a pii^ient of
morphine, carlx)lic acid, tannic acid,
glyoerln, water, 442
an8?sthesla. produced by cocaine. 457. 470,
495. 5M, 557. 5C«. 583. 603. 016. 617, 628
antpsthesia. piements. formulfP. 655
Loewenberg. forceps, illus.. 617
London Hospital Clinical Lectures and Re-
{Mirts. nose-bleeding preceding apo-
plexy. Hughllngs Jackson, 660
I^ancet, diagnosis of congenital disease ot
692
lyDBX.
Iha Imut iD cblldivD. s*Dtom. 9M:
MfnottaK fomlKn liodleti rroin the
tnuihwL rMjl«y. 4»4: icoltre. .Morcll
H»ckf nsiu, IQI : lutM-iiai^l tnttirlcture
of tha iniinphAffaii. Chutern J. S;--
Ijffndow Pnu^tioDer. trcittinffut of iilMratlvtt
eDdoc&rditlB. Sansom, Wi
Loocnl*. A. U. peivutMlon wMimH, iM; treat-
uwaitof pleurUy,TV.TH: doulile pueu-
mooia, IIA: treatinecit of iiuliimnary
liriii<>iTluiiri% l.ttt: murlKltt)- in iofMits
froiiiat0loctAftl>follovrli)t[>iron?)ilcfi.
HI; rliythni nt hv«rt houikIk. DliiH-,
I6S; redD|>llCBl4oD of hcftrt notiada.
l(M:piidocsrfllttB.2n: simple cardlH
hyytnrofilbf. Ml: Uioraoic aaetir*
Imui, te
Bttary P.. bacilli In tiMltbr peraona, lU
LiMffnice*. trochtwl or. forniutae. M'*MD
I.iihr^l-Bnrliou. tc))iiam of thtt icIiidiK. 4M
Lumtiicscr. JoMrf. cause of putrid broDohltla.
bl
Lung textr, popular sjrn. of pnmimonla. Its
Lunjpi' npoplaxr of th«. 15
collapse of tlie. TU
eooKolliuiloD of. 297, SH
hydatid oyatt at tho. 148-iao
re<tra«tloD of tbe. 28}
tirphillllr dliii-UH' of tli4-. 1SI. ttSS
L>'Vu]oD>I/'dtcAl<>. Kletn-Uifflorbatflllue.Boux
•od Terafn. 89: cam of ezoMilve
ooae-bleedlnit. BIartitM>a«i, sao
Lupu esetfrau. Don-wE«d«tii, G*>7
of the lAtynx. lllua. . 4ftl-41U
aaai., paib.. otlot, ISi; ajrmp.. AlAg..
tSt; proK.. treat.. 4BK
dlff. fr. tulftrculoats, fr. «yphlUa. fr.
caDcvr. 458, 4M, 4:V: fr. bunlKD tu-
mors. 4dD
or the uar«k. Cfrr, SfiS
aaat., path.. «tlot., wjjojt.. dine. B87:
proK. , treat., 694
dlfT. fr. atrophic rlilnliK M9: fr.
Rfpbilla. fr Rpillivlianin, fr. tubvr-
COloali. 087
of the pliarriix. dlff, fr. Krofiilous aore
tliront. H»
Tuljrarln. 540
vuttnrU tiuTdgia, Chlarl and ftliAI. «St
Lliachlra'a tooall faea bypartrophy of the
pbarjruseal tonal I)
tjon MMIoale. eaun of aotclna pocioriB, SBl
UcBaittft. ftOB«tbMtn of tbn lAr>-i)x. UK: ma-
pyt-mti of Ih4< nniruiu, (UM
MeSonalil. HnivHIis ainvphtu rhloUia moat
C'lDinoii In Eirla, &47: atrophic rhl-
Dltta. BSt: Duaal cwaMfua t^jata. STO;
ampyema of tbo aotnim. set ; h]rp«r-
tmptix tit tbe phar}rDK«at lonall. ni4
mckvinle. JotiQ N.. sTphillilc sore throat In
lafanta, U6; vrfiltlllllii larytiKtUa In
Infasta. 4IB: harfararralaicd toooci-
dIttOB In uwal paaMeea,aS8: fureepa,
at
Uackwile. Morell. rack movefDent buU'a-«ft
•-■OQileusM-. Illua., 37H, tfTD; foKHi Iv-
DomlnaiA. WT; «ryslpelatoui mott
thriMtt. .lift: lactlcoeid Id <)[|>htb«rU.
89b: ■j-plilliilc •Oft] throat, aaa; latrti-
geal launul, Illua . »f7: IdeaUrf of
dIpbUwria aud croup, 411; ayphlliUe
larjrnKilis, 44S. 94ft: lepra i<I Uw
lanirx. tM: larrai»Mi1 dilator. Illua.
4B8: laryDgtf&l lutuunv 44B, «flB: lub>
forcvpa. Illua. 471!: jnuir\lMl wtM^I
tonuNHir, 47* ; tJiynitoniy. CJ. (ni;
larrneeal cancer. 477 : mode i>r cunt-
plntvrstirpatlon iif Itir larjms. !«■:
tractaeooele. 4M: ByphUl* of llw
tracliML. 487: la^7DK(^al «lec(rod«4^
llliia.. an-, rblnltta. Mi; bay frwr.
fiSQ; mucmui pc^lypt. MC: o^mI t«-
plUarr tumnn. MW: aaaal eypbUta
B74. ftT7: tonaflHtta. B74: aooamla.
SU: itfiHrRtltin of tho aeptum. W:
rbiDn-pharnisftla. DOT. OW: throat
ilivfuMM. oil; ftoltrv. Bt; paralnte
ot tlM* (paophafus, m, (MO; el««tr1e
Inhaler. MS
MacKaniara, epUtuslft. fiBI
UamoH In Ibe Dnet». ■fo.. of mjroala narlum.
flOft
Ualfomatlou aod new rrotrtba of the urula.
»D
UnlltrbaBt (aee alao oanocr) diaeMMi of O*
(B»opb«jn» dlfT fr par«l)rat«. M
nodoeardlila, sj-n. of aoutr mdocBnflUa
Kruntliaon urula, SflO
tuniun tlUf. fr. beulCD lUBton, m
lumrir*. naaal, SO, S79
tumura ttl the larynx. Illua., *n, «i
anal., path., Kyrap., 471; dla^,
proe.. trnat . 410
dllT. tr. Ijphllti. fr. cbronli- ratairha)
loflamtnailoa, fr liipuH. fr. tiiWrm-
lar lAr>'DBitlB, fr. Iienigu jcrvanbi
478. 47B
tutnnnidt Ibe naswptiarynx, aaat.. path.
*.*tM..«rmp..dliui.. proit. tT««L.W
dllT. fr. rptro-tia«a) llbronuinMU ■■
mora. Oi&: fr. naaal cartlla^eui
tumnr«, tat
Mainmarr or nipple line, t
rrfclon, 4. n
Harej, Niitijutubfrrapfa. Illua.. ttn
Hartlurau. raaeof pxcvealvo Boee-bteadlltg, W
Haaaaipt with foreign bodiea Ui the OMopkag*
«tt
Matheaon. pnmtraonla, contAgloua, 118
Mathlou, tonaUlltunH*. Illoa. 873
Meaatee, aon< throat of. 8H. sas; larrndtladaa
to, «&&: naaal affMCtlooa lu, BBl
Meant*. lnf<>rlor, middle, aaperlor. AM
Unllnstlnal tumors, aoUd. in. ■?, MB
diff. fr. pn-lcardllU. 8I((
Mediate aitsmllaUun, 34
perm Ml tin, 9\
Unlical N<>va, danger la voableg pleural Mf
ity, Bowdlicb. taiMiktt «t rtla, W-
INDEX.
693
If. Strickler, 76: promotion of renal
secretion in children with capillary
broDchitlB, 96: asthma due to poison
In the blood, Robinson, 104:
Uedlcal Preaa and Circular, pneumonia —
contagious. Hosier, 116
Record, acute pleurlsr, Drzewlecki, 78
Register, pneumonia contagious, WelU,
116
Socletj' of London, Transactions, acute ton-
sillitis, HlKSton Fox, SOS
Hembranous croup, 14^ 411-1:^
eyn., anat.. path., etlol., 411 ; symp.,
dlag.. 413, 413; proK-. 415: treat., 416
dlff. fr. acute laryngitis, 896; fr. catar-
rhal laryngitis, fr. laryngismus stri-
dulus, fr. diphtheria. 413-415
laryngitis, syn. of ueoibraDOUs croup, 411
sore throat, simple. ftM-9137
Heningitls difr. fr. pneumonia, 121
Mensuration, 0, ]&-»). W
Menthol and alboleiie spray, 44], 561
Mercurial patches dlff. fr. leucoplakla bucca-
lis.S61
Mercury to infants, mode of applying, 677
Meaostemal line, 7
Metallic tinkling. 20, 54. 87
Mexico for phthisis, 175; nasal syphilis in. S74;
myaals narlum In, COi
Mlchelson, naaal tuberculosis, 578
Michigan for hay fever, 655
Micrococcus of Frledlander exciting pulmon-
ary iunnmmatlon. 35
Microscopic pxamliiatiou, lobar pneumonia,
114
Middle meatus, lllus.. WO
turbinated bodies, lllus., 808
Miliary tuberculosis, acute. lUK-ItTT
Milk most important nutritious driuk In diph-
theria, S!M
spots, '212
Minnesota for phthisis. 175
MInot. pneumonia In children. V.H
Mirrors for laryneoscopy, throat. STS; position
for, manipulation of, :!86-480
Ultra) area, llltis.. 108
constrictlnn. Illiis.. SlO
murmurs. 108. 201
obstniction. aan. aas, aw
regurgitation, lllus., W). 226. 228
stenoals. 225
valves, 7, 178
Moist r&les, 48. m
3IoDtana for jihlhlsls. 175
Morbid growths in the larynx, 14. 468-485
anat.. path., etiol.. 4G8: syuip., 464
Morbus OEpruleuH. 24<t, ^7
syn., syinp., diag.. a-W; prog., treat.,
a47
Morgagni, everslon of the vi'iitrlcle of. 488
Morsen, creaxote for phlliisls. 173
Mosetig-Moorliof niodn of Injecting iodoform
In goitre. &l
Mosler, pncuinnnla contagious. 110
Mountains for ptithiBiH 175: for hay fever, 555
Mount Bleyer. tongue depressor, lllus.. 4trl
Moure, regeneration of atrophied structura,
BfiO
Mucous click, 48. B3
patches. S58
polypi, myxomata or true, 466
polypi, nasal, 064-568
r&lec 48, CO
tubercles, S58
Mulhall. J. C, falsetto voice, SOS
MultUocular pleurisy difT. fr. other forma, 88
Mdnchener medlclnlsche Wochenschrlft, the
aneurismatlscope, Ferdinand Ejchnell,
261
Murmurs, vesicular, SO: cardiac, 105-211; exo-
cardial or pericardial friction sounda
or. 105; endocardial. 106; diastolic,
90S, S04; ventricular, congenital bn-
mlc, 204; subclavian, SD6
Myalgia diff. fr. angina pectoris, SSI
Myasis narlum, 606, 606
Bjru.. etiol., symp., dlag., prog., 605;
treat., 006
Mycosis of the tonsils, 876, S77
anat., path, etiol., symp.. dlag., S76
diff. fr. acute and chronic follicular
tonsUlitlH, S76, UTT
Myocarditis, 213. 231-28S
anat., path., etiol., symp., 231; dlag.,
prog. . treat. . 282
Myxomata or true mucous polypi, lllus., 466
Narks, tuberculosis of the, 678, 670; lupus of
the, 587, 588
Nasal affections In acute diseases, 601
bone forceps. 000
bones, dlslocatlou of the, 594
bony tumors. 571. 67S
syn., anat., path., etiol. symp., 671;
dlag., prog., treat.. 572
dlff. fr. exostoses, fr. rhioollths, fr.
cancer. 672
burrs, ilhis. , 546
cartilaginous tumors, syn., anat., path.,
symp , diag., prog., treat., 571
diff. f r. fibrous polypi, f r. malignant tu-
mors, fr. exotoses, fr. ecchondrosea,
fr. bony tumors, 571
cavities, diseases of the, 619-606
douches, illus.. 561
douches, fonnulaj. 658
dressing forct^ps, 576
fibrous polypi, syn.. treat.. 569
malignant tumors, 572. 573
anat., path., 572; etiol., symp., dlag.,
prog., treat.. 573
diff. fr. rhinoliths, fr. foreign bodies,
fr. abscess, fr. benign growths. 573
mucous polypi. .V>4-.Vi8
syn,. anat.. ^lath,. etiol.. symp., 564
dlff.fr. intumescent rhinitis, 6W; fr.
hypertrophic rhinitis. 548; fr. de-
viation of the septum, fr. thick-
ening of the turbinate<l bodies,
fr. chronic abscess of the nasal sep-
tum, fr. foreign bodies in the nose,
fr. fibrous, sarcomatous, and can-
694
INDEX.
ceroug fcrowthB, 665; fr. empyema,
5*^1 : fr. clironic nippuratlve eibmol-
ditifi. 5M5: fr. haimatoma. 60S; fr. for-
eign bodies. 608; fr. hypertrophy of
the pharyogeal tonsil. 616; tr. retro-
nasal flbroua tumoTB, 621 ; fr. retro-
nasal flbro- mucous tumors. 6SS
Nasal myxomata. syn. of nasal mucous polypi,
MM
osseous cysts, anat., path., etlol., symp.,
diar;., treat., 570
papillary tumors, 569, 570
syn.. anat.. path., symp., diag., prog.,
treat., 560
probe, flat, 5,37
saws. 50e, GOO
scissors, 545. 600
septum, deflection of the, 594; ecchon-
droma and exostosis of the. 597: per-
foratiou of tlie. 601; hepmatoma of
the, UXl; absceSBes of tbe. 608
snare. 8,W, ,'M7
spatula. 600
speouhim. 301
spud, illus.. 590
ayrinp". ."aO
trephliii-8, illus., 546
vaKCulnr tumors, syn.. treat.. 570
Naso-]>harynx. cystic tumors of the, 626
diseases of the. 607-6SU
uialiRnatit tumors of the. 635
Natural lljtht for laryngoscopy, S88
Navrntil. dilator. 457
Nebraska for phtliisis. 175
Neoplasms of the heart, rare, *^6; of tbe lar-
yn.v. 464
Nervous nplioiiin. syn. of bilateral paralysis
of ilif liilernl cri CO -arytenoid mus-
cles, aw
cnufrh. trent.. 4!W. -199
Netler. d i nkjcoccus ]iiieunioniEe, 115
Neuralcift, ii]ien.'"vtiil, iv, 352
of the larynx.. »*). .VH
iinnl.. path., eliol., symp., dlag.. .'SCO;
proft-. trHiii.. .^01
(lifT. fr, clirtKiic rheumatic sore throat,
-■illi
of thi- phiirynx. treat., 389
Neumsfs of the pharynx. »K«-39a
Keurotic or fiinctfdual dieM.>ase of the heart.
il7-tM'.i
etiol,, symp., '.M': diag., prog., treat,.
-MS
dilT. fr. chriiiilc eudtx'arditls. iCK
Kowcomh. Jjiiin's E . electrolysis iu disciise
of scpMiiii. Mi
New Hampshire for Ijiiy fever. 555
New Mexico fur jihrliisis. 173; rhinitis In.
New York Jlciiioil .Innrnnl. pneumonia, infec-
tive. rii'l;illi'lil, lITi; pneumiiiiia. con-
tiiKi'i'is. Wells, lll'i; acute tulierculnr
snrc thri'iit. 'ilcit«iiiiiiiii. -112: electric-
jly ill rl J in ills. T'. Brysiin I>elnvan,
.WJ; ua^il viisculiir tumors, J. O, Hoe,
67tf
New York Medical Record, iodide trichloride
InaurgerT, Wm. T. Belfield, 441 ; erer-
siOD of tbe reotriclea of Morgagni.
48S; fracture of tbe nose. J. O. Koe.
SH ; electrolysis in disease of septum,
James E. Newcomb, 601
Night sweats remedied, 171
Nipple Hue, mammary or, 6
Nitroglycerine for angina pectoris, ZSS: athe-
roma of the aorta. 256
Nitrous oxide gas for ana«thetic Id asplratiou
in empyema. BO
Norma) bronchial whisper, 66
bronchophony, 56
radical pulse, illus., SOe
vesicular resonance, 25
Tocal fremitus, 15
vocal resonance, 54. B5
North Carolina mountains for phthisis, 176
Nose bleeding, syn. of epistaxis, 560
congenital deformity of the, 508
diseases of the, 51&«i6
foreign bodies iu the. 608. 604
fractures of the, 598, S64
furuDculosis of the, 1»8. 6S9
syphilis of the, 574-577; congenital, S77
Nottinghamshire, goitre In. 6&0
Obstacles to laryngoscopy, S89-SaS
to i>o8terior rhinoscopy. SM-aoS
Obstruction, aortic, mitral, tricuspid, pul-
monic. 235. SS6. SSS. 380
Obturator for intubation tubes. Illus.. 418
OdoDtologlcal Society Transactions, empyema
of the antnim, Cliristopber Heath.
O'Dwyer, Joseph, intubation. 38R. 415. iVO: io-
tubatlnn instrumenis. Illus., 4IH, *X;
laryngeal tubes. 433, 434. 440, 4.^7, W,
4«5. 4(«. 470, 47S
CEdema glottldls. sjn, of oedema of the Isr-
ynx, 14. 4,%
of the lar>-nx. 4.'W-433
syn., 4.30; etlol,, symp., 431; prog.,
treat., 4»J
diff. fr. retropharyngeal abwcess. 3S4;
fr. chronic laryngitis. 40:!, 4IQ; fr.
tubercular laryngitis, 4.%
of the uvula, acutt^ Intlammation and, 3W
pulmonary. I.S. 4J, 14^144
dklematous laryngitis, syn. of cedema of the
larynx, 430
C£nothera biennis unsatisfactory with periui-
sis, I.U
Oertel, carbolic acid In diphtheria. 338; pilo-
carpine in diphtheria, 337
CEsophageal bougie. 6.t5
forceps, flexible. 641
tube. .3fC. 888. 3!W
CEaophaglsmus. syn of spasm of the cmopbfr
gns. 6.^
(E-sophagitis, fiJa-ft^
acutf. cm. (B3
chnmic, tilS. CAt
{EBophRK"I'iuie, 636
(Ivsophagotomy. 643
INDEX.
695
<EBOpbsgUB. compremloD of the, 687
diseases of the. fSfO-im
foreign bodies in the. 640-643
parieathesia of the, fAi, 643
par&lysls of the. 6.%-AW
spasm of the, 687. 6»8
stricture of the, 684-637
Oil atomiiser. 536
Olivary bougies, 63S
Oilier, retro-uasal fibrous tumors. 621, 62S
Opiates prohibited In caplllHry bronchitis, 96
Opium objectionable In pneumonia. 138
Orth, fcangrene lu lobar pueuiuonia, IIS
Osseous cj-8ta. ooaal. S70
tumors <llfr. fr. nasal mucous polypi. SOS
Osteoma dlff. fr. rhlnolltbs. 606
Osteomata of the nose, srn. of nasal bonj
tumors, 671
Outfn^>wths dtff. fr. benign tumors, 469
Owsley, F. D., spray of solution of clovea In
laryngitis. 442
OxyhydrogcD light fur laryngeal Illumination,
ars
Oiaena diff . fr. empyema of the antrum, 661
Packiko nasal cavities to check bleeding, 610
(See Plugging: see Tampon)
Padley. method of removing foreign bodies
from the trachea. 4(M
Falasclano, flbromata. 621
Palate retractom. 30(>
ulcerative dt-sinictlon of. 3S1
Pallor In chronic pulmonary disease, 11
Palpation. 9, 14-10. 186
Panas. fracture of the larynx. 4KQ
Fftpillary growths on the uviilu. .359
Papillomata of the laryux, llUis., 4fVS, 4T6
of the nares. syn. of nasal papillary tu-
mors, 569
FKrseethesta of the larynx. »». SOI
anat., path., etlnl., xymp., diag., 500;
prog., treat.. 501
of the (esophagus, &U. tUS
etlol.. syuip.. dlag., prog., treat., 648
diff. fr foreign bodies. 641
nuvesthesin of the p>iAr>-nx, 3«9
etlol., prog., tn-at.. SSO
Paralysis of the nlidiictorH illfT fr. stenosis of
the laryux. 4.'i7 (stee Paralysis of the
posterior crk-o-arjtenold muscles)
of the arytenoid muscles, symp., dlag.,
treat., .'ill
of the crieo-thyrold muscles, lllu8.,8}'mp.,
dlBK . prog., trfftt.. 500
of the 'esiipbagus. 0:iH-l>tO
annt. jMith., raw; etlol., symp., diag.,
ftW: prog, treat.. Wt)
diff. fr. Mpogni of the pharynx. 300; fr.
stricture of the rpsophagus, ^H; tr.
spnsni. fr. mnlignnnt disease. 6!M, 040
of the pharynx. *11. 3K.'
etlol,, symp.. dloE., prog.. 301; treat..
3W
dlff. fr. spasm of the pharynx, 300
of the poHifrinr crico- arytenoid iniiscles,
bilateral, Sll-513; unilateral, S14
Paralysis of the posterior crlco-arytenold
muscles, dlff. fr. steQosIs of the la-
rynx, 467
of the thyro-aryteuold muscles, iUus., S07.
906
anat., path., etiol., symp.. diag., prog.,
treat.. 507
of the thyro-epl glottic and ary-eplglottlc
muscles. 506. S06
etlol., symp., dlag.. prog., treat., 506
of the vocal cords, dlff. fr. acute laryngitis,
896; fr. chronic laryngitis, 403
Parosmia, diag., treat.. Sfll
Partial extirpation of the larynx described, 481
Passive aneurism of the heart, syn. of dilate*
tlon of the heart, 889
hs^periemla, 188
Pathological Society Trausactlons, men more
affected by plastic bronchitis. Pea-
cock, 90
Pear-shaped chest, 10
Pectoriloquy, B6, 57; whispering, aphonic. 68
Pendent epiglottis an obstacle to iaryngo*
•copy. 891
Percussion, 9. 21-33. 63, S5, 86. ffi, 188; mediate,
immediate. 21; in health, 81-ST: In
disease. 38-31: auscultatory, 88, 33
Perforated concave reflector. 275-278
Perforating ulceratiou Id syphilitic sore throat,
lllus.. 353
Perforation of the nasal septum, 601, 60S
treat., 601
Pericardial effusion and hydro -pericardium
diff. fr. eccentric cardiac hj-pertro-
phy. 888
frlctlou sounds or murmurs, 196
Pericarditis. IS, 218-817
anat.. path., 812; etiol.. symp.. 313;
diag., 215; prog., treat., 810
dlff. fr. pleurisy. OH, 'JIS; fr. endocar-
ditis, fr. mediastinal tumors. 216; fr.
endocarditis. 2811: fr. olironic endo-
carditis, ■£». 227: fr. hyjiertropby
anil dilatation uf tlie heart, 238; fr.
dilatation of rhe heart. 841
flbrinosa, serosa, 218
Pericanllum, the. 177
Perichondritis of the laryngeal cartilages,
chondritis and. 433. -MJ
Perl ■pneumonia, i>eri-iineuruonla vera, syn. of
pneumonia. 113
Pertussis or wlio<iping-i'ough. I.W-ISB
anat.. path., 153: etlol.. symp., diag.,
prog.. \7A: treat., l.W
Perverted sense of siiiell. T-f.n, r>02
Peter, M., deviwd the iilcsslgrapli. 31; pulsa-
tion on line),' of linnds. 8UT
Phagetlenic ulceration. 3.^4
Pharyngeal bursa, lllus.. 309
toHHil. hyjiertroiihy of the. 01S-K30
Pharyniritls. ncnte foJli.-iilttr. :m. 340
chroiiii- fiillicular. ."MO-.'Hi;
sicca, or atrophic folliciilar. ,i43
Pharynx, anit-stliesitt of the, 388
and posterior nasal cavities, vault of the,
illus.. 307-310
696
INDEX.
nukrytuc, csDcer of the, 88S, 387
df§easefl of the, 8SS-898
foreigD bodies In the, 8S3. 88S
bjrperaestheeia of the, 888, 889
lupua of tbe, 349
neuralgrfa of tbe. S8B
nenroHes of tbe. 388-302
parsstbesla of the. 380
paralysis of th«, 301. 89S
scalds and bums of the, 3SS
spanm of the, 390
tumors of the, SHO
Phlebectasis larynicea, anat., path., etlol.,
STTup.. dian., treat., 409
PblegmonouB laryoKftis, 437, 4S8, 431
syn., etiol., Bjrmp., diag., 42r; prog.,
treat., 438
dlff. fr. laryngismus stridulus, fr.
retro-pharyugeal abscess, fr. foreign
bodies In the larynx, fr. diphtheritic
laryngitis, 427, 428
sore throat, syn. of pblegmonous toDsilll-
tis, we
toDsillftts. S6B-S70
syn.. anat.. path., etlol., symp., diag.,
888: prog., treat.. 860
dlff. fr. diphtheria, 382; fr. acute ton-
sillitis. 860
Pbtblsls infectious, I7Q
fibroid, 167-169
pulmonary, 13, 16. 20, 31, 161-16*
of the heart, syn. of atrophy of the heart,
242
PbyBical diagnosis, 3-50
examination, methods of, 9-58
examination of the heart, 18S-104
Phyciological action of the heart, itlus.. 180-183
Physiology of the heart, anatomy and, 177-180
Pigeon breast, illus. . 12
Pigments, formula-. 856. 656
Pilocarpine In <li])htherla, 837; In erysipelas,
429; In cedema of the larynx, 439
Pincette, 301
Pineapple Juice Id diphtheria, 335
Plus, E., pericarditis. 214
Piorry, mediate percusBlon, 21
Pitch of Bound. Si, 39
of heart sounds mmllfled by disease, 191
Pityriasis as a sign. 11
Plastic bronchitis, 00, 100
syn., anat., path., etlol., aymp., 90;
prog., treat., 100
diff. fr. pl.'uriay, fr. pneumonia, 99
or dry plouriay. 61
PlessiKraph. ttic, 3\
Plesainicifr, ph-ximeU'r or, 21
Pleurisy, acuti'. 'Ji-72
bilociiliir. H3
clroHinwrilM-d. S2. 150
dinphragtimtii.'. S3
henicirrhntrif. 'il
of thf nj"'x. W
or fnipyi-ruii, chronic. 70-itt
or pleiiritis. I:.'. ■^.}. iHt-Ht
anat., imlh., i'*i
iMtC. fr. plastic broncbitlu, 90; fr, pnou-
monla, 110; fr. pulmonair coUapM,
141
Pleurisy, plastic or dry, 61
subacute, 73-75
multilocular. 83
UDil ocular. 83
sero-flbrlnous. 61
Pleuritic friction sounds dlff. fr. pericardial,
106
FleuritiB, pleurisy or, 60-84
Pleurodynia or intercostal neuralgia, dlff. fr.
pleurisy, 68: fr. pneumonia, 119
Pleurotomy, 78
Pleximeter, 21. 32
Plugging for eplstaxls. 661-«a3. 6SS, SSt
Pneumococci in endocarditis. 222
Pneumo-hydropericardlum. etiol., - synip.,
diag., prog., treat.. 218
Pueumo-hydrothorax, illus.. 85-88
diag.. 87; treat., 88
diff. fr. emphysema, fr. chronic plsn-
risy. fr. diapbragmatlc hernia. 88
Poeumouia, 119-120
syn., 118
dlff. fr. pleurisy, 89; fr. plastic bron-
chitis, 99; fr. pulmonary oedema, IIS,
143 ; f r. abscess of the lung, ISO; b.
pulmouary collapse. 141
bilious. 129
chronic or Interstitial, typhoid. 1!8
from disease of the heart, from Brighfi
disease. 128, ISO
lobar. 318-128
lobular. 12S-1S8
Pueumo-hydroperlcardium. etiol., symp.,
diag., prog., treat., 218
Pneumo-hydrothorax. 85
diag., 87; prog., treat., 88
diff. fr. emphysema, fr. chrnuic plea*
risy. fr. diaphragmatic bemla, 87. 88
Pneumothorax, IS. 15. 31, M. HS
etlol.. 84: symp., 85; diag.. 87; prog.,
88; treat.. 88
dlff. fr. emphysema. 87; fr. chronic
pleurisy, fr. diaphragmatic hernia,
88: fr. emphysema. 110
PneumonorrliaKla. syn. of pulmoDary apo-
plexy. 13J. 137
Pocket tongue-depresBor. illus., 271
Polasciano, retro-nasal fibrous tumors. Ofl
Pollkler. B., foreign bodies In oesophagus. 6fi
Polypi, nasal fibrous. 509
nasal huicouh. AtM-SRR
Polj-pus. diff. fr. phlegmonous laryngitis. 4*
Poruher. neir- retaining uvula and palate re-
tractor, illus.. 806
Position for rhinoscopy, illus.. 304
Positions of bead for laryngoscopy, good.
poor, lIluB., 284. 285
Posterior crico-arytenoid muscles, bilateral
paralyxis of. 511-513
region. !)
rhinoscopy. Illus.. 302-306
POBt-nasal catarrh, syn. of rblDOpbatrngltis,
(W7
snare applicator, 633
INDEX.
697
POflt-nasal Rrringe, lUus.. 609
PoBt-tracbeotomr TegetationB, 48B
etlol.. srmp., dla;;.. prog., treat., 4BB
m>tsin, use of sterilized air In pneumothorax,
m
Potassluin iodlda for aii(;lna pectoris, S47, S5S
Poulet, epileptiform asthma, IM
Powder-blower for insutSation, illus., KM
Powell, R. Doufclas, siphon drainage In pleu-
risy. 7S; cause of angina pectoris,
800: aortitis, SM
Prentiss, claaslflcatlon of causes of slow pulse,
fiSO
pTMcrlptlons. formulie for, 045-608
Presystolic venous pulsation, cause of, 807
Probanft, cotton. 406
Probe, Bat nasal, 68?
ProcesmiH vocales, the, illui., 2M
Professional patches, dlff. fr leucoplakla buc-
calls. S61
Proti^resslve bulbar paralysis. 891
Prolonged interval between inspiration and
expiration, cause of, 43
respiration, cause of, 44
Prophylactic treatment most Important for
distoma pulmonale, l&I ; for acute
rheumatic sore throat, SSI ; for diph-
theria, 833, 884; for rhinitis In catar-
rhal tendencies, 684
Prophylaxis in phthisis, 170; In rhluo-pharyn-
gitls, 609
Pnidden, T. H., streptococcus of dipbcheria,
pBeudo-anglna pectoris, dift. tr. angina pec-
toris, 2S£
Pseudo-apoplexy. £48
Pseudo-diphtheria, 839
pBeudo-membranouB bronchitis, syo. of plastic
bronchitis, 99
Psoriasis linguse. dlff. fr. leucoplakla buc-
calls, Sttl
PolmouarT apoplexy, 39, 187, 188
syn.. anat.. path., etlol., aymp., 187;
diag., treat., 188
area, illus.. 196, 199
artery, ISO; aneurism of the, 8&I, 96S
cancer. 146-148
anat., path., etlol., symp., 140; dlag.,
147, proK., treat., 148
dlff. fr. chronle pleurisy, fr. phthisis,
fr. aortic aneurism, 146
Pulmonary collapse, 189, 142
syo., anat., path.. 139; etlol., symp.,
140; diaK., prog., treat., 141
dlff. fr. lobar pneumonia, 130; fr. lob-
ular pneumonia, 136; fr. pneumonia,
fr. pleurisy, 141
Pulmonary emphyttema. IS. 107-113
anat., path., 107: etlol., symp., 106;
diag., 110; prog., troat.. 113
dlff. fr. chronic bronchitlit, 08; fr.
asthnia, 105: fr. pneumothornx. 110;
fr. acute tulierculnsis, fr. fibroid dis-
ease of the lungs, fr. asthma. 111
fissures, 6
gangrene, 144, I4S
Pulmonary gangrene, anat.. path,, 144; etioL,
symp., dlag., prog., treat., 14B
difT. fr. phthislH, fr. bronchitis, fr. dU'
latation of the bronchial tubes, 146
hemorrhage, 134-1S6
syn., anat., path., 184; etlol., symp.,
dlag., 186: prog., treat., 186
dlff. fr. bronchitis, 98, 94: fr. heema-
temesls, fr. epistaxls, fr. hemor-
rhage from the gums or the phar-
ynx, 186, 186
hypertemia. 1S3-184
anat., path,, ISS; et'Iol., symp., prog;.,
183; treat., 184
oedema, 80. 142-144
anat., path., etlol., 14S; symp., diag..
prc^., treat., 148
dlff. fr. capillary bronchitis, 97, 148; fr.
pneumonia, 130, 143; fr. pneumonia,
fr. hydrotborax, 148
phthisis, 18, 166-176
^n., 166: pn^.. 169; treat., 170
difr. fr. pleurisy. 69; fr. bronchitis, 9S,
94: fr. capillary bronchitis, %; fr.
bronchiectasis, 101; fr. pneumonia,
190; fr. pulmonary gangrene, 146: fr.
pulmonary cancer. 147: fr. hydatid
cysts of the lungs, 149; tr. syphllltio
disease of the lungs. 161 ; fr. enlarged
bronchial glands. 158
resonance, exaggerated, 38
semilunar valves. 178
thrombosis and embolism, 186, 189
anat., path., ISH: etlol., symp., dlag.,
prog., treat.. 189
tuberculosis, 30, 166-166, 169, 170
anat. path.. 166; etlol.. 168; symp.,
ISO: dlag.. 164: prog., 169, 170; treat.,
170
dlff. fr. other forms of phthisis, 166
tumors, 148-168
Pulmonic obstruction, regurgitation, 2M
Pulsating empyema, 77
dlff. fr. aortic aneurism, 363
Pulsation in the veins on the ba^h of tli9
bands, cause nf. 307
Pulse, an Indication of action of the heart, 18S
normal radial. Illua., 306
senile, Illus.. 310
Punch forceps. 4W
Purring tremor, 1**7
Pua, dlff. fr. serum in the pleural sac, 77
Putrid or fetid bronchitis. Ul. 103
Pyaemia, dlff. fr. glanders. 590
Pyo- per (card I urn. 217
Pyo-pueumothorax, 88
Pyramidal, pyrlform sinusen. 206
Pyrenees, goitre In. 089
Pyriform sinuses, diseases of the, 898
Qtain's stethometer. illus.. 17
Quality of a murmur, third in importance. 198
of sound, 38, 39, 41 ; of heart sounds modi-
fled by disease, 191
Quinsy, sj-n. of acute tonsillitis, 8fta; syn. of
phl^monoua tonslUllls, 868
698
INDEX.
IUlks or rboDchf, titiis., 4S-GS
RamoD de la Boto, lupus of the larynx, 46S
Rampolla, ratro-Daaal flbrous tumora, 021
Rankin, D. N.. mj'asfs narium. 0C6
Rapid tracheotomy, 4S6. IX
Raulln. rhinttis. 53S ^
Recefisus pharyngel, illus., 809
RtMl hepatization, 113. 114; IDus., 117
Reduplication of sounds of the heart. 196
Reference Handbook of the Medical Sciences,
leptotlirix buccal is. STG
Reflected light for larjnKOBCopy. 375-878
ReflectorB, laryntreal. 275-S8S; perforated con-
cave. 283
itef^neration of atrophied structure, 000
RegioDS of the chest. lUus., 4-8
ReEUrftitsrtion, aortic, mitral, tricuspid, pul-
monic, 22S. as. aw
Renal origin of dropsy, 11
Resection of the ribs in pleurisy, dlfTerlng
views. 78-80: In abscess of the lung,
131 ; of the larynx described, 481
Resonance, normal vesicular. 25: cracked pot,
S8, 31: exaggerated pulmonary, 38;
tympanitic, S8, 89; amphoric, veslc-
ulo-tymiwnltic, S8, 80; nurmal vocal,
OS, sa
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
ResiJiratory orffans, physiological action of,
88. 39
Retraction uf the lung. syn. of consolidation
of the IiiQg, 237
Retro-uaiuil cartilaginous tumors, 6SS
catarrh, syn. of rhino-pharyogitls. 607
flbro-iiiucdiia tumors, illus.. fQ4. ISS
aunt., path., etiol., syuip., diag., 624;
prcig.. treat., m5
diff. fr, flbroUB tumora. fr. mucous
polypi, fr. malignant growths, 624
fibrous tumors. 620-621
auat.. path,, etiol., syiiip., G20: diag.,
Iiriig., treat., 631
(liff, fr. polypi, fr sarcomata. 621
Retro-pharynKenl abscess. 383.^86
anat.. ]>.tth.. etiol., 383; symp.. diag.,
.184: pniK-, trt-at,. 385
diff. fr. iToiip. fr. iBdemaofthe glottis,
fr, fi)ti?ii:n lioilies, fr. convulsive dis-
oi'ilrt-s, r-i-M. 3K'); fr, phleguionoits lar-
yin;itis. i'^: fr, aliscfssof the larynx,
43>i
Eevue d'ilvKi'^no ft de Police sanltaire, Infec-
ti'ni iif riiphtheria, Grancher, 834
de IjjryngoloKie. d'Otologie et do Rhino-
ogie. rhinitis. Raulin. S.'K
mensnellc ili-s MalnOit's de I' En fa nee, spasm
of the glottis. LubelBarbon, 490; for-
eign iKidjes iu the oesophagus, B. Po-
likier. VAC
Bheumatic pharyngitis ditl. f r. diphtheria, 331
Rheumatic K>r« throat, SKMSl ; acute, 818, 817;
chronic, 816-821
Rheumatism, dlflT. fr. glanders, fiOO
nasal affections In, SOI
Rhinitis, 022-052; simple acute, S8S-028; acute
in lnfants,traumatic.096: chronic, SI7-
562; iDtumescent, 081-MO: hypertro-
phic, UO-A47; atrophic Mr-OCS; in
measles, scarlet fever, SOI
chronica, syn. of chronic rhinitis, szr
hjrpenesthetica, syn. of bay fever. 5S8
RhlnoliUis, 6M, eOO
symp., WM; diag., prog., treat, MB
diff. fr. atrophic rblnitlfl, S49; fr. nasal
bony tumors, 572; fr. malignant tu-
mors, STS; fr. osteoma, fr. cancer, W
RbiDO-pbarrngitiB, 60T-G1O
syn., etiol., 607; symp., diag., prog.,
606; treat, 600
diff. fr. adenoid growths, fr. syphilis,
606
Rhinoncleroma, 068, 089
etiol., diag., prog., treat., 080
diff. fr. syphilis, fr. epithelioma, fr.
keloid. 680
Rhinoecope, a, STS
with uvula holder, Illus., 806
RhinoBcopIc Image, illus.. 807
Rhinoscopy, Illus., £72, 298-310; anterior, 801,
802; posterior, 802-S06
obstacles to posterior, 804, SOS
Rhonchl or r&les. 46-02
Rhoncbial fremitus, bronchial or. 16
Rhythm of sounds. 80. 41 : of a murmur, aetxmA
in importance. 106. 200: of heart
sounds modified by disease, 101, 198
Of the heart, illus,, 1ft!. If9
Ribs, resection of the, 78-80. 181
Riegel, signs of chronic myocarditis, S3S
RIehl (see Chiari and Riehl)
Right-angle cutting forceps, S07
Rima glottidis. 296
Robiason, Beverley, asthma due to poison In
the blood. 104; feeding in laryngitia.
443; rhinopharyngitis. 607, fiOO
Roe, J. O, , hoy fever related to conditions in
nasal pastsages, 653; nasal vascular
tumors, S70: fracture of the Doee. bM
Rose cold, syn. of hay fever. 5B8
Rotcb, T. M., pericarditis. aiS
Rouge, retro-nasal flbr^Mia tumors, 621
Koux aud Yersln. Kletis-LOtQer bacilluB In
mouths of healthy children. S2S. car-
lK)lic or boric acid In diphtheria, 836
Rubber palate retractor, illus., 806
Rude, broncho- vesicular or harsh roBpiration.
■44
Ruffer. Armand, diphtheritic bacilli, 8S0
^Rupture of the heart, symp., 215
SACct'Lrs laryngts. the, 297
Sajous. Charles E., self -retaining naaal speca-
luui. illus.. 801; simple ineuibraoous
sore throat, 396; cocaine In tubercular
sore throat, Slffi; syphilitic sora
throat, 806 ; chromic acid In tracbomtt
INDEX.
699
of Tocal cordfl. 40B ; hay fever related
to conditions lu nasal paasafies, SBS;
iinare, 507; nasal osseous cysts, 570;
knife, nasal saws, iUus., 596
Salicylic acid, objectionable In pericarditis,
Salter, heredity In asthma, 108
Sands, cBSophagotome, lllus.. 6S0
SaDsom, treatment of ulceratlTe endocarditis,
223; dlaKnoais of congenital diaeaees
of the heart in children. 246
Sarcomata, 4G7, 476
diff. fr. nasal mucous polypi, 566
Saws, nasal, SOS
Scalds and bumsof the pharynx, 8ymp.,diaf;.,
proff.. treat., tlS&
Scapular region, 4, 7
Scarification of the tonsils, 807. 869
Scarlatina, dlff. fr. acute sore throat. B]2; fr.
diphtheria. 38!!; fr. acuttr tonsillitis,
864, S6S
Scarlet fever, sore throat of. 323, 82) ; laryn-
gitis due to, 455; nasal affections lu,
691
Sctaftffer, Haz, nasal papillary tumors, 5(ffl:
differentiation of nasal affections, SBS
Schecb. ancpsthesia of the larynx, 499
SchifTers, myxomata transformed Into sarco-
mata, 566
Schmidt's Jahrbuch, pleurisy, Bleirauskl, 66;
epilepsy followtnt; irritation of pleu-
ral surfaces, De Cereuvllle, 7H
Scboell, Ferdinand, the aneurismatoscope, 361
Bchrfltter, bead band for reflector In laryngo-
scopy, illuB..27T<: tubes, dllators.bou-
gles or aound. 438. 440. 457, VTi, 4tt5. 615
Schuller, Max, tracheotomy. 486
Schuster, nasal Byphllis. 576
Scirrbus of the lungs, syn. of fibroid phthisis.
187
Scissors for amputating the uvula, lllus., 859;
nasal, .^45; heavy bone, IVIO
Scrofulous eruptions, diff. fr. glanders, G90
sore throat, .W8-350
etiol., 848; symp., diag.. 284; prog.
treat., -WO
din. fr lupus of the pharynx, fr. syph-
ilis, fr. tubt(n:ulo8l8, AV.^-. fr. iicutotu-
bercular sore throat, 352 :fr. syphilitic
sore throat, 85.^
8-curve, illus. , IH
Sea voyage for coiivnlesoenla from subacute
pleurisy, 75: for plasttc bronchitis,
100 : for bay fever. 555
Seashore for hay fevpr, 455
Seat of a niuntiur flrxt In Importance, 106
of heart sounds nioilifled bydlsense, 191. 102
Second stage of pneumonia, period of red hepa-
tization. 117: of phthisis, 101, lOS; of
perlcar.iiti«. 213. 214
Sections of hea<l. llbiH.. 302. .MI. 579, 5fll
Sedatives, fonuultE. gargles, lUT ; trocblsci or
lozfngi-«. (M7; vnpor inhalations. 650;
npray inhalations. fc'>l ; dry iiihahi-
tions. iVA: fuming Inhalations, liiU;
inau (nations, 6SU
Seller, Carl, tube forceps, illus.. 496
Self -retaining: naaal speculum, 301
Senile pulse, lllus., 210
Senn, Nicholas, gualacol in phthisis, ITS; lar-
yngoscopy, 2iS
Septic endocarditis, syn. of acute endocardltia
219
Septum forceps, knife. OOC
Septum narium. lllus., 806
abscesses of the nasal, 60S
deflection of the nasal. 594-607
eccbondroma and exostosis of the nasal,
697-601
hsamatoma of the nasal, 6QS
perforation of the nasal, 601, 602
Sero-flbrinous pleurisy, 61
Serum dlff. fr. pua in the pleural sac, 77
Sex modifies form of chest and percussion
sounds, 10. 11, 27
Shattuck cites Soltmann on ■ asthma among
Hebrews, 108
8bawl-pin removed from the trachea, a, 496
Shoemaker, pilocarpine for erysipelas, 420
Short fmnulum obstacle to laryngoscopy, 290
Shortened inspiration, 4S
Shurly, E. L.. battery, 345; iodine hypode rail -
cally for Immunity to tubercular
virus, 173. 442
Sibilant r&les, 48, 49
Slbson, treatment of endocartlltlR, 231
Signs and symptoms differenttated, 9
of Inter -thoracic disease, 16
tussive. 69
nervous, 206
Simon, capillary bronchitis Id children, 08
Simple acute rhinitis, 52;!-526
syn., anat., path., etiol., 623; eymp.,
623; dlag., prog., treat., 524
dlff. fr. hay fever, 624. 604; fr. luHam-
matlon of the antrum or frontal si-
nuses, fr. measles. 524
acute sore throat diff. fr. acute follicular
pharyngitis, 839
canllac hy|>ertrophy, 394-336
syn., etiol., sytnp., 29)4; diag., prog.,
aS: treat., 286
catarrhal inflammation dilf. fr. syphilitic
Kore throat In Infants. 857
chronic rhinitis, 528-580
etiol., synip., 528; diag.. prog., 6S9:
treat.. .WO
diff. fr. bay fever, 620; fr. intumescent
rbiultis, 584
membranous sore throat, 824-327
syn., anat., path., 324; etiol., symp.,
$25; dJAK.. prog., treat.. 820
diff. fr. diphtheria. 820. 832; fr. syphi-
litic sore throat, 8.'i5
Sinus, empyema of the frontal, 681; of the
sphenoidal, 588. 5W
inRammntion of the frontal, 5^4, 685
Sinuses. dJM'aset) of the valeculte and pyrl-
form. SOS
uf Valsalva, aneurism o the 257, S60
pyrairiiilal. pyriform, laryngo-pharyngeal,
200
700
INDEX.
BiphoD drafnage in pleurls;, 79, 8B
Skoda, bronchial Bound, 4G: heart soands, 190
Bmall-poz, sore throat of. 3S1, S8S; laryngitis
due to. 4S6 ; nasal affections Id, BU
Bmeleder, support of reflector Id larTngoecopy.
877
Bmltb and Warner, paeudo-dlphtheiia, BS9
Bmoker'B patches diff. fr. leuooplaUa buccalls,
aei
Snare for exclsfoDS In the throat, 886, 667, STO
applicator, post-nasal, 6SS
forceps, 4TS
Sodium sutpbo-carbolate In endocarditis, S38
Solid mediastinal tumors, 387, 868
symp., 867; diag., prog., treat., 886
ditr. fr. thoracic aneurism, 868
SoItmaDn. asthma among Hebrews, 106
Sonorous r&les. 48
Sore throat, acute, Sll-SH; eryslpetalous, 814-
816; rheumatic, 816-331 ; acute rheu-
matic, 816, 817; cbroDic rheumatic,
818-381 ; simple membranous, 894-887:
scrofulous. 348-8BU; acute tubercular,
860-858; 8yphf""o. 868-8C?r
throat of measles, symp., diag., prog.,
treat., 822
throat of scarlet fever, S38. 824
anat., path., symp., diag., 888; prog.,
treat.. 384
throat of small-pox, 881, 829
anat., path., diag., prog., treat., 8S8
Sound in moving fluid transmitted In the di-
rection of motion, 197
Bouth America, myasls narlum, 600
South Carolina for phthisis, 175
Spain for phthisis, 175
Sparteine in chronic eDdocardttis, 889
Spasm of the adductors diff. fr. paralysis of
the abductors. GI8
of the glottis, 4B6, 497
syn., symp., diag., 496; prog., treat., 497
diff. fr. acute Iar>-Dgiti8, 396, 306; fr.
phlegmonous laryngitis, 437; fr. true
croup, 414, 497
of the larj-Dx in adults, 497. 498
etlol., 497; symp.. diag.. prog., treat.,
498
diff. fr. asthma, 105
of the WBOphagUB, 637, 688
syn., etfol.. symp., 637; diag., prog.,
truat,, 638
diff. fr. stricture of the oesophagus,
635; fr. paralysis. 689
of the pharynx, etlol.. symp., diag., prog.,
treat., .100
diff. fr. stricture of the (psophagus, fr.
paralysiii, fr. paralysis of the pha-
rynx or the wBophaguB, 390
of the vocal cords. HH, 503
anat., path,, .WS: Hymp., treat., 503
Spasmodii' UHthum iliff, fr. hay fever. K4
strlcturt- of the (I'MOjihaKus. syn. of spasm
of the (fsnj)liHKUH, 1-37
croup, Nyn. nf .sjm^m of the glottis. 49G
SpasmuH elnitlilis. syn. of spaeui of the glot-
tis, 490
Spatula, naaal. 600
Sphenoidal slDuaea, empyema of the, S88,
664
Bphygmt^craph, the. lllus.. 806-811. 860
Spirometer, lllus., 18
Spleen, variable In size. 87; enlargeDnent of.
' diff. fr. pleurisy, 70
Spray iDhalations, formuUe, 061-608
Sprays, powders, plgmeots, of suocOMive value
for chronic laryngitis. 40K
Spud, nasal. 69S
Staining tubercular bacilli, 164, 106
Staphylocoocl Id pleurisy, 01
Starvation treetmeDt of aortic aneurism. 806
Btenosla of the aorta, syn. of coarctatioo of
the aorta. 860
of heart valvea produced, 284, 888
of the larynx, chronic. 460-4GB
of the trachea, diag.. prog., treat., 460
Sterilized air In pDeumothorax, 88
Sternal region, 4, 6. 7
Sternberg, diplococcus pneumonln, 115
Stethogonlometer, 16
Stetbometer, 17
BtethosCopes, S4-S7; disadvantages of, 84
Stimulant and caustic pigmeuts, 8U <aee
astringents and stlmulaota, aatlsap-
tics and sllmulanta)
StlmulADts, formulee. gargles, 647: trocbinci
or lozenges. 043; vapor inbalatioiia,
660, 061 : dry InhalatloDS, 654
Stimulating injections for pleurisy, 61
Stirling, inhalation of lime water In plaMic
broDchitls. 100
Btoerk, teraseur. guillotines, forceps, blartes.
lllus., 473
Stokes, pseudo -apoplexy and fatty heart, S44
Stowell, C. H.. sections of bead, lllus., 808,
Ml. 679. 684
Streptococci in pleurisy, 61
Streptococcus eryHlpelatosuB, 81S
Strickler, W. M., resection of ribs for pleu-
risy, 78
Stricture of the cesophagus, 684, 6ST
anat., path., etlol., symp., 6S4; diag.,
prog., 6S5; treat., 638
diff. fr. spasm of the laryox, 890; fr.
tubercular laryDgitis, fr. tumors in
the pharynx, larynx. (Bsophagua, fr.
spasm, fr. paralysis, fr. f<H?eigD
bodies, fr. spasm, 686
Strong, A. B., resection of ribs for pleurisy,
78; drainage tubes, lllus., 79
Strophanthus In exopthalmtc goitre. 6S2
Struma, syn. of goitre, 629
Subacute broDchitlB (see acute bronchitis)
laryngitis. 897. 896
prog., treat., 397
pericarditis. 213
pleurisy. 12. 79-75
anat., path., etiol., 78; symp., dlaf.,
prog., treat.. 78
Subclavian murmurs. 206
Suborepitant r&tes, 4ft-50
Sul)CutaDeouB emphysema shonm, 11
Subglottic hypertrophy, 401
INDEX.
701
Submucous iDflltratiou of the sides of the
vomer, fllus., <)i«K-. treat, 547
luTDRitls, Bjm. of phlegmonous IsryDKltis,
427
laryoKitis, syn. of cedema of the larynx,
4»
SuccussloD. 9. SO. 86
Suffocative laryngismus, syn. of spasm of the
glottis, 490
stage of croup, 412
Superficial ulceration In syphilitic 8or« throat.
363; of vocal cords, of epiglottis, 11-
lus.. 8S6
Superior costal breathing, 11
m«atu8, llluB., 800
sternal region. 4, 6
turbinated bodies, illus., 809
Suppressed respiration, 48
Suppuration of the anterior ethmoid cells ditf.
fr. empyema of the antrum, 581
of the antrum, diff. fr. atrophic rhinitis,
540: fr. chronic suppurative ethmoN
ditls. 586
Suppurative etbemolditls, chronic, 685-A87
tonsillitis, syn. of phlegmouous tonsillitis,
SBB
Supra-arytenold cartilages. 306
Supra-clavicular region. 4
Supra-glottic dropsy, syn. of cedema of the
larynx, 480
Supra -scapular region, 4, 7
Supra -sternal region, 4, 6
Supra-thyroid laryngotoiny, 476
Swallowing the tongue, TOi, 898
treat., 398
Swiss mountains for phthisis. ITS: goitre In,
639
Symoods, Charters J.. gum-elaKtic tube to keep
Stricture of resopbagus pervious, 686
Symptoms and signs ditTerentiated, 9
Syphilis of the nose, 5T4-r>77
anat, path., etiol., 574; dlag., prog.,
treat., 575
dlff. fr. atrophic rhinitis. 540. 575: fr.
simple catarrhal rhinitis, fr. lupus,
875; fr. empyenia of the antrum, 5**! :
fr. lupuB of the nares. 58H: fr. rhi-
noacleroma, 580; fr. glanders. 500;
fr. rhinopharyngitis. 006
Of the trachea, IIIuh.. 4K7, 488
anat., path., etiol., symp., 487; dlag.,
prog., treat., 488
fijphilltlc condylomata of the larynx ditf. fr.
benign growths, 466
disease of the heart, S45
disease of the lungs. 151, 15S
symp., diag., 151; proK., treat., 158
laryngitis, illus., 443, 450. VJ^
etiol., symp., 444; diag., 446; prog.,
treat. , 448
dlff. fr. chronic laryngitis, 403; fr.
tubercular laryngitis. 430, 440; fr.
tubercular laryngitis, fr. tumors.
448-448; fr. liipiiK. 4.Vi; fr. benign
tumors of the larynx, 4tM;fr. cancer,
479
Byphilitlc laryogltls In Infants, 449. iSO
diag., 449; prog., treat., 400
patches diff. fr. leukoplakia buccalla, 889
sore throat. Illus.. 853-357
anat., path., 858; etiol., symp., diag.,
854; prog., treat, 85S
diff. fr. chronic rheumatic sore throat.
890; fr. chronic follicular pharyn-
gitls, 844; fr. scrofulous sora throat,
S49; fr. catarrhal sore throat, fr.
scrofulous sore throat, fr. tubercular
sore throat, 304. 80S: fr. acuta tonsil-
litis, 866; fr. cancer of the pharynx,
387
sore throat In infants, 856. 3ST
anat, path., etiol.. dlag.. prog., treat*
857
diff. fr. simple catarrhal Inflammation,
357
ulceration of the tonsil dlff. fr. tubercular
ulceration of the tonsils, 878; fr. can-
cer. 380. 381
Syringe, nasal. KSO; hypodermic. 568; post-
nasal. COU
Systole of the heart. 180: auricular, illus., SOI ;
ventricular, ilhis., SOa
Systolic murmur. 301, 302
souffle. S44
venous pulsation, cause of, S07
Tachtcardia. 340
prog., treat. 849
Taenia et-hinoc, coccus, cause of hydatid cysts
of the lungs, 148
Talt'e Cllnlquesde Laryngotomle, thyrotomy,
Krishaber, 475
Tampon, for the nose, wool, 553; surgeons'
lint 501. SG3: Untorgauze, GOO; styp
tic gauze. 631
Teeth, empyema of the antrum from diseased
570
Tennessee mountains for phthisis, 175
Texas for phthlRis. western. 175
Thickening of turbinated bodies dlff. fr. mu-
cous polypi, 565
Third stage of pneumonia, period of gray he-
patization. 117; of phthisis, 161-lM;
of pericanlitis. 313. 31S
Thompson, R. E., percussion sounds, 88, 80;
gmlmouary emphyxcnia, 110
Thoracic aneurism, aortic or. 35ft-S6n
arteries, diseases of the. 2.^4-868
Three stages of ainite pleuriny, 81 ; of pneu-
mnnla, 117: of phtiiisis. 161; of peri-
canlitis. 313; of croup, 413
Throat, the. 271-310
acute rheumiitlc sore. 310-317
acute sore. 311-314
acute tubercular sore. 350-353
chronic rheumatic sore. 318-.*S1
consumption, syn. of tubercular laryngltii,
4.'M
deafnpss. SlO-fllS
etiol.. symp., 610; dlag., prog., 611:
treat.. 013
diseases of the, 871-515
703
INDEX.
Tliroat, eiynipelatous nore. SH-S16
gouty afTectlons of the, 31ft
tnirpors for laryngoscopy, HluB., JTS
of measlea, oore, 3itt
of scarlet fever, sore. 333, 334
of small-pox, sore. 831. SSi
rheumatic sore, 316-321
scrofulous BO re, 348-350
simple membranous eore, 834-33?
syphilitic sore, 3S3-357
TI)roTiil)Osi8aDd embolism, pulmonary, 138, 130
Thymus vulgaris, unsatisfactory with pertus-
sis, 155
Thyro-arytenoid muscles, paralysis of the,
B07, 606
Thyro-epiRlottic and ary -epiglottic muscles,
paralysis of, 005
Thyroid gland, diseasee of the, 630-033
Thyrotomy described. 474-170. 483
Tinkling, metallic. 30. 54, t<7. m
Tobacco smoking a cause of leukoplakia buc-
cal is. 860
sore Ibrotit. ilifT. fr. chronic rheumatic
sore throat, 830
Tobold, illumluator, S80; larj'ngeal knives, U-
lus., 474
Tongue, arching of the. 200: swallowing the,
303; enlargeil glands and vt^ins at
base of thp. 310 (see parieathesia of
the pharynx): depressors, lllus., 2T1,
4ftl
Tonsil forceps. S7S
Tonsilln pharyngea, 310
TonsillitiR. acute. afW-JCTT: phlegnvmnus. 36R.
3fi0: chronic (see hypertrophy of the
tntisil)
Tonsiliitome, Ihc. 373. 373
Tonsillotomy, 873. 374
Tonsils, concretions in the, 375
cancer of the, 3«0, awi
hypertrophy of the, :tr,',i-37.'S
to generutive organs, relation of the, 375
hyiH-rtrophy of tin- pharyngeal, 013-6*
I.iUschkA's. til3
niyciwis of the. .376. 377
obwtncle to laryiigoseopy. enlarged, 2!K3
reiiiovnl of the. .'K'l-.375
tuliercular ulceration of the. 37fl-380
Tomwaldl. naKal tulwrcKlosis. 57B; rhlno-
phnryngliis. 007
Trachea, e.vaiiiination of the. 800
involtitiiin of the. 4H5, 4NJ
stenosis i)f the. 4riO
syphilis of the. 4K7. 4W
Trncheal eartilag'-'s. illus., STO
respiratioti. lurynceiil and. 41
tumors, illus.. 4H3. 4fl4
eticil.. syiiip,, diftg,, prog., treat., 4ftl
Tracheitis. 4110-16-J
atiat,, path., etiol,, symp., 460; diag.,
prog., treat.. 4t'>l
diff. fr. laryngitis, fr. bronchitis. 461
Tracheocele. 4fti. 4'*?
syn,. anat.. path,, etiol.. symp., 4W;
diag.. pnig., treat., 4K7
Tracheophony, 54
Tracheotomj' described. 4S1H9B
Id anmirlsm of the aorta. :M
yi various tbTOat diseases. 836, S97. 433. 4Kn-.
442, 446, 4S0, 464. 45S, 457. 450, 470. 47U.
474, 481, 484, 486, 488, 496
rapid, 4SS, 430
vegetations after, 485
Trachoma of the vocal cords. Illus., 406. 409
syn., anat.. path., etiol., symp., diag..
prog., treat.. 408
Transillumination of the antrum, 580; electric
lamp for, 681
Traube. pulmonary percussion, M
Traumatic laryngitis, symp., diag., prog.,
treat., 896
rhiniti.' 620, 537
symp., treat., 6S7
Traveller's nasal douche, illua., 051
Trephin(.-s. nasal. 646
Triangle of dulness, lllus., 64
Tricuspid area, lllus.. 106, 199
obstruction. S36, 23H
regurgitation. 235, 328, 380
stenosis. 320. 338
valves, 7. 178
Trocar, flat, 79
TrochlBci or lozenges, formulep. 647-949
Trousseau, percussion, S3: laryngoscopy, 873:
tracheal forceps, 406
True croup, syn. of membranous croup, 411
Tube for anti-um. drainage, 683
forceps, 472
to kei-p stricture of oesophagus pervious, 638
Tubes for chronic pleurisy, drainage, 7St-83
for iiituliation. 418
Tubercle liacilll. lllus., 157; staining, IM; Id
lupus of the larynx, 451
bacillus, Koch, ISO
Tuherelt*s, mucous.' 368
Tubercular laryngitis, illus.. 484-443
STU.. 4-34; anat., path.. 435; etiol.,
symp., 43C; diag.. 437: prog., treat.,
4.11
difr. fr. chronic laryngitis, 403; fr.
anaviiia. fr. wdema of the larynx, fr.
catarrhal laryngitis, fr. syphilis.
437-140; fr. syphilitic laryngitis. 447;
fr. lupus. 453: fr. benign tumors. 404:
fr. cancer. 479
sore throat (see acute tul>ercu)ar sore
throat)
ulceration of the tonsils. 878-3)^)
anat,. ;iath., symp., diag., STB: prof(.,
STO: treat., 880
diff. fr. syphilis, fr. cancer. STB
Tuberculin of doubtful value Id phthisis, ITS;
disastrous results in lupus of tb«-
larynx. 453; in tuberculosis of the
nares, .170; curative In lupua of the
nares. SNH; inactive In rbiDo«K.'lero-
ma. .^8«
Tuberculosis (see acute tubercular tore throat)
acute miliary, 165-167
of the nares. 678, 670
anat.. path., etiol., symp., dUg.,
prog. , treat. , 67S
INDEX.
703
Tuberculosis of the Dares did. fr. lupus of the
ntires, SW
pulmuuary, 150-163
Tufnell. treattiieut of thoracic aneurlBin,*306
Tumors, Me also aiieurlnm
nasal: fibrous, SCJ; papillary, 909, BTO;
vascular, GTO; card lagt nous, 571;
bony. 571, 57d; malignant, STi, 673
of the heart, diae.. pro;;., treat., ^46
of ibe larynx: Ifenlfin, 44)5-470; carcilagi-
noii8, 4014; maliKnant, 470-488
of the naHO-pIiaryux ; malignant, OSS; cys-
tic. 630
of the pharynx, lUus., treat., 880
pulmonary, I4*J-1S8
retm-niittal fibrous, 030-034; flhro-mucous.
634: cartila^inoufi, 035
solid iDMliustinal, 193, 307, 3G8
tracheal, 4H3, 484
Turbinated bodies, 30ft; hypertrophy of , 541, 543
TQrck, toDRue depressor, illus., 371; larj-ufco-
Bcopy, 373; attempt to maitnlfy laryn-
iceal hiiag«, 383; syphilitic laryngitis,
446
TurKescence, venous, 300, S68, 307
Tussive slRna, 50
Tympanitic resonance, 36, 38, 39, 30, 06
Typhoid fever, nasal affecllons In, 591; diff.
fr. pneuuionia, 121; fr. glanders, GOO
I pneumonia, I^
Ulciratioh of the pharynx, 357
of the tonsils: tubercular, 37S-380;
Byphilitlc, 879, 881
Ulcerative endocarditis. 333. 333
etlol., symp., dlag.. prog., iSS, treat.,
as
Unilateral paralysis of the lateral crlco-aryt<t-
noid muacli^, Illus., 510, 511
etiol., synip., diag., 610; treat., fill
paralysis of the posterior crico- arytenoid
muscles, illus., sj'mp., dlag.. prog.,
treat.. T,U
Unilocular pleuriBy diff. fr. other forms, 83
United States, goitrv in, 039
Utah for phthixls. 175
Uvula, abscissioD of the. 359
acute Inflammation and redema of the, 3SH
and palate retractor, self -retaining. 3U0
dlseikBefl of tlie, U5H-300
eloDgatMl. 'ieQ. JOS. S43
chronic inHnriitnation and elongation of
the. .ViH. aw
malforiiiat ions and new growths of the, 359,
360
malignant growths In the, 360
Uvulatoiiiu scissors, illus., 359
VAi,BcfLX, the, illun.. 300
and pyrlfonn sinuttes, diseases of the, 893
Valsalva, sinuses of, 357, 359; treatment of
aortic aneurlnm. S66
Talves of the heart, 7. 17H; position of the, 179
VftlTutar disease of the heart {see chronic en-
docarditis)
murmurs, ace
Vapor Inhalations, formula, 649-651
VapcHiser, 013
Vapors from lime water In membranous croup,
416
Varicose veins at base of tongue, 3ft9
diff. fr. chronic rheumatic aore throat,
319
Vascular tumors, angiomat^ or, 4S7
tumors, nasal, 570
Vault of the pharj'nx and posterior nasal cari-
ties, 307-310
Vegetations, ixtsi-trucheotomy, -IW
Veins at base of tongue, varicost^, 819, 389
Velum palatl attacked in syphilitic sore throat.
353, 854
Venous murmur or hum, 307
pulsation, prtsystolic, systoltc, 206, 307
signs, 3i)6-30K
Ventilation with diphtheria, mode of, 834
Ventricle of Morgagnl, eversion of the. 483
Ventrlcleii of the lieart, right and left, 178
of the larynx, the, 2^7
Ventricular bands, lilus., 397
niurmiin*. 304
systole, 182; illus., 303
Vemeull. ntsophageol dilaior, 638
Vertigo, laryngeal, 504
Vesicular emphyseina, 107
murmur, the standard of comparison, 80.
40
resonance, normal. 35
Te8lculo-tym|>anil Jc n-Konance, 30
Vlerteljahreaschrlft fUr Dermatologie und
Syphilis, lupus of the larj'nx, Chiarl
and Kiehl. 451; nasal syphilis and
lupus of the larynx, ShuKter, .'i76
VIrchow, pulmonary emphysema. 107; malig-
nant enducnrditls. 319
Vlrchow's ArL-hiv, nasal pupillar>' tumors,
Hopmnnn, 500
Virginia mountains for phthisis, 175
Vocal corils, illus.. S1P7
conls. atrojihy of the, .M5
cords, paraljBia afftfting the. ,'■05-514
conis, spasm of the, 503, 503
corils. trncliomu of ihe, 4(»<, 409
cords. lumors of the. 4tK''>-4l)H
COrd«, ulci-rs of the, 3115
fremitus, normal. 15. 16
rt:sonani-e, normal, diminished, 55: in
;.Ti'ns(Hl or exaggerated, 56; whisper
Ing. 5rt
sounds. 54-59
Voltollnl, attempt *o magnify laryngeal iin
ng('. 3tft!; maff for lifting the epiglot
tls. 301 ; friction in laryngeal tumora,
473; translllutiiioationof the antrum
5Hn
Vomer or si^ptum, Illus.. 307; submucous infll
tnition of the sides of tlie, Illus., 547
Von Rtoffellft, p«TicBnlitis, 314
Vulsella forceps, 307
Waoszr, Cu.xTON. pneumonia contaglouR, 116;
retrn-nasal cystic tumors. 630
Walsham, deflection of the nasal septum, 590
704
INDEX.
Warden, larynitowxtpy. Z7S
Warner CSM Smith and Warner)
Wash bottle, S86
WaxhoQ), gag, lUus., 419
Weber, cauae uf astbnia. 108
Weber-Liel, throat deafness, 010
Welchselbauni, diplococcus pneumoDlB, IIB
Weill, carbon dioxide In aatbma, 100
laryngeal lllnniliiatlon, S80
Wells, pneuoioti la contagious, 110
Werthelm, attempt to magnlty laryngeal Im-
age, 88*
.Whisper, normal bronchial, exaggerated, cft-
vernous, amphoric, B8
Whispering bronchopfaony, pectoriloquy, vocaI
resonance, 58
Whistler, cuning dilator, lllus., 4S6
White Mountains for hay ferer, 5BS
Whlttoker. James T. , transmissloQ of bacilli to
foetus, 1S8
Whooping cough, pertussis or, 158-lU
Wiener medislnlsche Prease, cause of putrid
bronchitis, Josef Ltimnlcier, 91;
pericarditis, E. Pins, 214
Williams. C. J. D., rhinitis, OSS.
Winter cough, 01
WIntrich, tympanitic resonance. 66; pleurisy,
83; cause of asthma, 1U3
Woakes, Edward, maoous polypi, S54; throat
deafness, 010
Wolff, pnvumonla contagious, 115
Wool tampcKts, 5CS
Wright, C. H., burr for nasal surgery, 006
Wrdblewskl, adenoid growths In deaf mutes,
014
Wyoming for phthisis, 17B
Yellow hepatisation, US, 114
Teo. J. Bumey, pleurisy of the apex and low-
necked dresses, 63
Tersln (see Roux and Yersin)
7xiTscHRirr der Bolcterienlniode, contagious
pneumonia. Wolff. 119
fOr kllnische Hedlcin, signs of chronic
myocarditis. Rlegel, S33
Zlehl, solution for Btainlng bacilli, 164
Zlemssen. chorea laryngls, 601
Zlemssen's Cyclopedia of Medicine, carbolic
acid in diphtheria. Oertel. 886; glan-
ders eleven years. BolliUKer, SOO
Zlmmermann, siphon drainage in pleurisy. 79
Zuckerkandl. nasal papillary tumors, fi09; de-
flector of the nasal septum. !m
ZwiUlDger, H., nasal osseous cysts, 670
L941
145
1898
Ingals,Ephralm Fletcher
Diseases of the chest,
throat £c nasal cavltlps
NAME DATE DUE . |
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